Asthma ICD-9M Code 493.9 Asthma, Unspecified 493.1 Intrinsic Asthma 493.0 Extrinsic Asthma 1.

Definition: Asthma Is Characterized by Episodic Reversible Bronchospasm Resulting From An Exaggerated Bronchoconstrictor Response to Various Stimuli. It Is Best Considered A Chronic Inflammatory Disorder Of The Airways. 2. Types of Asthma: A. Extrinsic Asthma: (Allergic Asthma) 1. Typically Initiated by a Type 1 Hypersensitivity Reaction Induced By Exposure To A Specific Antigen 2. Forms: A. Atopic Asthma: 1. Onset First Two Decades Of Life 2. Commonly Associated With Allergies In The Child & Other Family Members 3. Elevated Serum IgE 4. Elevated Eosinophil Count B. Occupational Asthma: 1. Lung Injury Initiated By Exposure to Inhalation Of Fumes, Dusts, Or Chemicals C. Allergic Bronchopulmonary Aspergillosis 1. Bronchial Colonization With Aspergillus Organisms Followed By The Development Of IgE B. Intrinsic Asthma: 1. Triggering Mechanisms Are Non Immune. 2. Factors That Trigger Bronchospasm: A. Aspirin B. Pulmonary Infections Esp. Those Caused By Viruses C. Psychological Stress D. Exercise E. Inhaled Irritants Including Ozone & SO2

C. Exercise Induced Asthma: 1. Seen In Adolescents 2. Bronchospasm After Initiation Of Exercise 3. Improves After Discontinuation Of Exercise D. Drug Induced Asthma: 1. NSAIDs 2. Beta Blockers 3. Sulfites 4. Certain Foods and Beverages E. Genetics and Asthma: 1. Strong Association With ADAM 33 Gene 3. Pathogenesis: A. Common Denominator Underlying All Forms Of Asthma is Hyperresponsiveness Of The Airways To A Variety Of Stimuli. B. Airway Hyperresponsiveness Can Be Demonstratd By Histamine Or Methacholine Presssor Testing C. Bronchial Inflammation Is The Mechanism For Hyperresponsiveness Of The Airways D. Persistent Inflammation Of Bronchi Manifested By The Presence Of Mast Cells, Eosinophils & Lymphocytes & by Damage To The Bronchial Epithelium Is The Constant Feature Of Bronchial Asthma. E. What Causes The Bronchial Inflammation? Answer: For Extrinsic Asthma It Appears To Be An IgE Type 1 Mediated Hypersensitivity Reaction

The Mechanism: A. Mast Cells Are Released To Mucosal Surface Mast Cell Release Histamine Which Open Mucosal Intercellular Junctions Allowing Penetration Of The Antigen To More Numerous Mucosal Mast Cells B. Histamine Induced Bronchoconstriction Via H-1 Receptors Also Stimulate Mucus Secretions ( Contributing to Plugs). It Also Increases The Permeability Of The Subluminal Bronchial Vasculature. C. Parasympathetic Reflex Bronchoconstriction Is Stimulated By Irritants & Mechanoreceptors. In Addition Histamine Activates The Irritant Receptors .This Reflex Muscarinic (mAchR) Activation Characterizes The Non-Specific Airway Hyperreactivity In Asthma D. Mast Cell Activation Leads To The Release Of Various Mediators That Function In The Early & Late Phase Of The Illness E. The Mediators Include: 1. Leukotrienes C4, D4, E4 That Cause 1. Prolonged Bronchoconstriction 2. Increased Vascular Permeability 3. Increased Mucin Production 2. PGD2, E2, F2 Alpha That Cause: 1. Bronchoconstriction 2. Vascular Permeability 3. Histamine: That Causes: 1. Bronchospasm 2. Increases Vascular Permeability 3. Stimulates Mucus Secretion Contributing To Plugs 4. Plays A Role Primarily In The Immediate (Early) Response 5. Plays A Role In The Newly Synthesized Mediators In The Late Response

4. Platelet Activating Factor: Causes: 1. Aggregation of Platelets 2. Release Of Histamine From Platelets The Late Phase Is Dominated By The Additional Recruitment Of Leukocytes, Basophils, Neutrophils & Eosinophils The Mast Cell Mediators Responsible For Their Recruitment Are As Follows: A.Chemotactic Factors & Leukotriene B4: 1.Recruit & Activate Eosinophils & Neutrophils To The Airways Inflammation is Potentiated By Generated Prostaglandins While The Late Phase Bronchospasm Is Primarily Mediated By Leukotrienes G. Intrinsic Asthma: 1. Mechanisms Incriminated A. Viruses B. Inhaled Air Pollutants Eg: SO2 and NO2. 2. The Mechanism Bears Resemblance To Extrinsic Asthma. 3. The Basic Mechanism Of Susceptibility Remains Largely Unknown.

4. Clinical Course: A. Severe Dyspnea B. Tachypnea and Tachycardia C. Hypoxemia (V/Q Mismatch) D. Cough E. Wheezing F. Decreased FEV and VC G. P CO2 Is Normal Except In Severe Cases H. Bronchial Hyperreactivity I. Attacks Last 1 To Several Hours & Subside With Therapy Or Spontaneously. J. Attack Free Intervals But Respiratory Deficits Still Remains K. Paradoxical Abdominal & Diaphragmatic Movement On Inspiration L. Severe Asthma: Pulsus Paradoxus< 18 mm Hg Respiratory Rate> 30 Breaths/Minute Tachycardia With Heart Rate > 120 Beats/Min 5. Workup: A. FEV1: 200 ML After Inhaling A Short Bronchodilator Or A Short (2-3 Week) Course Of Oral Corticosteroids B. Questions: 1. Had Problems With Coughing, Wheezing, Shortness of Breath Or Chest Tightness ? 2. Awakened At Night From Sleep Due To Coughing Or Other Asthma Symptoms? 3. Awakened In The Morning With Asthma Symptoms? 4. Symptoms Did Not Improve Within 15 Minutes of Inhaling A Short Acting Beta Agonist? 5. Missed School Or Work Days? 6. Had Symptoms While Playing Or Working? 7. Highest & Lowest Peak Flow Rates Since Your Last Visit? 8. Has Peak Flow Dropped Since Your Last Visit?

6. Laboratory Tests: A. ABGs : 1. Mild Cases: Decreased PaO2 and PaCO2, Increased pH 2. Moderate Cases: Decreased PA O2, Normal PA CO2, Normal pH 3. Severe Cases: Marked Decrease PaO2, Increased PaCO2, Decreased pH B. CBC: Leukocytosis With A Left Shift C. Spirometry: 1. Initial Assessment 2. Every 1-2 Years D. Pulmonary Function Tests: 1. Severe Bronchospasm: A. FEV< 1 L B. Peak Expiratory Flow Rate < 80 L/Min 7. Imaging Studies: A. CXR: Thoracic Hyperinflation 1. Flattening Of Diaphragm 2. Increased Volume Over Retrosternal Space B. EKG: 1. Tachycardia 2. Non Specific ST-T Changes 3. Cor Pulmonale Pattern 4. RBBB 5. RAD 6. Counter Clockwise Rotation

8. Rx: A. Step 1 : Mild Intermittent Asthma: 1. Short Acting Inhaled Beta 2 Agonist: A. Albuterol (Ventolin) (Proventil) B. Terbutaline ( Brethaire) C. Bitolterol (Tornalate) D. Pirbuterol (Maxair) B. Step 2: Mild Persistent Asthma: 1. Low Dose Inhaled Corticosteroid A. Beclmethasone (Beclovent) (Vanceril) B. Flunisolide ( AeroBid) C. Triamcinolone (Azmaxort) 2. Cromolyn(Intal) or Nedocromil(Tilade) 3. Leukotriene Receptor Antagonist: A. Montelukast (Singulair) C. Step 3: Moderate Persistent Asthma: 1. Long Acting Oral Beta-2-Agonist 2. Long Term Systemic Corticosteroid A. Methylprednisolone B. Prednisolone C. Prednisone

D. Status Asthmaticus: 1. Oxygen A. 2-4 Liters of Oxygen B. Venti Mask 40% FiO2 C. Adjust According To ABGs 2. Epinephrine SQ 3. Nebulizer Solutions: A.Levalbuterol (R-Albuterol,Xopenex) B.Ipatropium (Atrovent) 4. Corticosteroids: A. Methylprednisolone (Solu-Medrol) 0.5-1 Mg/Kg/IV Loading Dose Then Q6H PRN 5. Taper Corticosteroids & Change To Oral Prednisone & Taper Prednisone 6. IV Antibiotics 7. Judicious IV Hydration 8. Possible Intubation & Mechanical Ventilation 9. IV Magnesium In Children With Low Magnesium Levels E. General Comments 1. Leukotriene Receptor Antagonists May Be Effective Aternative To Corticosteroids In Some Adults 2. Xolair: Omalizumab: Recombinant IgG Monoclonal Antibody Binds To IgE