Professional Documents
Culture Documents
Disease
Dr. Khalid Al-Mobaireek
King Khalid University
Hospital
Reversible = Asthma
Irreversible: Bronchiectasis because the membrane is destroyed
therefore the obstruction is permanent. They present with
productive cough with high amount of sputum that are more in the
morning with clubbing (indicating pus formation).
very important to know if its localized or systemic (diffuse)
Diffuse:
Aspiration
Muco-ciliary clearance:
primary ciliary dyskinesia (PCD) is an autosomal recessive disease
where the ciliary function (clearance of mucous) is impaired and
do not have good coordination, with normal mucous secretions.
They are at increased risk of bronchiectasis. 50% have
kartegners syndrome.
CF very thick and sticky secretions,, cilia and cough can not clear it
out its the worse than PCD
Immune deficiency because of recurrent infections.
Post-infectious: Pertussis, TB, adenovirus..
Swallowing difficulties: Neuromuscular disease, GERD, and
congenital defects e.g. palate diseases or congenital defect in
the cartilage, T-E fistula. These can cause aspiration leading to
bilateral bronchiectasis.
Congenital bronchiatasis born with abnormal cartilage.
Bronchiectasis:
CT is the diagnostic method of choice, characteristic
finding is signet ring appearance. Normally each
bronchus is accompanied by a vessel and shouldnt
exceed the vessel diameter. In bronchiectasis, the
diameter of the bronchus is larger than that of the
vessel. Tram line appearance (two airways running in
parallel lines) in cross section.
Definition of Asthma
Bronchospasm
Edema, Mucus
Hyper-responsiveness
INFLAMMATION!!!
(hallmark)
NORMAL
ASTHMA
AIR TRAPPING
INSP
EXP
Air trapping leads to enlargement of the alveoli, if these ruptured the air
will leak leading to pneumothorax and air under the skin (sub-cutaneous
emphysema).
In inspiration the airway pressure is negative and the outside pressure is
positive therefore the airway expands and dilate. The opposite happens
during expiration and the airways get narrowed.
If the obstruction was intra-thoracic, the obstruction will be more evident
during expiration (extra-luminal pressure higher than intra-luminal
pressure during expiration), because airway will be narrowed and the
pressure is positive inside the airway. While obstruction outside the
thoracic cavity will be more evident during inspiration (extra-luminal
pressure higher than intra-luminal pressure during inspiration e.g. vocal
cord paralysis). If the manifestations are present equally in both phases
think of sub-glottic stenosis.
There will be V/Q mismatch because the blood coming to the lung is not
being oxygenized due to obstruction.
Burden of Asthma
Asthma Prevalence
Asthma Prevalence
Qaseem 13%
Khobar 6%
Riyadh 10 %
Jeddah 13%
Abha 17%
Environmental Factors
Indoor allergens are biological
and not dose dependent.
Outdoor allergens
Occupational sensitizers (low
dose stimulate asthmatics
whereas high dose will stimulate
asthmatics and non-asthmatics
Tobacco smoke
Air Pollution
Respiratory Infections
Diet
POLLENS
Management of Chronic
Asthma
Depends on
Exacerbations and attacks.
Exacerbations requiring steroids.
Night symptoms: how many times you
wake up from sleep due to symptoms (if
more than twice a month, it is
uncontrolled).
Symptoms: cough, etc.
Use of bronchodilators.
History
Symptoms (cough, wheeze, SOB)
Wheeze: not every patient with a wheeze has asthma. A 2 or 3 months
child who has similar asthma symptoms you need to check for
structural abnormality compressing the airways as cystic disease.
Foreign body is suspected when the child presents with sudden acute
cough and wheeze worse in expiration, it needs index of suspicion,
when you do CXR the expiratory film will show failure of emptying in
the obstructed side (one is larger than the other but you wont see
the obstruction itself) the bronchoscopy is diagnostic and
therapeutic.
Onset, duration, frequency and severity
Activity and nocturnal exacerbation
Previous therapy
Triggers
Other atopies
Family history
Environmental history, SMOKING
Systemic review (widen your DDx)
Physical Examination
Most important is growth parameter asthma
usually doesnt impair growth if it did then think
of another diagnosis as cystic fibrosis or
immunological problem (immunodeficiency) .
ENT part of respiratory problem because it is
lined by ciliary epithelium examine the ear if
there was a ciliary problem the ear will be
effected.
Features of atopy.
Chest findings
PEF
Check for clubbing its present its unlikely
asthma, think of other suppurative diseases.
The diagnosis of asthma should depend on history
and examination.
Investigations
Dont usually need investigations, and is
mainly history and physical to role out
other systemic diseases.
Pulmonary Function Test
Chest X ray: not done except in the
suspicion of another disease or severe
asthmatics.
Allergy testing in some
PFT is only complementary and is not done
to children less than six years.
Skin Testing
Differential Diagnosis
Infections
Congenital Heart Disease
Foreign body are mostly food because they cant
grind due to lack of molars and are not radioopaque by CXR, but you see its effect during
expiration CXR will show and emptying of one lung
only. However, foreign body in the esophagus is not
food and tends to be radio-opaque.
GERD
Bronchopulmonary dysplasia
Structural anomalies (any child with severe asthma
at the age of 3-4 months think of something else
like structural problems because asthma doesnt
start severe early in its course.
Levels of Asthma
Control
Characteristic
Daytime symptoms
Limitations of activities
Nocturnal symptoms /
awakening
Need for rescue /
reliever treatment
Controlled
(All of the following)
Exacerbation
(requirement of systemic
steroids)
More than
twice / week
Any
Normal
None
Uncontrolled
Any
None
Lung function
(PEF or FEV1)
Partly controlled
(Any present in any week)
3 or more features
of partly
controlled asthma
present in any
week
More than
twice / week
< 80% predicted or personal
best (if known) on any day
1 in any week
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
partly controlled
consider stepping up to
gain control
INCREASE
controlled
uncontrolled
exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
Treatment objectives
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as
possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
Pharmacological therapy
Relievers
Controllers
Feel better
Fear of side effects
Dont notice any benefit
Fear of addiction
Fear of being seen as an
invalid
Too complex regimen
Cant afford medication
Forget treatment
Misunderstand regimen / lack
information
Unable to use their inhaler
Run out of medication
Cromolyn Sodium
Non-steroidal antiinflammatory
Weak action on Early and
late phases
Slow onset of action
If no response in 6 weeks
change to ICS
Side effects: Irritation
Inhaled Corticosteroids
Effective in most cases
Safe especially at low doses
The anti-inflammatory of choice in
asthma ( drug of choice coz they
are broad spectrum so they target
many cells and mediators)
Laitinen LA
Inhaled Steroids
Side Effects
Assessment: History
Symptoms
Previous attacks
Prior therapy
Triggers
Physical examination:
Signs of airway obstruction:
Fragmented speech
Unable to tolerate recumbent position prefer
to sit in order to use accessory muscles.
Expiration > 4 seconds
Tachycardia, tachypnea and hypotension
Use of accessory muscles
Pulsus paradoxus > 10 mmHg
Silent hyper=inflated chest
Air leak
Wheezing is a poor sign of obstruction.
Physical examination:
Signs of tissue hypoxia:
Cyanosis
Cardiac arrhythmia and hypotension
(due to increase in thoracic pressure
causing a decrease in venous return
and consequently hypotension).
Restlessness, confusion, drowsiness
and obtundation
Physical examination:
Signs of Respiratory muscles
fatigue:
Increase respiratory rate
Respiratory alterans (alteration
between thoracic and abdominal
muscles during inspiration)
Abdominal paradox (inward movement
of the abdomen during inspiration)
Investigations:
Investigations do not help in acute
asthma, and blood gases are rarely done
except in severe cases
Peak expiratory flow rate
ONLY IN FEW CASES
Pulse oximetry
ABG ( its very painful)
Only done in
CXR
severe cases
CBC will show leukocytosis because its
an inflammation.
Oxygen
Hypoxemia is common
It worsens airway hyperreactivity
Monitor saturation
Inhaled 2 agonist
Every 20 minutes in the
first hour ( 6-8 puffs )
Assess after each nebulizer
-better than nebulizer
because its more
localized, less side
effects and faster onset
of action.
Steroids
Do not wait for inhaled B2 agonist
response, start immediately on
suspicion with oral steroids because it
takes 3-4 hours to work.
If not responding to the agonist
If severe in the beginning
If on PO prednisolone or high dose
inhaled steroids.
Previous severe attacks
Ipratropium Bromide
POOR
Admit
Good
Discharge
Partial
Keep for 1-2 hours
Admit
Discharge
Follow up
Give inhaled 2 agonist
Steroids
When to come back?
Turbohaler came in the last osce.