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Peribronchial edema
Flow-volume loops
Normal Spirometry
Ventilatory dysfunctions
1. Obstructive: FEV1 below 80% of predicted value,
FEV1/FVC ratio (Tiffneau index) below 70%.
Degrees of severity (after FEV1 values):
Mild: FEV1 > 80%
Moderate: FEV1 = 60-80%
Severe: FEV1 < 60%
1. Restrictive: FVC below 80% predicted value.
FEV1 is less decreased, and the FEV1/FVC ratio
is normal or increased
2. Mixt: FVC, FEV1 and the FEV1/FVC ratio are
decreased
Flow-volume loops in
ventilatory dysfunctions
Obstructive pulmonary diseases
Bronchial asthma
COPD
Bronchiolitis obliterans
Child viral induced asthma (post viral recurrent
wheezing)
Pulmonary emphysema
Bronchiectasis
Interrelation of the main clinical
entities
Emphysema Chronic
Bronchitis
Airflow
limitation Asthma
Bronchial asthma
Chronic airways inflammatory disease, accompanied
by hyperactive airways and recurrent episodes of
wheezing, dyspnoea, cough, and thoracic constriction,
associated usually with diffuse, variable airways
obstruction, reversible spontaneously or with
treatment.
Specific bronchial inflammation pattern Th2
lymphocytes (cytokine IL-4,Il-5,Il-13), activated
eosinophiles
Heterogeneous syndrome group
Affectes all ages, may be severe and is sometimes fatal.
The most frequent chronic disease and the most
frequent childs medical emergency
approx.10% of the nonviolent deaths in children and
young adults
Etiopathogenesis
Alergic/nonalergic
50% - sensitisation to aeroallergens (dust mites,
molds, pollens, pets, cockroaches)
- food allergens( flour, metabisulfites)
Irritant factors : vapors, gases, smoke
Outdoor pollution (ozone, sulfur dioxide)
Viral infections : rhinovirus, human respiratory
syncytial virus, influenza virus
Triggers:
1.Exercise
2.Associated diseases: GERD, sinusitis, nasal
polyposis, rhinitis
3.Concomitant medication: beta blockers si NSAID
Signs and symptoms
1. History: wheezing episodes, dyspnea, cough, chest
tightness
2. Exacerbation: nocturnal, exertion, aeroallergen
contact or irritant factors
3. Other allergic diseases association: rhinitis, atopic
dermatitis
4. Other familial cases of asthma or other allergic
diseases
5. Signs: pulmonary hyperinflation, wheezing or
prolonged expiration, sibilant rales and/or ronchus
6. Associated signs: nasal or cutaneous
Differential diagnosis in
adults
COPD
Heart failure (not all elders with dyspnea have
ischemic heart disease!)
Pulmonary embolism
Pulmonary neoplasm
Vocal cords dysfunction
Tracheal and bronchial carcinoid tumors
Foreign body aspiration
Interstitial lung disease
Differential diagnosis in
children
Foreign body aspiration
Cystic fibrosis
Tracheal and bronchial
Thoracic vascular malformations
Gastroesophageal reflux disease
Viral induced asthma (postviral wheezing)
Rhino-sino-bronchial syndrome
Classification (1)
Etiological
allergic (extrinsec)
Non-allergic (intrinsec)
(different triggers, similar inflammation
pattern)
SeverityGINA guide 2002
intermittent
persistent : mild, moderate or severe
Clinical types
acute (status astmaticus)
chronic, with fixed obstruction
Classification (2)
Particular clinical types : unstable, difficult
to control,
corticodependent/corticoresistant
Time of onset- early onset asthma
- late onset asthma (>50 years)
Degree of control (Gina 2006)
- uncontrolled
-partially controlled
-controlled
Particular clinical
patterns
Corticorezistant
Difficult to control
Brittle asthma
Cough variant
Occupational asthma
NSAID-intolerant asthma (Vidal
syndrome)
Churg Strauss vasculitis
Allergic bronchopulmonary aspergillosis
Classification of asthma severity
(Gina 2002)
Signs and symptoms
Daytime Nocturnal
symptoms FEV1 /PEF
symptoms
STEP 4 - continuous
60% predicted
persistent - restriction of frequent
severe variability > 30%
physical activity
STEP 3 - every day 60 - 80% predicted
persistent > 1 time / week variability > 30%
- crisis limits
moderate
activity
STEP 2 > 2 times / month 80% predicted
> 1 time / week.
persistent but < 1 / day variability 20-30%
mild
< 1 time / week.
STEP 1 asymptomatic and
2 times / month 80% predicted
intermittent normal FEV1 (PEF) variability < 20%
between crisis
Asthma classification
level of control (Gina 2006)
Controlled Partially controlled Uncontrolled
Anticholinergics Antileukotrienes
Ipratropium bromide
montelukast
Systemic Long acting beta 2
corticosteroids agonists
Methylxanthines Combined therapy
ICS+LABA
Dosages
recommendation
ICS side effects
Local side effect:
oral candidiasis occur in 10%. Increase risk with poor
technique, concomitant use of antibiotics and reduced by
use of spacer and rinsing mouth.
Dysphonia (30%) - in high risk professions
Osteoporosis
Bone densitometry carried out in adult asthmatic on low
and medium doses of ICS showed no signs of osteoporosis
No growth retardation in children if daily dose > 200mcg
Posterior subcapsular cataract - risk slightly increased
with high doses of ICS and use of pMDI
Risk of lung infection -no relevant risk of TB reactivation
in usual doses
Beta 2 agonists side
effects
Mild tremor (effect on skeletal muscle receptors)
Tachycardia( effect on cardiovascular receptors)
Hypokalemia ( increase K+ entry to skeletal muscle)
No evidence of increased or induced serious
arrhythmias if used less than one canister per
month and associated with controller therapy
Risk of death significantly increased (10 fold) with
two or more canisters /month. (uncontrolled
asthma)
Asthma management GINA
2006
Step 2 Sep 3 Step 4 Step 5
Choose one Choose one Add one or more Add one or more
Severe exacerbation
Oxygenotherapy
alfa-1-antitripsine deficiency
Probable
Outdoor and indoor pollution
Social and economical factors
Possible
Low birth weight, family history
Respiratory diseases in childhood
Dyspnea
Progressive
Usually aggravated by exercise
Persistent
Described as an increased effort to breathe
Chronic cough
It can be intermittent and dry
Chronic expectoration
Any chronic expectoration points out COPD
Clinical examination
Rarely diagnostic, especially in mild or moderate
COPD
Inspection
Central cyanosis
Thoracic cage changes, such as barell chest
Palpation and percussion
Usually not useful in COPD diagnosis
Auscultation
Decreased breath sounds (this is not characteristic)
+/-Wheezing
Spirometry
Spirometry represents a reliable method for the
detection of obstruction in the airways and should
be performed to all patients suspected of COPD
Airflow decrease evaluation is very important to
confirm COPD
Gold standard to diagnose and monitor COPD
progression
The absence of significant reversibility must be
confirmed in order to exclude asthma
Severity degree classification of
COPD
Stage Predicted FEV1 Description
I Mild >80% Chronic cough and sputum production
FEV1/FVC <70% may be present
Clinical signs:
Fever > 38,5C
Peripheral edema
Confusion
Spirometry:
PEF< 100L/min
dermatomyositis)
Drugs: amiodarone, golden salts, Busulfan
Hypersensitivity pneumonia
Acute bronchiolitis in
children
Usually after viral infections- respiratory syncytial virus,
rhinovirus, parainfluenza virus, adhenovirus, coronavirus.
More frequent in children under 2 years during december-
february period
Risk factors:
male gender
age between 3-6 month
lack of breast feeding
maternal smoking
collectivities