Asthma 2

1. Bronchial Asthma
Dr. Rafea Rasheed
PGY1

2. Objectives
I. Diagnosis
II.Severity of Asthma
III.Complication of Asthma

3. Diagnosis
 History
 Physical Examination
 Investigation

4. History
• Respiratory symptoms : occure with triggers
(eg, allergen, exercise, viral infection) and
resolve with trigger avoidance.
Three classic symptoms
Wheeze (high-pitched whistling sound, usually
upon exhalation)
Cough (often worse at night)
Shortness of breath / difficulty breathing

5. • Precipitating and/or aggravating factors
 Viral respiratory infections
 Environmental allergens, indoor (e.g., mold, house-dust,mite,
animal dander ) and outdoor (e.g., pollen)
 Characteristics of home including age, location, cooling and
heating system, wood-burning stove, humidifier, carpeting
over concrete, presence of molds ,presense of pets with fur or
hair.
 Characteristics of rooms :(e.g., bedroom and living room with
attention to bedding, floor covering, stuffed furniture)
 Smoking (patient and others in home or daycare)
 Exercise
 occupational chemicals and dust..
 Environmental change (e.g., moving to new home; going on
Vacation; workplace.

6.  Irritants (e.g., tobacco smoke, strong odors, air
pollutants.
 Emotions (e.g., fear, anger, frustration, hard crying or
laughing) Stress (e.g., fear, anger, frustration)
 Drugs (e.g., aspirin; and other nonsteroidal anti-
inflammatory drugs, beta-blockers including eye drops,
others)
 Food, food additives, and preservatives (e.g., sulfites)
 Changes in weather, exposure to cold air
 Endocrine factors (e.g., menses, pregnancy, thyroid
disease)
 comorbid conditions (e.g. sinusitis, rhinitis,
gastroesophageal reflux disease (GERD )

7. Family history
 History of asthma, allergy, sinusitis, rhinitis,
eczema, or nasal polyps in close relatives
Social history
Daycare, workplace, and school characteristics
that may interfere with adherence
Social factors that interfere with adherence,
such as substance abuse
Social support/social networks Level of
education completed Employment

8. Impact of asthma on patient and family
 Episodes of unscheduled care (emergency department
(ED), urgent care, hospitalization)
 Number of days missed from school/work
 Limitation of activity, especially sports and strenuous
work.
 History of nocturnal awakening
 Effect on growth, development, behavior, school or
work performance, and lifestyle.
 Impact on family routines, activities.
 Economic impact.

9. Assessment of patient’s and family’s
perceptions of disease
 Family knowledge of asthma and belief in the chronicity
of asthma and in the efficacy of treatment
 Patient’s perception and beliefs regarding use and long-
term effects of medications
 Ability of patient and parents, spouse, or partner to
cope with disease
 Level of family support and patient’s and parents’,
spouse’s, or partner’s capacity to recognize severity of an
exacerbation
 Economic resources
 Sociocultural beliefs

10. Physical Examination
The examination focuses on:
 upper respiratory tract (increased nasal secretion, mucosal
swelling, and/or nasal polyp)
 Sign of atopy/allergic rhinitis: conjunctival congestion,
occular shiners, transeverse crease on nose due to
constant rubbing
 chest(sounds of wheezing during normal breathing or
prolonged phase of forced exhalation, hyperexpansion of
the thorax, use of accessory muscles, appearance of
hunched shoulders, chest deformity)
 skin (atopic dermatitis, eczema).
 Manfistaion of an acute episode of Asthma can be mild,
moderately sever, sever.

12. Mild episodes
RR is increased
accessory muscles of respiration are not used
HR is <100 bpm
pulsus paradoxus (an exaggerated fall in
systolic blood pressure during inspiration) is
not present.
Auscultation of the chest reveals moderate
wheezing, which is often end expiratory.
Spo2> 95%.

13. Moderately severe episodes
 RR is increased.
 accessory muscles of respiration are used.
 In children, also look for supraclavicular and intercostal
retractions and nasal flaring, as well as abdominal breathing.
 HR is 100-120 bpm.
 Loud expiratory wheezing can be heard.
 pulsus paradoxus may be present (10-20 mm Hg).
 SPo2 is 91-95%.
 breathless while talking
 Infants feeding difficulties and a softer, shorter cry.
 severe cases, the patient assumes a sitting position.

14. Severe episodes
 breathless during rest
 sit upright
 talk in words rather than sentences
 agitated.
 RR > 30 p/m
 Accessory muscles are usually used
 suprasternal retractions are commonly present
 HR is >120 bpm
 Loud biphasic (expiratory and inspiratory) wheezing can
be heard, and pulsus paradoxus is often present (20-40
mm Hg)
 SPO2 < 91%.
 tripod position

15. Objective measures:
• Lung Function Test: Spirometry
• Lung function is expressed as FEV1/FVC
• Person with normal lung funtion can exhale
75% of the total capacity in 1 second.
• Any value <75% indicates decreased lung
function

16. Spirometry

17.  maximal inhalation is followed by a rapid and forceful
complete exhalation.
 includes measurement of forced expiratory volume in
one second (FEV1) and forced vital capacity (FVC) .
 baseline spirometry obtained in all patients with a
suspected diagnosis of asthma.
 The results of spirometry can be used to determine the
following:
– Determine whether baseline airflow limitation
(obstruction) is present (reduced FEV1/FVC ratio)
– Assess the reversibility of the obstructive abnormality if
the testing is repeated after administration of a
bronchodilator
– Characterize the severity of airflow limitation

18. Serial measurements of
lung function over time

19. Bronchodilator response
 Should be done in all adult and adolescent patients with
airflow limitation on their baseline spirometry.
 Acute reversibility of airflow obstruction is tested by
administering 2 to 4 puffs of a quick-acting bronchodilator
(eg, albuterol), preferably with a chamber device, and
repeating spirometry 10 to 15 minutes later.
 An increase in FEV1 of 12 %or more, can be attributed to
bronchodilator responsiveness with 95 percent certainty.
 The presence of a bronchodilator response, in isolation, is
NOT sufficient to make the diagnosis of asthma.

20. Peak expiratory flow

21.  PEF is measured during a brief, forceful
exhalation, using a simple and
inexpensive device (approximately $35).
Usually use to monitor patients with a
known diagnosis of asthma or to assess
the role of a particular occupational
exposure or trigger, rather than as a tool
for the primary diagnosis of asthma.

22. Technique
can be performed sitting or standing.
Proper technique involves taking a maximally
large breath in, putting the peak flow meter
quickly to the mouth, sealing the lips around
the mouthpiece, and blowing out as hard and
fast as possible into the meter.
 between 1-2 sec
three times and the highest of the three
measurements is recorded.

23. Exhaled nitric oxide
The measurement of nitric oxide in a patient's
exhaled breath (eNO) but is not widely available.
The test is based on the observation that the
eosinophilic airway inflammation associated with
asthma leads to up-regulation of nitric oxide
synthase in the respiratory mucosa, which in turn
generates increased amounts of nitric oxide in
the exhaled breath.
 Further studies are required to assess the validity of exhaled nitric oxide as a diagnostic test for asthma,
particularly among persons with other, potentially confounding respiratory diseases.

25. Bronchial challenge test (AHR)
 Demonstrates airway hyper-reactivity due to
bronchoconstriction -↑ concentrations of
histamine/ methacholine causes a ↓ in FEV1 if
asthmatic.
Note: Has a high –ve predictive value but +ve results
may be seen in other conditions e.g COPD, CF.
Exercise test
For patients whose symptoms are related to
exercise
If asthmatic exercise should cause ↓ PEF/ FEV1.
Diagnostic: FEV1 ≥ 15% ↓ after 6 mins of exercise.

26. Radiological
Generally unhelpful but may show alternative
diagnosis.
Acute asthma signs: Hyperinflation and ± lobar
collapse.
Measurement of allergic status
 Skin-prick tests: Measurement of IgE to confirm
sensitivity to specific agent.
 Atopic asthma: ↑ sputum or peripheral blood
eosinophil count and ↑ serum total IgE.
Pulse oximetry
 May show ↓ SaO2 level.

27. Limitations with Lung Function Tests
Normal values may differ between patients:
Gender, age, sex, height
 All (FEV,FEV1,FVC,PEFR) cannot detect early
lung function deterioration due to
bronchspasm and mucus plugging in the small
airways.

28. Confirming diagnosis of Asthma
By responding to bronchodilators
PEFR measured before and after
administration of bronchodilator
Improvement of the PEFR by >= 15% could be
confirmation of diagnosis
No improvement doesn't not exclude Asthma
The test is repeated at several times pre-and-
post bronchodilator to confirm or exclude

29. Diurnal variation in PEF of more than 20%
suggests a diagnosis of Asthma
The presence of allergies or allergic rhinitis in
symptomatic patients also suggest diagnosis
of Asthma
Confirming diagnosis of Asthma

31. Complications of asthma include:
Atelectasis
Bronchitis
Pneumothorax
Pneumonia
Respiratory failure

32. Impact of Quality of Life
The presence of asthma accounted for 3.18% of
people reporting poor life satisfaction
12% of people reporting poor health status
 5.90% (reporting high psychological distress,
3.58% reporting any reduced activity days.
The proportions of people with these adverse
health states attributable to asthma were higher
than the proportions attributable to diabetes but
lower than the proportions attributable to
arthritis.

33. Thank you