1. Noninvasive Tests for Asthma Diagnosis & Monitoring BY DR. TAKI ALMOSAWI Mafraq Hospital

2. LEARNING OBJECTIVES 1) Describe the various non-invasive tests used to diagnose and monitor patients with asthma 2) Discuss the recent advances in the technology of monitoring asthmatic patients 3) Define the difference in the laboratory findings between patients with asthma and with other pulmonary obstructive diseases under different circumstances.

4. Chronic Diseases Assessment of severity Diagnostic tool Chronic Disease Numerical judgment Sphygmomanometer Hypertension 18% Numerical judgment Blood Sugar hemoglobin A1c Diabetes 6% ????? Variable Spirometer, Peak flow meter Asthma 6-10%

7. Mechanism of allergic inflammation

8. Mechanism of allergic inflammation

16. Methacholine Challenge test result of normal and asthmatic patients

28. Precautions during NO measurement Pulmonary hypertension Bronchiectasis ,Lung cancer Cystic fibrosis Allergic rhinitis ,Atopy ,active COPD HIV infection Upper respiratory tract infection Primary ciliary dyskinesia Asthma Mouth wash Nitrite- enriched food Alcohol, Caffaine intake Ozone inhalation Smoking, Spirometery Exposure to allergens Decreased Nitric Oxide level Increased Nitric Oxide level Diseases Diseases

30. NO Values in diseases Exhaled nitric coxide (ppb) Before ICS After ICS In patients with (COPD), exhaled NO has been reported to be high in exacerbations compared with stable patients. The increase is derived from alveolar NO Asthmatics

31. Modification

36. Standard Protocol for Sputum Induction 8. Stop the procedure after 20 min or if lung function has dropped by 20%. 7. Continue induction for 3 x 5 min . 6. Check FEV1 or, peak expiratory flow every 5 min. 5. Ask the patient to expectorate whenever he feels the need or every 5-min. 4. Begin induction with either 3% or 4.5% saline, and progress to 5% saline, 3. Place a nose clip on the patient's nose. 2. Measure lung function before and 10 min after b2-antagonist is given 1. Pre treat the patient with 200 ug broncho-dilator, b2-antagonist.

37. Change of Sputum eosinophil after ICS therapy Before ICS After ICS Sputum eosinophil count (%) Asthmatic = 30

39. eNO & Sputum eosiophils in diseases

40. Sensitivity and specificity of the diagnostic tests Sensitivity, specificity, and positive and negative predictive values for each of the diagnostic tests for asthma * Some Patient did not complete procedure 88 86 27 * 3 4 * 34 Sputum eosino. > 3% 81 89 25 * 6 3 * 36 eNO > 20 ppb 100 17 32 0 34 7 FEV 1 improvement with steroid > 15% 100 28 32 0 30 11 FEV 1 < 80% predicted 100 0 31 * 0 41 0 Peak flow variation > 20% % % No Yes No Yes Diagnostic test Specificity Sensitivity Non asthma ( n = 32 ) Asthma ( n = 41 ) Disease

41. Pulmonary Function Tests & ENO PFT is reduced in COPD (eNO) is normal in stable COPD Sensitivities for PFT is (0–47%) Sensitivities with FE NO is (88%) and sputum eosinophils (86%). PFT is NOT useful in monitoring the effectiveness or the compliance of (ICS) therapy in the asthmatic patient useful in monitoring the effectiveness & the compliance of (ICS) therapy PFT is not so sensitive to treatment with (ICS) very sensitive to treatment with (ICS) .Eno Start to decrease, 6 hrs after (ICS) therapy PFT cannot be estimated adequately in mild asthma and in preschool children, it can be estimated in mild asthma and in preschool children Showing normal level before clinical symptoms of asthma & asymptomatic asthmatics Showing increased level in asthmatics even before clinical symptoms & asymptomatic asthmatics Pulmonary Function tests eNO conc. & Sputum eosinophilia