ASTHMA – CURRENT MEDICAL
DIAGNOSIS AND TREATMENT
2015
ESSENTIALS OF DIAGNOSIS
(trang)
Episodic or chronic symptoms of
airflow obstruction.
▶▶ Reversibility of airflow
obstruction, either spontaneously or
following bronchodilator therapy.
▶▶ Symptoms frequently worse at
night or in the early morning.
▶▶ Prolonged expiration and diffuse
wheezes on physical examination.
▶▶ Limitation of airflow on
pulmonary function testing or positive
bronchoprovocation challenge.
General Considerations (hoàng)
Asthma is a common disease, affecting
approximately 7–10% of the population.
It is slightly more common in male
children (< 14 years old) and in female
adults. There is a genetic predisposition
to asthma. Prevalence, hospitalizations,
and fatal asthma have all increased in the
United States over the past 20 years. Each
year, approximately 500,000 hospital
admissions and 4500 deaths in the United
States are attributed to asthma.
Hospitalization rates have been highest
among blacks and children, and death
nguyenthaiduy.med@gmail.com Pulmonary Disorders Mark S. Chesnutt, MD Thomas J. Prendergast, MD
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rates are consistently highest among
blacks aged 15–24 years.
▶▶Definition & Pathogenesis (ngân)
Asthma is a chronic inflammatory
disorder of the airways. No single
histopathologic feature is pathognomonic
but common findings include
inflammatory cell infiltration with
eosinophils, neutrophils, and
lymphocytes (especially T lymphocytes);
goblet cell hyperplasia, sometimes with
plugging of small airways with thick
mucus; collagen deposition beneath the
basement membrane; hypertrophy of
bronchial smooth muscle; airway edema;
mast cell activation; and denudation of
airway epithelium. This airway
inflammation underlies disease chronicity
and contributes to airway hyper-
responsiveness and airflow limitation.
(hòa)The strongest identifiable
predisposing factor for the development
of asthma is atopy, but obesity is
increasingly recognized as a risk factor.
Exposure of sensitive patients to inhaled
allergens increases airway inflammation,
airway hyper-responsiveness, and
symptoms. Symptoms may develop
immediately (immediate asthmatic
response) or 4–6 hours after allergen
exposure (late asthmatic response).
Common allergens include house dust
mites (often found in pillows, mattresses,
upholstered furniture, carpets, and
drapes), cockroaches, cat dander, and
seasonal pollens. Substantially reducing
exposure reduces pathologic findings and
clinical symptoms.
 (Thanh LA) Nonspecific precipitants
of asthma include exercise, upper
respiratory tract infections, rhinosinusitis,
postnasal drip, aspiration,
gastroesophageal reflux, changes in the
weather, and stress. Exposure to products
of combustion (eg, tobacco smoke, crack
cocaine, methamphetamines, and other
agents) increases asthma symptoms and
the need for medications and reduces lung
function. Air pollution (increased air
levels of respirable particles, ozone, SO2,
and NO2) precipitate asthma symptoms
and increase emergency department visits
and hospitalizations. Selected individuals
may experience asthma symptoms after
exposure to aspirin, nonsteroidal anti-
inflammatory drugs, or tartrazine dyes.
Other medications may precipitate
asthma symptoms (see Table 9–23).
Châu - Occupational asthma is
triggered by various agents in the
workplace and may occur weeks to years
after initial exposure and sensitization.
Women may experience catamenial
asthma at predictable times during the
menstrual cycle. Exercise-induced
bronchoconstriction begins during
exercise or within 3 minutes after its end,
peaks within 10–15 minutes, and then
resolves by 60 minutes. This phenomenon
is thought to be a consequence of the
airways’ attempt to warm and humidify
an increased volume of expired air during
exercise. “Cardiac asthma” is wheezing
precipitated by decompensated heart
failure.
Clinical Findings
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Symptoms and signs vary widely between
patients as well as individually over time.
A. Symptoms and Signs (yến)
Asthma is characterized by episodic
wheezing, difficulty in breathing, chest
tightness, and cough. Excess sputum
production is common. The frequency of
asthma symptoms is highly variable.
Some patients have infrequent, brief
attacks of asthma while others may suffer
nearly continuous symptoms. Asthma
symptoms may occur spontaneously or be
precipitated or exacerbated by many
different triggers as
discussed above. Asthma symptoms are
frequently worse at night; circadian
variations in bronchomotor tone and
bronchial reactivity reach their nadir
between 3 am and 4 am, increasing
symptoms of bronchoconstriction.
Some physical examination findings
increase the probability of asthma. Nasal
mucosal swelling, secretion increases,
and polyps are often seen in patients with
allergic
asthma. Eczema, atopic dermatitis, or
other allergic skin disorders may also be
present. Wheezing or a prolonged
expiratory phase during normal breathing
correlates well with the presence of
airflow obstruction. (Wheezing during
forced expiration does not.) Chest
examination may be normal between
exacerbations in patients with mild
asthma. During severe asthma
exacerbations,
airflow may be too limited to produce
wheezing, and the only diagnostic clue on
auscultation may be globally reduced
breath sounds with prolonged expiration.
Hunched shoulders and use of accessory
muscles of respiration suggest an
increased work of breathing.
B. Laboratory Findings
Arterial blood gas measurements may be
normal during a mild asthma
exacerbation, but respiratory alkalosis
and an increase in the alveolar-arterial
oxygen difference (a–a–
Do2) are common. During severe
exacerbations, hypoxemia develops and
the Paco2 returns to normal. The
combination of an increased Paco2 and
respiratory acidosis may indicate
impending respiratory failure and the
need for mechanical ventilation.
C. Pulmonary Function Testing
Clinicians are able to identify airflow
obstruction on examination, but they have
limited ability to assess its severity or to
predict whether it is reversible. The
evaluation for asthma should therefore
include spirometry (forced expiratory
volume in 1 second [FEV1], forced vital
capacity [FVC], FEV1/FVC) before and
after the administration of a short-acting
bronchodilator. These measurements help
determine the presence and extent of
airflow obstruction and whether it is
immediately reversible. Airflow
obstruction is indicated by a reduced
FEV1/FVC ratio. Significant reversibility
of airflow obstruction is defined by an
increase of ≥ 12% and 200 mL in FEV1
or ≥ 15% and 200 mL in FVC after
inhaling a short-acting bronchodilator. A
positive bronchodilator response strongly
confirms the diagnosis of asthma but a
lack of responsiveness in the pulmonary
function laboratory does not preclude
success in a clinical trial of
bronchodilator therapy. Severe airflow
nguyenthaiduy.med@gmail.com Pulmonary Disorders Mark S. Chesnutt, MD Thomas J. Prendergast, MD
0985 53 53 36 – 0938 057 921 Current medical diagnosis and treatment
obstruction results in significant air
trapping, with an increase in residual
volume and consequent reduction in
FVC, resulting in a pattern that may
mimic a restrictive ventilatory defect.
Bronchial provocation testing with
inhaled histamine or methacholine may
be useful when asthma is suspected but
spirometry is nondiagnostic. Bronchial
provocation is not recommended if the
FEV1 is less than 65% of predicted. A
positive methacholine test is defined as a
≥ 20% fall in the FEV1 at exposure to a
concentration of 8 mg/mL or less. A
negative test has a negative predictive
value for asthma of 95%. Exercise
challenge testing may be useful in
patients with symptoms of exercise-
induced bronchospasm.
Peak expiratory flow (PEF) meters are
handheld devices designed as personal
monitoring tools. PEF monitoring can
establish peak flow variability, quantify
asthma severity, and provide both patient
and clinician with objective
measurements on which to base treatment
decisions. There are conflicting data
about whether measuring PEF improves
asthma outcomes, but doing so is
recommended to help confirm the
diagnosis of asthma, to improve asthma
control in patients with poor perception of
airflow obstruction, and to identify
environmental and occupational causes of
symptoms. Predicted values for PEF vary
with age, height, and gender but are
poorly standardized. Comparison with
reference values is less helpful than
comparison with the patient’s own
baseline. PEF shows diurnal variation. It
is generally lowest on first awakening and
highest several hours before the midpoint
of the waking day. PEF should be
measured in the morning before the ▶▶Differential Diagnosis
administration of a bronchodilator and in Patients who have atypical symptoms or
the afternoon after taking a poor response to therapy may have a
bronchodilator. A 20% change in PEF condition that mimics asthma. These
values from morning to afternoon or from disorders typically fall into one of four
day to day suggests inadequately categories: upper airway disorders, lower
controlled asthma. PEF values less than airway disorders, systemic vasculitides,
200 L/min indicate severe airflow and psychiatric disorders.
obstruction.
Upper airway disorders that mimic
D. Additional Testing asthma include vocal fold paralysis, vocal
Routine chest radiographs in patients with fold dysfunction syndrome, foreign body
asthma are usually normal or show only aspiration, laryngotracheal masses,
hyperinflation. Other findings may tracheal narrowing, tracheomalacia, and
include bronchial wall thickening and airway edema (eg, angioedema or
diminished peripheral lung vascular inhalation injury).
shadows. Chest imaging is indicated
when pneumonia, another disorder Lower airway disorders include
mimicking asthma, or a complication of nonasthmatic chronic obstructive
asthma such as pneumothorax is pulmonary disease (COPD) (chronic
suspected. bronchitis or emphysema),
bronchiectasis, allergic
Skin testing or in vitro testing to assess bronchopulmonary mycosis, cystic
sensitivity to environmental allergens can fibrosis, eosinophilic pneumonia, and
identify atopy in patients with persistent bronchiolitis obliterans.
asthma who may benefit from therapies
directed at their allergic diathesis. Systemic vasculitides with pulmonary
Evaluations for paranasal sinus disease or involvement may have an asthmatic
gastroesophageal reflux should be component, such as Churg-Strauss
considered in patients with pertinent, syndrome.
severe or refractory asthma symptoms.
Psychiatric causes include conversion
▶▶Complications disorders (“functional” asthma),
emotional laryngeal wheezing, vocal fold
Complications of asthma include
dysfunction, or episodic laryngeal
exhaustion, dehydration, airway
dyskinesis. Rarely, Münchausen
infection, and tussive syncope.
syndrome or malingering may explain a
Pneumothorax occurs but is rare. Acute
patient’s complaints.
hypercapnic and hypoxemic respiratory
failure occurs in severe disease.

nguyenthaiduy.med@gmail.com Pulmonary Disorders Mark S. Chesnutt, MD Thomas J. Prendergast, MD

0985 53 53 36 – 0938 057 921 Current medical diagnosis and treatment