ASTHMA RULE IN Clinicalfeatures:Associated with exertional dyspnea, chest pain, and non- productive cough.

Smoking can serve as a respiratory irritant that destroys cilia and causes excessive mucus production of cells in the airways (bronchus), thereby causing difficulty of breathing. RULE OUT Clinical features: Main symptom includes wheezing triggered by breathing in allergy-causing substances
(allergen). Radiography: Advanced asthma is characterized by varying stages of hyperinflation which are reflected

by a flattening of the hemidiaphragm and increased retrosternal airspace.

CENTRIACINAR EMPHYSEMA RULE IN Clinical features:Occurs predominantly in heavy smokersand involves the upper half of the lungs, often in association with chronic bronchitis.Commonly associated with exertional dyspnea resulting to shotness of breath (most common symptom), non-producative cough, and weight loss. RULE OUT
Radiography: Findings of hyperinflated lungs, flattened diaphragms, diminshed vascular markings

suggest emphysema.Also, hyperlucent lung fields and multiple blebs are present.

DISCUSSION Asthma is caused by inflammation in the airways that can be triggered by breathing in allergycausing substances called allergens. The classic asthmatic attack lasts up to several hours and is followed by prolong coughing. The presence of wheezing, considered as the main symptom of emphysema, was not manifested in the case. Radiographic studies suggest varying stages of hyperinflation which are reflected by a flattening of the hemidiaphragm and increased retrosternal airspace. The latter chest x-ray result was not evident in the case. The clinical diagnosis is aided by the demonstration of an elevated eosinophil count in the peripheral blood and the finding of eosinphils, Curschmann spirals, and Charcot- Leyden crystals in the sputum. Occasionally the disease disappears spontaneously. In the more severe forms, the progressive hyperinflation may eventually produce emphysema. In some cases, cor pulmonale and heart failure eventually develop.

Emphysema, a subtype of COPD, is a progressive disease that usually manifests itself in patients after 50 years of age. In centriacinar (centrilobular emphysema), the central or proximal parts of the acini, formed by repiratory bronchioles, are affected, whereas distal alveoli are spared. The lesions are more common and usually more severe in the upper lobes, particularly in the apical segments.This type occurs predominantly in heavy smokers, often in association with chronic bronchitis. It was postulated that the impaction of smoke particles in the small bronchi and bronchioles, with the resultant influx of neutrophils and macrophages and increased elastase and decreased 1-AT activity, causes the centriacinar seen in smokers. The clinical manifestations of emphysema do not appear until at least one third of the functioning pulmonary parenchyma is damaged. Dyspnea is usually the first symptom; it begins insidiously but is steadily progressive. In some patients, cough or wheezing is the chief complaint, easily confused with asthma. Cough and expectoration are extremely variable and depend on the extent of the associated bronchitis. Weight loss is common and can be so severe as to suggest a hidden malignant tumor. Classically, the patient is barrel-chested and dyspneic, with obviously prolonged expiration, sits forward in a hunched-over position, and breathes through pursed lips. Expiratory airflow limitation, best measured through spirometry, is the key to diagnosis. Radiography findings of hyperinflated lungs, flattened diaphragms, diminshed vascular markings suggest emphysema, hyperlucent lung fields and multiple blebs are indicative of emphysema. The latter chest x-ray findings were not seen in the case.