BRONCHIAL ASTHMA

Episodic and chronic inflammatory disorder of airways

Characterized by chronic symptoms of air flow obstruction
Reversibility occurs either spontaneously or with bronchodilator therapy
Symptoms worse at nite (Circadian bronchoconstriction )
 PATHOLOGY

Disease is characterized by
Inflamatory cells infiltertion (eosinophils,neutrophils,lymphocytes )
Goblet cell hyperplasia
Plugging of small airways
Collagen deposition
Hypertrophy of smooth muscles
Mucosal edema
Epithelial cells denudation
CAUSES AND PRECIPITATING FACTORS
Atopy /allergy
Obesity
Repeated upper tract infections (rhinosinusitis,post nasal drip)
GERD
Stress
Cold weather exposure
Air pollution
Combustion products (tobacco,crack coaine,dyes)
Occupation
Exercise
Catamenial
 SYMPTOMS AND SIGNS

Episodic wheezing
Chest tightness
cough
Excessive sputum
Worsoning at night (circadian variation on bronchomotar tone and
bronchial reactivity )3 to 4 AM
Wheeze
 LABORATORY INVESTIGATIONS
Arterial blood gases normal during attack
Or respiratory Alkalosis can develop
If PCO2 is increased with decreased O2 …….resp failiure
(Needs mechanical ventilation)

Pulmonary function tests

FEVI Forced expiratory volume in I sec
FEV1/FVC checked before and after bronchodilator therapy
If 12% increase occurs after bronchodilator therapy this confirms
bronchial asthma .
Peak expiratory flow meter
Home measuring device
In asthma peak expiratory flow is lowest on first awakening and
highest in the midpoint of waking day
20% change in PEF morning to afternoon

X Ray chest PA view

Evidence of infection
Bronchialwall thickening
Reduced pulmonary markings
X RAY Paranasal sinuses
evidence of sinusitis (loss of haze )

Skin testing
Serum IgE LEVELS
Complete blood count to see for eosinophils count
DIFFERENTIAL DIAGNOSIS
Upper resp tract
Vocal cord dysfunction
Vocal cord paralysis
Foreign body impaction
Lower resp tract
COPD
Bronchiectasis
Cystic fibrosis
Eosinophilc grnulomatosis with poly angitis
Psychiatric (Munchausens Syndrome)
COMPLICATIONS
During acute attack exhaustion
dehydration
Tussive syncope
Pneumothorax
Hypercapnia
Hypoxemia
Respiratory failiure
ABPA
 TREATMENT
Bronchodilators short acting …salbutamol ,terbutaline
long acting ……salmeterol ,formoterol

Steroids anti-inflammatory agents Inhaled and systemic

Mediator inhibitors (mast cell mediator release and eosin recruitment )

cromolyn sodium and nedocromil
Anticholinergic drugs decrease mucus tiotropium, ipratropium
Leukotriene modifiers reduce leukotriene production….Montelukast and
Zafirlukast

Phosphodiesterase inhibitors (anti inflammatory ,immune

modulation,diaphragmatic contractility ) theophylline

Omalizumab /rezlizumab recombinant antibody that binds IgE

Immune therapy to specific allergen

Vaccination H1N1 yearly
Pneumococcus 5 yearly
Antibiotics for sinusitis and pneumonia
Clinical features of Acute severe Asthma
Breathlessness at rest interferes conversation
Talks in words
Agitated
Resp rate >30/min
Sits upright
Uses accessory muscles
Wheeze throughout inspiration and expiration
Pulse >120/min
Pulses paradoxus >25mmhg
PEFR <40% of patients predicted,PaO2<60 ,PCO2 >40,SaO2 <90%
Treatment during severe attack
Oxygen
Nebulized salbutamol (b2 agonist)
Hydrocortisone intravenous
Antibiotics if required
Fluids
Get X RAY chest done to rule out pneumothorax
If worsening of the features repeat the above steps
Add magnesium sulphate
May require intubation and artificial ventilation