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Clinical Manifestations of Asthma

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Clinical Manifestations of Asthma The classic symptoms of asthma are wheezing , cough & shortness of breath( with chest tightness ). During periods of relatively ... – PowerPoint PPT presentation

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Title: Clinical Manifestations of Asthma


1
Clinical Manifestations of Asthma
  • The classic symptoms of asthma are wheezing ,
    cough shortness of breath( with chest
    tightness ).
  • During periods of relatively normal lung function
    , patients are likely to have no physical
    findings

2
  • Wheezing
  • Wheezing is the most common finding during
    acute airway obstruction, the chest may be
    hyperresonant on percussion.
  • Cough
  • The cough can be nonproductive or raise copious
    amounts of sputum ( particularly in the presence
    of infection )
  • Eosinophils their debris may cause a yellow
    discoloration of sputum , even when infection is
    absent
  • Occationally , cough is the only manifestation of
    asthma.

3
  • Shortness of breath
  • Dyspnea tends to vary greatly over time ,
    depending on the severity of airflow obstruction.
  • Chest tightness
  • commonly occurs with dyspnea may be confused
    with angina pectoris .
  • Most patients associate their chest tightness
    with the sensation of being unable to take in a
    full satisfying breath .

4
Physical signs of asthma (in the chest)
  • During an attack the chest in held near position
    of full
  • inspiration percussion note may be
    hyperresonant.
  • Breath sound are vesicular with prolong
    expiratory phase.
  • Bilateral expiratory may be inspiratory ronchi.
  • In very sever asthma the chest may be silent,
    because of insufficient air flow.
  • No physical signs between attack except in
    patients with chronic asthma which there is
    usually expiratory rhonchi
  • Sever asthma starting from childhood may cause
    pigeon chest deformity (pectus carinatum)

5
  • According to the clinical features we can divide
    asthma into the following
  • 1- Episodic asthma (usually atopic).
  • 2- Chronic asthma (non atopic).
  • 3- Acute sever asthma (status asthmatics).
  • History of allergy is very important.
  • An extremely common feature of asthma is
    nocturnal awakening with dyspnea wheezing .

6
Episodic asthma (atopic)
  • No respiratory symptoms between episodes.
  • Paroxysms of dyspnoea wheeze may occur at any
    time, may be sudden onset.
  • Paroxysms may last hours, days or weeks, may be
    mild, moderate or severe.
  • Triggers are allergens, cold, exercise
    respiratory infections (specially viral).

7
Chronic asthma (non atopic)
  • symptoms are wheeze , cough , dyspnoea chest
    tightness.
  • cough wheeze at night (an extremely common
    feature of asthma is nocturnal awakening with
    dyspnoea and/ or wheezing).
  • Episodes of sever acute asthma.
  • Recurrent episodes of chest infection with
    productive cough are common
  • (It may be difficult to differentiate from
    chronic bronchitis).

8
Acute sever asthma (status asthmaticus)
  • This is a life- threatening attack of asthma .
  • -patients are usually extremely distressed,
    usually adopts an upright position, fixing his
    shoulder girdle to assist the accessory muscle of
    respiration .
  • -The patient usually have dyspnoea,tachypnoea
    ,wheeze , dry cough, sweating ,tachycardia
    pulses paradoxes (a large fall in blood pressure
    during inspiration the pulse may be impalpable
    due to reduced cardiac return as a consequence of
    sever hyperinflation).
  • -In sever cases central cyanosis, silent
    chest (no wheeze) bradycardia may occur.

9
Triggers of asthma (not causes)
  • 1- Exposure to allergens such as home dust,
    fungal spores, gases , fumes or wood dusts.
  • 2- Cold exposure (cold air).
  • 3- Exercise.
  • 4- Smoking
  • -Smoking during pregnancy increases the
    risk of developing atopic asthma in infancy.
  • -Passive exposure to cigarettes smoke
    immediately following birth increase the risk of
    developing asthma.
  • 5- drugs B- blockers (even when used topically
    or eye drops), aspirin (and other NSAID)
  • about 10 of asthmatic patients develop
    bronchospasm when given aspirin.
  • 6- Infection viral bacterial infection of
    respiratory tract (viral more than bacterial).
  • 7- Anxiety psychological factors
  • Sever anxiety or stress can exacerbate
    asthma.

10
ALLERGENS
11
Investigation in asthma
  • 1/ CXR.
  • 2/ pulmonary function test.
  • 3/ skin hypersensitivity tests.
  • 4/measurement of allergic status .
  • 5/ blood gases

12
1- Chest X- ray
  • Normal between attacks.
  • During an attack looks hyperinflated.
  • In chronic cases looks similar to the
    hyperinflation caused by emphysema.
  • In chronic cases a lateral view may show pigeon
    chest deformity.
  • There may be segmental or lobar collapse due to
    obstruction of a large bronchus by thick mucus
    (mucus plug).
  • Pneumothorax a rare but may be fatal
    complication of asthma.
  • Rarely in sever cases CXR may show mediastinal or
    subcutaneous emphysema.

13
2- Pulmonary function tests
  • FEV/VC lt70
  • FEV, VC and PEF all are reduced, they should be
    recorded for diagnosis follow up .
  • PEF rate should be recorded twice daily to all
    patients admitted to hospital by a peak flow
    meter a chart arranged which will show marked
    diurnal variation.
  • The lowest values recorded in the morning
    called (morning dipping).
  • Morning dipping PEF over nigh fall (morning
    dipping) subsequent rise during the day in
    patients with asthma.

14
Reversibility test
  • in asthma usually there is an improvement in FEV1
    or PEF following administration of a
    bronchodilator .
  • Reversibility test is defined as a 15 or more
    increase in FEV1 20 min. after inhalation of a
    ß-agonist

15
Measurement of bronchial reactivity
  • can be of value in diagnosing asthma in
    assessing the effects of treatment
  • this can be achieved by administering increasing
    concentration of substances such as histamine by
    inhalation until there is a 20 fall in FEV1, or
    PEF.
  • Patients with asthma show evidence of
    broncho-constriction as much lower concentrations
    than normal subjects.

16
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17
  • 3- Skin hypersensitivity test
  • By intradermal injection of common allergens to
    differenciate atopic from non-atopic .
  • In atopic there is positive skin test .
  • 4- Measurement of allergic status
  • 1- elevated sputum /or peripheral blood
    oesinophil .
  • 2- elevated serum IgE level.
  • 3- skin test (simple provide rapid assessment
    of atopy).

18
DIAGNOSIS OF ALLERGIC CONDITION
SKIN TEST SENSITIVITY
POSITIVE SKIN TEST

WHEAL FLARE REACTION
19
5- Blood gases
  • PaO2 is diminished .
  • PaCO2 is normal or diminished due to
    hyperventillation .

20
  • Making a diagnosis of asthma
  • History Examinatio Plmonary function test
  • ( including Reversability test ).

21
Diagnosis of bronchial asthma
  • Techniques to establish diagnosis
  • - History
  • Physical exam (resp. tract, skin, chest)
  • Pulmonary function test (Spirometry to
    demonstrate reversibility)
  • Additional studies
  • evaluate alternative dx., ID precipitating
    factors
  • assess severity, ID potential complications

22
Diagnosing Asthma (history examination)
  • Troublesome cough, particularly at night
  • Awakened by coughing
  • Coughing or wheezing after physical activity
  • Breathing problems during particular seasons
  • Coughing, wheezing, or chest tightness after
    allergen exposure
  • Colds that last more than 10 days
  • Relief when medication is used

23
Diagnosing Asthma ( con)
  • Increased nasal secretions or nasal polyps
  • Atopic dermatitis, eczema, or other allergic skin
    conditions
  • Wheezing sounds during normal breathing
  • Hyperexpansion of the thorax
  • Vesicular breath sound with prolong expiratory
    phase , with diffuse rhonchi .

24
Diagnosing Asthma ( Pulm. Func. Test)
  • Compatable clinical history either/or
  • 15 improvement in FEV1 or PEF following
    administration of a bronchodilator . or
  • 15 spontaneous change in PEF during one
    week of home monitoring .
  • FEV1 15 decrease after 6 min. of exercise
  • A trial of corticosteroid (eg. 30 mg daily for 2
    weeks ) may be useful in documenting the
    improvement in PEF seen in pt. with asthma

25
Diagnosing Asthma Spirometry
  • Test lung function when diagnosing asthma

26
DIfferential diagnosis of asthma
  • Asthma shoud be differentiated from other
    conditions associated with dyspnea wheeze .
  • 1- COPD no true symptom free periods .
  • 2-Upper airway obstruction by tumour or laryngeal
    oedema cause stridor ( mostly cause inspiratory
    wheeze ), need laryngoscope or bronchoscope .
  • 3- Glottic dysfuction narrowing of the glottis
    during inspiration expiration .need exam. Of
    glottis during the attacks.
  • 4- Endobronchial diseases (foreign body ,
    neoplasm ) cause persistence localized wheeze
    with attacks of cough

27
  • 5 Acute left ventricular failure basal
    crepitation , gallop rhythm .
  • 6- Recurrent pulmonary embolism .
  • 7- Eosinophilic pneumonia .
  • 8-Chemical pneumonia.
  • 9- Systemic vasculitis with pulmonary
    involvement.
  • 10-Carcinoid tumour may cause episodes of
    bronchospasm

28
  • Specific forms of Asthma

29
1- Early onset (extrinsic, atopic,
IgE mediated).
  • Start in early life.
  • Associated with a personal /or family history
    of allergic diseases (rhinitis , urticaria,
    eczema).
  • Increased level of IgE.
  • positive response to provocation test (involving
    inhalation of specific Ag, positive skin
    reaction to intradermal injection of extracts of
    Ag ).

30
  • 2- Late onset (intrinsic)
  • Start in late life.
  • No personal or family history of allergy.
  • Normal IgE level.
  • Negative skin test .
  • Usually develop symptom ( exacerbation ) after
    upper respiratory tract infections.
  • many patients have a mixed features of both
    extrinsic intrinsic types .

31
  • 3- Exercise induced asthma
  • The attacks induced by exertion.
  • After exercise pulmonary obstruction develop (
    wheeze , cough , SOB chest tightness ).
  • The magnitude of obstruction is directly related
    to the length of exercise the coolness
    dryness of the inspired air.( the colder drier
    the inspired air , the greater the airflow
    obstruction that develops after exercise.).
  • The obstruction spontaneously resolves 30 60
    minutes after onset.

32
  • 4- Aspirin- sensitive Asthma
  • 10 to 20 o f patiens with asthma exhibit
    an idiosyncratic reaction to acetylsalicylic acid
    ( aspirin ) .
  • Within 15 minutes to 4 hours after ingestion of
    as little as 10 mg of aspirin , patients may
    experience significant worsening of airflow
    obstruction nasal or ocular symptoms ( nasal
    congestion , rhinorrhea , conjuctival injection
    ).
  • Nasal polyps are common in aspirin sensitive
    asthmatic patients.
  • Aspirin triad combination of asthma , nasal
    polyps , idiosyncratic reaction to aspirin .
  • Aspirin other NSAIDs may trigger
    bronchoconstriction in susceptaple asthmatic
    patients by blocking the cyclooxygenase
    mediated convertion of arachidonic acid to
    prostaglandins ( particularly prostaglandin E 2
    , a potent anti-inflammatory prostaglandin ) .

33
  • 5- Occupational asthjma
  • Refers to asthma of new onset that is caused
    by prolonged exposure to a specific inhaled
    substance in the workplace.
  • Such as allergy to wood dust , cotton dust ,
    animal protiens , irritant gases ...
  • It is the most common form of occupational
    respiratory disorder .
  • It is about 5 of all adult onset asthma .
  • The symptoms improve during times away from
    work ( holidays ) .
  • Atopic smokers are at particular risk .
  • Early diagnosis removal from exposure lead
    to a significantly improved prognosis may resut
    in cure .

34
  • 6- Nocturnal asthma
  • In which the cough SOB mainly at night
    disturb the sleep .
  • The patient may awaken at 200 to 400 AM
    with typical symptoms.
  • Measurement of pulmonary function before after
    sleep usually document a significant worsening of
    obstruction in the morning ( morning dipping ).
  • Most of asthmatic deaths occurs in the hours
    between midnight 8 00 A.M.

35
  • Many causal factors have been involved in
    nocturnal asthma
  • -Sleep-related changes in airway tone , lung
    volumes , airway inflammation .
  • -Circadian variation in circulation histamine ,
    cortisol , epinephrine levels.
  • -Prolonged exposure to allergic or irritants in
    the bed room .
  • -Late asthmatic reactions to daytime allergens .
  • -Gastroesophageal reflux related to the supine
    posture .
  • -Retained airway secretions resulting from
    depressed cough reflex
  • -Increase in the intervals between antiasthmatic
    medication use .
  • .

36
  • 7- Cough variant asthma
  • Cough is the dominant symptom with absence of
    wheeze SOB .
  • Usually there is delay in reaching the
    diagnosis because the patient have no wheeze .

37
  • 8 - Cardiac asthma
  • The patient develop wheeze in the chest due to
    heart failure .
  • Treat as heart failure.

38
  • 9- Allergic Bronchopulmonary Aspergillosis
  • ABPA , a hypersensitivity reaction to
    colonization of the airways by Aspergillus
    species , rarely occurs except in patients with
    asthma.
  • This disorder typically develops in patients with
    atopy long term asthma is marked by fever ,
    SOB , cough worsening of asthmatic symptomes.
  • CXR- pulmonary infilrtares
  • The pulmonary infiltrates may resolve
    spontaneously but commonly recur, leading to the
    radiographic appearance of migratory pulmonary
    infiltrates.

39
  • Chronic disease commonly involves the upper lobes
    , typical features include bronchiectasis
    fibrosis with retraction .
  • Chronic ABPA may be mistaken for tuberculosis
    because commonly involves the upper lobes may
    cause hemoptysis.(in one third to one half of
    cases ).

40
  • The diagnosis of ABPA can be cofirmed by
  • 1- repeated isolation of Aspergillus organisms
    from the sputum .
  • 2- positive immediate skin test reaction to
    Aspergillus antigen.
  • 3- elevated total serum IgE level.
  • 4- elevated levels of specific IgE IgG
    antibodies against Aspergillus(levels usually
    twice those of asthmatic patients who do not have
    ABPA ).
  • 5- peripheral blood eosinophilia .

41
  • Management of ABPA
  • Suppression of immunological responses t to
    Aspergillus fumigatus by giving pednisolone 1o
    mg. daily.
  • some times combination of steroid itraconazole
    may be useful.
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