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 normal lung function
  , patients are likely to have no physical
  findings

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• 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.

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• 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 .

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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)

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• 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 .

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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).

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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).

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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.

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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.

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ALLERGENS
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Investigation in asthma

• 1/ CXR.
• 2/ pulmonary function test.
• 3/ skin hypersensitivity tests.
• 4/measurement of allergic status .
• 5/ blood gases

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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.

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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.

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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

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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.

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• 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).

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DIAGNOSIS OF ALLERGIC CONDITION
SKIN TEST SENSITIVITY
POSITIVE SKIN TEST

WHEAL FLARE REACTION
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5- Blood gases

• PaO2 is diminished .
• PaCO2 is normal or diminished due to
  hyperventillation .

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• Making a diagnosis of asthma

• History Examinatio Plmonary function test
• ( including Reversability test ).

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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

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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

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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 .

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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

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Diagnosing AsthmaSpirometry

• Test lung function when diagnosing asthma

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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

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• 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

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• Specific forms of Asthma

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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 ).

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• 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 .

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• 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.

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• 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 ) .

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• 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 .

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• 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.

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• 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 .
• .

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• 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 .

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

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• 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.

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• 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 ).

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• 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 .

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• 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.