Asthma.pdf

7/23/2019 Asthma.pdf

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Asthma

Basics

DESCRIPTION

• Characterized by 3 components:

1. Reersib!e air"ay obstr#ction

$. %ir"ay in&!ammation

3. %ir"ay hyperresponsieness to a ariety o& stim#!i

• Dia'nosis (the 3 )R*s+

1. Rec#rrence: Symptoms are rec#rrent.

$. Reactiity: Symptoms are bro#'ht on by a speci&ic occ#rrence or e,pos#re (tri''er+.

3. Responsie: Symptoms diminish in response to bronchodi!ator or anti-in&!ammatory a'ent.

CINIC%:

• Pit&a!!s:

1. Not reco'nizin' that asthma can mani&est as chronic co#'h/ "heezin' may not be eident

$. Re!#ctance to )!abe!* chi!d "ith hain' asthma (#sin' terms s#ch as reactie air"ays

disease or bronchitis+

3. 0re#ent antibiotic or co#'h medicine #se to treat asthma symptoms

4. “Rec#rrent pne#monias* o&ten are act#a!!y asthma e,acerbations/ s#bse'menta!

ate!ectasis on chest ,-ray misdia'nosed as an in&i!trate

2. nderreportin' o& asthma symptoms/ be"are the chi!d "ho )doesn4t !i5e to p!ay sports*/

he6she may hae !earned that e,ercise ca#ses dyspnea

7. Poor adherence "ith therapy "hen symptoms are contro!!e

8. 0ai!#re to #se inha!ed medications proper!y: Inha!ed medication #se m#st be ta#'ht and

reie"ed at each isit. % &i,ed-o!#me ho!din' chamber sho#!d a!"ays be #sed "ith a

press#rized metered-dose inha!er (p9DI+ re'ard!ess o& patient a'e. p9DIs sho#!d be

re&i!!ed based on the n#mber o& doses #sed not by estimatin' contents by sha5in' or

sprayin'.

EPIDE9IOO;<

Incidence• 9ost common chronic i!!ness in chi!dren

• Death &rom asthma in chi!dren more than trip!ed &rom 1=8= to 1==7 b#t has been decreasin' since

then perhaps d#e to better reco'nition and increased #se o& anti-in&!ammatory medications. The

incidence o& death &rom asthma does not seem to corre!ate "ith seerity.

>%SICS-EPIDE9IOO;<-Prea!ence

• ?heezin' in chi!dren is e,treme!y common in the ind#stria!ized "or!d (c#m#!atie prea!ence 3@A



7@B+.

• In yo#n'er chi!dren most episodes occ#r &o!!o"in' ira! in&ections.

• 2@B o& chi!dren "ho "heeze in ear!y chi!dhood stop "heezin' by a'e 7 years.

• 1B o& a!! yo#n' chi!dren (@B o& those "ho "heeze d#rin' in&ancy+ contin#e to "heeze.

RIS 0%CTORS

;enetics

• Chi!dren o& asthmatics hae hi'her incidence o& asthma.

1. 7A8B ris5 i& neither parent has asthma

$. $@B ris5 i& 1 parent has asthma

3. 7@B ris5 i& both parents hae asthma

• Seera! 'enes are 5no"n to be associated "ith the dee!opment o& atopy and bronchia! m#sc!e

responsieness.

P%TFOPF<SIOO;<

• Imm#ne and in&!ammatory responses in the air"ays are tri''ered by an array o& enironmenta!

anti'ens irritants or in&ectio#s or'anisms.

• %topy and asthma are re!ated.

1. Eosinophi!ia and the abi!ity to ma5e e,cess I'E in response to anti'en is associated "ith

increased air"ay reactiity.

$. %sthma is more common in chi!dren "ho hae a!!er'ic rhinitis and eczema.

• Gira! in&ections partic#!ar!y respiratory syncytia! ir#s (RSG+ d#rin' in&ancy may p!ay a ro!e in the

dee!opment o& asthma or may modi&y the seerity o& asthma.

• E,pos#re to ci'arette smo5e and other air"ay irritants in&!#ences the dee!opment and seerity o&

asthma.

• %ir"ay is stim#!ated and primary in&!ammatory mediators re!eased.

• %ir"ay is inaded by in&!ammatory ce!!s (mast ce!!s basophi!s eosinophi!s macropha'es ne#trophi!s

> and T !ymphocytes+.

• In&!ammatory ce!!s respond to and prod#ce ario#s mediators (cyto5ines !e#5otrienes !ympho5ines+

a#'mentin' the in&!ammatory response.

•

%ir"ay epithe!i#m is in&!amed and becomes disr#pted and basa! membrane is thic5ened.

• %ir"ay smooth m#sc!e is hyperresponsie and bronchoconstriction ens#es.

• %ir"ay smooth m#sc!e hypertrophy and air"ay epithe!ia! hyperp!asia are characteristic chronic

chan'es res#!tin' &rom poor!y contro!!ed asthma.

Diagnosis



SI;NS %ND S<9PTO9S

Fistory

• In#ire abo#t these symptoms: Co#'hin' "heezin' shortness o& breath chest ti'htness:

1. 0re#ency o& symptoms de&ines seerity.

$. Precipitatin' &actor (tri''er+

3. Response to bronchodi!ator or anti-in&!ammatory medication

. 0ami!y history o& asthma or atopy

• Pattern o& symptoms:

1. Perennia! ers#s seasona!

$. Contin#o#s ers#s ac#te

3. D#ration and &re#ency o& episodes

. Di#rna! ariation6noct#rna! symptoms

• Do any o& the &o!!o"in' set o&& the breathin' di&&ic#!tyH

1. In&ections (#pper respiratory sin#sitis+

$. E,pos#re to d#st (mites+ anima! dander po!!en mo!d

3. Co!d air or "eather chan'es

. E,ercise or p!ay

2. Enironmenta! stim#!ants (e.'. ci'arette smo5e stron' odors po!!#tants+

7. Emotiona! &actors (e.'. !a#'hin' cryin' &ear+

8. Dr#' inta5e (aspirin nonsteroida! anti-in&!ammatory dr#'s -b!oc5ers+

J. 0ood addities

=. Endocrine &actors (e.'. menses pre'nancy thyroid dys&#nction+

• Reie" o& systems:

1. Symptoms o& comp!icatin' &actors ('astroesopha'ea! re&!#, sin#sitis a!!er'ies+

$. Dyspepsia so#r taste ('astroesopha'ea! re&!#,+/ throat c!earin' p#r#!ent nasa! dischar'e

ha!itosis cepha!a!'ia or &acia! pain (sin#sitis+/ nasa! itchin' ()a!!er'ic sa!#te*+ eye r#bbin'

sneezin' "atery nasa! dischar'e (a!!er'ies+

• Impact o& asthma:

1. N#mber o& hospita!izations6intensie care #nit admissions

$. N#mber o& emer'ency room isits6doctor4s o&&ice isits

3. %sthma attac5 &re#ency

. N#mber o& missed schoo! days6parent "or5days

2. imitation on actiity



7. N#mber o& co#rses o& systemic steroids needed

• Enironmenta! history:

1. Type o& home

$. ocation o& home (#rban s#b#rban r#ra!+

3. Featin' system6air conditionin'

. se o& h#midi&ier

2. Presence o& mo!ds coc5roaches rodents

7. 0irep!ace

8. Carpetin'

J. St#&&ed anima!s

=. Pets

[email protected],pos#re to ci'arette smo5e

Physica! E,am

• P#!monary e,amination may be norma! "hen asymptomatic.

• %ssess "or5 o& breathin':

1. ee! o& distress

$. Intercosta!6s#prac!aic#!ar m#sc!e retractions

• Chest shape (i.e. norma! ers#s barre!-shaped+

• #n' a#sc#!tation:

1. ?heezin'

$. End-e,piratory ino!#ntary co#'h

3. Pro!on'ed e,piratory phase

. Crac5!es or coarse breath so#nds

2. Stridor (indicates e,trathoracic air"ay obstr#ction+

• Fead eyes ears nose and throat e,amination. Si'ns o& a!!er'ies or sin#sitis:

1. ?atery or itchy eyes

$. %!!er'ic shiners

3. Dennie !ines

. Nasa! con'estion

2. >o''y nasa! t#rbinates

7. Nasa! po!yps

8. Postnasa! drip



• ;enera! e,amination (ita! si'ns+:

1. >!ood press#re (p#!s#s parado,#s+

$. Respiratory rate (tachypnea+

• S5in: Eidence o& eczema

• E,tremities: Di'ita! c!#bbin' (ery rare in asthma/ s#''ests a!ternatie dia'nosis+

• Physica! e,amination tric5: 0orced-e,ha!ation mane#er to obsere &or "heezes or &or precipitatin'

co#'hin'

TESTS

%>OR%TOR<

• P#!monary &#nction tests:

1. Essentia! &or the assessment and on'oin' care o& chi!dren "ith asthma

$. Spirometry meas#res the de'ree o& air"ay obstr#ction and the response to bronchodi!ators.

3. Ga!#es obtained can meas#re abso!#te de'ree o& air"ay obstr#ction.

. Seria! a!#es can &o!!o" pro'ress o& disease and response to treatment.

2. Chi!dren as yo#n' as A2 years o!d can #s#a!!y per&orm spirometry "ith practice.

• Proocationa! testin':

1. E,ercise cha!!en'e: Determines e&&ect o& e,ercise on tri''erin' air"ay obstr#ction

$. Co!d-air cha!!en'e: Indirect test o& air"ay hyperresponsieness

3. 9ethacho!ine cha!!en'e: % positie test s#pports the dia'nosis o& asthma (#se&#! in cases

&or "hich history is e#ioca! and p#!monary &#nction test is norma!+ meas#res the de'ree

o& air"ay hyperreactiity

• %!!er'y ea!#ation:

1. >!ood tests (eosinophi! co#nt I'E !ee!+

$. S5in testin' (best test &or assessin' a!!er'en sensitiity+

3. R%ST testin' (not as acc#rate as s5in testin'+

. Sp#t#m6nasa! e,amination &or presence o& eosinophi!ia

• Other st#dies:

1. ;astroesopha'ea! re&!#, ea!#ation

$. pF probe

3. 9i!5 scan

. >ari#m s"a!!o" (con&irms norma! anatomy+

• Pea5 &!o" meter (home testin'+:

1. 9eas#res pea5 &!o" rate (PE0R+



$. E&&ort dependent

3. %ssesses centra! not periphera! air"ay obstr#ction

. sed "ith patients "ho hae poor symptom reco'nition or !abi!e asthma

2. Dips in pea5 &!o" rate precede onset o& c!inica! asthmatic symptoms.

7. Pea5 &!o" rate sho#!d be per&ormed at !east once a day.

8. Pea5 &!o" rate a!#es are diided into 3 zones:

• ;reen: KJ@B o& base!ine

• <e!!o": 2@AJ@B o& base!ine

• Red: 2@B o& base!ine

J. Speci&ic pea5 &!o" rate '#ide!ines sho#!d be indiid#a!ized &or each patient based on the

best meas#rement obtained d#rin' a 1-day period "hen the chi!d is "e!!.

I9%;IN;

• Chest ,-ray sho#!d be obtained i& the dia'nosis is #ncertain or there is not the e,pected response to

treatment to r#!e o#t con'enita! !#n' ma!&ormations or obio#s asc#!ar ma!&ormations.

1. 0indin's can be norma!.

$. Common &indin's are peribronchia! thic5enin' s#bse'menta! ate!ectasis and

hyperin&!ation.

• Sin#s CT is #se&#! i& symptoms s#''est sin#sitis.

• Chest CT sho#!d be per&ormed i& bronchiectasis or anatomic abnorma!ity is s#spected.

DI%;NOSTIC PROCEDRES

>ronchoscopy can r#!e o#t:

• %natomic ma!&ormations

• 0orei'n bodies

• 9#c#s p!#''in'

• Goca! cord dys&#nction

• %ssess &or aspiration (!ipid-!aden macropha'es+

DI00ERENTI% DI%;NOSIS

• In&ectio#s:

1. Pne#monia

$. >ronchio!itis

3. Chlamydia in&ection

. aryn'otracheobronchitis

2. Sin#sitis



7. Imm#ne de&iciency

• 9echanica!:

1. E,trinsic air"ay compression

$. Gasc#!ar rin'

3. 0orei'n body

. Goca! cord dys&#nction

2. Tracheobronchoma!acia

• 9isce!!aneo#s:

1. Cystic &ibrosis

$. >ronchop#!monary dysp!asia

3. P#!monary edema

. ;astroesopha'ea! re&!#,

2. Rec#rrent aspiration

7. >ronchio!itis ob!iterans

Treatment

;ENER% 9E%SRES

DIET

• %oid &oods or &ood addities (i& tr#!y a!!er'ic+.

• 0ood-ind#ced asthma is #ncommon.

SPECI% TFER%P<

Comp-%!t-9edicine

• 9isce!!aneo#s dr#'s #sed in seere cases

• Steroid-sparin' a'ents:

1. Tro!eandomycin (T%O+: 9acro!ide antibiotic/ decreases c!earance o& corticosteroids th#s

pro!on'in' the e&&ects o& corticosteroids on the !#n'/ !o"er corticosteroid dosin' re#ired

$. 9ethotre,ate: Potent imm#nos#ppressie dr#'/ needs &#rther inesti'ation in chi!dren

3. Cyc!osporine: Sho"n to hae steroid-sparin' e&&ect in ad#!t pop#!ation "ith asthma/ side

e&&ects are si'ni&icant and may !imit #se

. 9a'nesi#m s#!&ate (9'SO+: sed intraeno#s!y as a smooth m#sc!e re!a,er in seere

ac#te asthma e,acerbation

• Fe!i#m:

1. 9ay improe air&!o" in seere asthma

$. Can improe enti!ation and potentia!!y o,y'enation



• Imm#notherapy:

1. E&&icacy in asthma is controersia!

$. 9ost e&&ectie i& a sin'!e anti'en can be identi&ied

3. sed on!y in se!ect cases i& medica! mana'ement and enironmenta! contro! meas#res are

ine&&ectie

9EDIC%TIONS

• Corticosteroids (anti-in&!ammatory a'ents+:

1. 9ost e&&ectie anti-in&!ammatory a'ents

$. Inha!ed: Red#ce air"ay in&!ammation and hyperresponsieness more than any other

inha!ed a'ents/ inhibit prod#ction and re!ease o& cyto5ines and arachidonic acidAassociated

metabo!ites/ enhance -adrenoceptor responsieness/ side e&&ects inc!#de ora! thr#sh/ may

minima!!y a&&ect 'ro"th e!ocity at moderate or hi'h doses

3. Dosa'e indiid#a!ized to each patient. %'ents ary in topica! potency and systemic

bioaai!abi!ity/ aai!ab!e as p9DIs dry-po"der inha!ers (DPIs+ orneb#!ized. 0!#ticasone (0!oent+ 11@ $$@ mc'6p#&& p9DI/ b#desonide(P#!micort+ $@@

mc'6p#&& DPI/ $2@- and 2@@-mc' ia!s &or neb#!izer/ bec!omethasone (>ec!oent Ganceri!

Lar+ @ $ J@ J mc'6p#&&/ triamcino!one (%zmacort+ 1@@ mc'6p#&&/ &!#niso!ide (%erobid+

$2@ mc'6p#&&

. Ora!: sed &or asthma e,acerbations or &or seere asthma that cannot be other"ise

contro!!ed. E,acerbations: Prednisone 1A$ m'65'6d &or 3A8 days or !on'er/ #s#a!!y tapered

i& 8 days o& therapy re#ired or i& systemic steroids are #sed &re#ent!y. On'oin' therapy:

@.2A1 m'65'6d dai!y or eery other day &or patients "ith seere asthma. ndesirab!e side-

e&&ect pro&i!e. ?hen #sed dai!y assess bone density and &or cataract &ormation at !east

year!y.

2. IG: 9ethy!predniso!one (So!#medro!+ 1A$ m'65' IG 7A1$h #nti! improed and ab!e to ta5e

ora! medication

• e#5otriene modi&iers (anti-in&!ammatory a'ents+:

1. >!oc5 the synthesis and6or action o& !e#5otrienes

$. 2-ipo,y'enase inhibitors zi!e#ton: 9ay ca#se hepatic dys&#nction

3. e#5otriene receptor anta'onists: %a&ir!#5ast (1@ m'/ %cco!ate+ and monte!#5ast ( 2 and

1@ m'/ Sin'#!air+

. Indicated as monotherapy &or mi!d or e,ercise-ind#ced asthma and in combination "ith an

inha!ed corticosteroid &or more e&&ectie symptom contro! or #sin' a !o"er dose o& inha!edcorticosteroid

• 9ast-ce!! stabi!izers

1. ?ea5 anti-in&!ammatory a'ents

$. Preparations: Cromo!yn sodi#m(Inta!+/ nedocromi! sodi#m (Ti!ade+

3. Decrease bronchia! hyperresponsieness



. Can be #sed prior to e,ercise &or e,ercise-ind#ced symptoms

2. No si'ni&icant side e&&ects

7. Inha!ed: Neb#!izer/ 9DI

• $-%'onists (bronchodi!ators+: Indication is &or re!ie& o& ac#te bronchoconstriction (#ic5-re!ie&

medicine+/ #sed as needed in peop!e "ith asthma "ho hae brea5thro#'h symptoms/ #sed prior to

e,ercise in e,ercise-ind#ced bronchospasm/ re'#!ar #se or oer#se associated "ith "orsened contro!

o& asthma/ ro#tes inc!#de inha!ed (most e&&ectie metered-dose inha!er or neb#!izer+ and ora! (!east

e&&ectie most side e&&ects+/ short-actin' (A7 ho#rs+ preparations inc!#de a!b#tero! (Gento!in

Proenti! Pro%ir+ terb#ta!ine (>rethaire >rethine+ and metaprotereno! (%!#pent+/ a sin'!e-isomer

preparation o& a!b#tero!(Mopene,+ may hae a s!i'ht!y !on'er d#ration o& action and perhaps &e"er

side e&&ects/ !on'er-actin' (#p to 1$ ho#rs+ preparations inc!#de sa!metero! (Sereent+ aai!ab!e as

p9DI and DPI can be #sed dai!y in con#nction "ith anti-in&!ammatory a'ent &or improed symptom

contro!. 0i,ed combination prod#cts o& inha!ed corticosteroid and a !on'-actin' beta a'onist (%dair

Symbicort+ are aai!ab!e as DPIs and p9DIs.

1. Theophy!!ine (bronchodi!ator+: $nd-!ine a'ent #sed "hen more conentiona! therapies are

#ns#ccess&#!/ indications are chronic poor!y contro!!ed asthma and noct#rna! asthma (i& no'astroesopha'ea! re&!#,+/ ad#nctie therapy "ith

$ dr#'s and steroids in hospita!ized

patients in se!ected cases/ ro#te (ora! or IG+/ ser#m !ee!s m#st be ro#tine!y monitored

(therape#tic !ee!s are 1@A$@ m'6m+. Side e&&ects are seen "ith increased !ee!s. 9any

&actors a&&ect theophy!!ine !ee!s. Increased !ee!s are seen "ith erythromycin

cipro&!o,acin cimetidine ira! i!!nesses &eer. Decreased !ee!s are seen

"ith phenobarbita! phenytoin ri&ampin.

• %nticho!iner'ic a'ents (bronchodi!ators+: %d#nctie bronchodi!ators may be #se&#! in patients "ho

on!y partia!!y respond to -a'onists/ preparations inc!#de Ipratropi#m bromide 9DI or amp#!e &or

neb#!ization (%troent+

•9onoc!ona! antibodies a'ainst I'E (Mo!air+ can be 'ien as a month!y SC inection in seere asthmapatients "ith moderate!y hi'h I'E !ee!s.

Follow-up Recommendations

on'-term &o!!o"-#p is essentia! to maintain norma! actiity and p#!monary &#nction. %!! patients sho#!d #se a

a!ed ho!din' chamber "ith p9DIs and techni#e &or a!! inha!ed medications sho#!d be reie"ed re'#!ar!y.

DISPOSITION

0OO?P-DISPOSITION-Iss#es-&or-Re&erra!

• % patient "ho re#ires hospita!ization more than once a year or "ho has re#ired intensie care

• % patient "ho re#ires &re#ent b#rsts o& systemic corticosteroids

• % patient "hose air"ay obstr#ction is not easi!y reersib!e

• % patient "ho has c!inica! &eat#res s#''estin' another p#!monary process

EMPECTED CORSE6PRO;NOSIS

?ith proper therapy and 'ood adherence to treatment re'imen: E,ce!!ent



POSSI>E CO9PIC%TIONS

9orbidity:

• 0re#ent hospita!izations and absence &rom schoo!

• Psycho!o'ic impact o& hain' a chronic i!!ness

• Dec!ine in !#n' &#nction oer time

P%TIENT 9ONITORIN;

Si'ns that may indicate prob!ems:

• Increased symptoms (co#'h day or ni'ht "heeze+

• E,ercise !imitations or symptoms d#rin' e,ercise

• Decrease in pea5 &!o" rate

• Increasin' #se o& inha!ed bronchodi!ators

• S#bect not improin' on enhanced home therapy

Patient Teaching Medication

%CTIGIT<

• 9ost patients "ith asthma can participate &#!!y in sports een at a hi'h !ee! "ith c!ose &o!!o"-#p.

E,tra medications s#ch as a!b#tero! and6or cromo!yn may be re#ired be&ore i'oro#s e,ercise. %!!

ath!etes sho#!d hae their #ic5-re!ie& medications on hand at a!! times.

• %th!etes "ith asthma may need to report their medications to the 'oernin' bodies o& their sport.

PREGENTION

• Patient and care'ier ed#cation is mandatory to estab!ish proider6care'ier partnership and ens#re

adherence "ith treatment p!an.

• Eery patient6care'ier sho#!d be ta#'ht that asthma is a chronic in&!ammatory condition that can be

contro!!ed "ith proper therapy.

• %!! medications sho#!d be e,p!ained and potentia! ris5s (side e&&ects+ and bene&its reie"ed.

• % "ritten asthma mana'ement p!an sho#!d be proided o#t!inin' dai!y therapy and an )action p!an* &or

mana'in' e,acerbations o& asthma.

• Enironmenta! co#nse!in':

1. %oid airborne irritants (tobacco smo5e "ood stoes no,io#s &#mes+.

$. 9inimize d#st-mite e,pos#re.

3. 9inimize st#&&ed anima!s #i!ts boo5s and c!#tter.

. se d#st miteAproo& coerin's on mattresses pi!!o"s and bo, sprin's.

2. ?ash pi!!o"s b!an5ets and sheets in hot "ater.

7. %oid mo!ds by decreasin' re!atie h#midity to 2@B.

8. Remoe pets &rom chi!d4s bedroom and &rom ho#se i& patient is a!!er'ic to the anima!.



Additional Reading

%!!en >ryant-Stephens T Pa"!o"s5i N%. The Children’s Hospital of Philadelphia Guide to

Asthma. Phi!ade!phia: ?i!ey-iss/ $@@.

Frequently Asked Questions

• L: ?i!! my chi!d o#t'ro" his or her asthmaH

• %: 0ami!y history and a!!er'ies a&&ect the #!timate o#tcome. ?heezin' d#rin' the 1st 3 years o& !i&e is

e,treme!y common "ith @A2@B o& a!! chi!dren "heezin' at some time. 9any o& these chi!dren do not

dee!op asthma and )o#t'ro"* their i!!ness by schoo! a'e. Some patients dee!op asthma a'ain as

yo#n' ad#!ts.

• L: Can my chi!d become dependent on asthma medicationsH

• %: Chi!dren do not become )dependent* on these medications as they "o#!d "ith narcotic a'ents.

Dai!y asthma medications are re#ired to maintain air"ay patency and to contro! air"ay in&!ammation.

• L: ?i!! my chi!d be on medications &or the rest o& his or her !i&eH

•

%: This depends on the seerity o& the asthma. The types doses and &re#ency o& asthmamedications "i!! chan'e oer a patient4s !i&etime.

• L: Do inha!ed steroids a&&ect patient 'ro"thH

• %: There is some transient and s!i'ht decrease in 'ro"th e!ocity seen in chi!dren "ho receie

moderate-dose inha!ed corticosteroids (@.2 m'6d+. !timate hei'ht does not seem to be a&&ected.

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