Approach To Asthma

Question 1

Asthma broad overview

Answer 1

Chronic inflammatory disease of the airway due to hyper responsiveness of the airway

• symptoms initially are variable, reversible and recurring.
• overtime with no treatment, symptoms become irreversible and scar tissue takes over
• smooth muscle hypertrophied and hyperplasia

Is a type 1 hypersensitivity reaction

• type 2 helper T cells release IL-4/5
• mast cells releases histamines, leukotrienes and prostaglandins

Causes bronchoconstriction which decreases airflow and increases resistance

Question 2

Types of asthma

Answer 2

Atopic/ allergic asthma
- most common kind of asthma
- most are diagnosed in people before age of 7 (75%)
Most resolve by puberty

Nonatopic asthma

• infection induced asthma
• primarily diagnosed as adults

Drug-induced asthma

• caused by aspirin in patients with rhinitis and nasal polyps
• primarily diagnosed as adults

Occupational asthma

• causes by fumes or gases
• primarily diagnosed as adults

Question 3

Asthma triad

Answer 3

Personal history of allergies

Eczema

Asthma symptoms

these 3 usually occur together

Question 4

Wheezy bronchitis/ reactive airway disease

Answer 4

Found in 1-4 year old children that have wheezing due to viral URIs

• looks like asthma, but is technically not since asthma is a chronic illness not acute
• this resolves on its own by 5 usually, however if it doesnt then it can be considered asthma

Question 5

History associated with asthma

Answer 5

Symptoms

• dyspnea (especially with exertion)
• wheezing (sometimes is audible but it is always heard on auscultation)
• coughing (especially at night)
• cyanosis

symptoms come in waves, hence “asthma attack”

Physical exam

• tachypnea/tachycardia
• possibly normal vitals in some patients
• decreased inspiration:expiration ratio (1:2 -> 1:4) this is similar to COPD
• wheezing can be inspiratory only, or both inspiratory and Expiratory
• possible hyper resonance when percussing
• substernal and intercostal retractions (stomach sucks in when breathing)
• accessory muscle overuse (very clear to see)

NOTE: severe asthma attacks can show no wheezing on auscultation, so wheezing alone is not enough to diagnose

Question 6

Tripod position

Answer 6

Found in patients with emphysema or severe asthma

Patients need to hunch over to breath properly

Question 7

Pulsus paradoxus

Answer 7

Found in patients with asthma but also in a lot of other disorders

Systolic BP drops by > 10mmHg during inspiration

Question 8

Ways to diagnosis asthma

Answer 8

1) Spirometers/PFTs are the best inital diagnostic tests to use
- is very dependent on patient effort so you must know that the patient can take orders
- FEV1 will decrease (<80% predicted)
- FEVs/FVC is decreased (<70% predicted)

2) If spirometers shows possible asthma, give SABA (albuterol) and then retest
- asthma should show symptoms improve after
- if symptoms dont improve, COPD

3) Peak flow monitoring
- note this isnt the best to diagnose asthma by itself
- very effort dependent again

4) X-rays
- shows flattening of diaphragm and increased lung volumes (however these findings just prove is some sort of obstructive disorder, not asthma entirely)

5) methacholine challenge test

6) biopsy/pathology
- shows Curschmann spirals
- muscle hypertrophy
- Charcot-Leyden crystals

Question 9

Treatment of asthma

Answer 9

1) Avoid triggers
2) Treat underlying causes of asthma

Acute asthma attacks = SABA every 1-6 hrs and prednisone for 5-10 days

*always try to step down if possible* 
Step 1 (mild intermittent):
- just SABA 

Step 2 (mild chronic)
- prednisone 

Step 3 (moderate chronic) 
- LABA or SABA & prednisone

Step 4 (severe chronic) 
- LABA + medium dose glucocorticoids