Asthma

Question 1

If this is your problem list; what are some possible DDx?

• Wheeze
• Difficulty breathing
• Exertional symptoms
• Night cough
• Chronic rhinitis not controlled
• Recurrent sinusitis
• Peanut allergy, possible accidental ingestion

Answer 1

• Asthma
• Paradoxical vocal fold motion

• Laryngeal edema/anaphylaxis

• Allergic rhinitis
• Cystic fibrosis

Question 2

What tests/labs/imaging would be recommened in pt you suspect has asthma?

Answer 2

• PFT
• CXR
• Allergy testing
• Laryngoscopy (could be vocal cord misfolding)
• Sweat chloride test

Question 3

What diseases could cuase this type of spirometry result?

Answer 3

Restrictive lung disease:

asthma or Cystic fibrosis

Question 4

Define Restrictive lung diesease

Answer 4

category of extrapulmonary, pleural respiratory diseases that restrict lung expansion,[2] resulting in a decreased lung volume, an increased work of breathing, and inadequate ventilation and/or oxygenation. Pulmonary function test demonstrates a decrease in the forced vital capacity.

Question 5

What do we expect to see on pt with asthma for their:

FVC

FEV1

FEV1/FVC

Answer 5

both FVC and FEV1 will decrease but FEV1 more so thus:

ratio often LESS then 80%

Question 6

You tx pt you suspect has asthma with SABA. If they truly have asthma, what would you expect to see on repeat spriometry

Answer 6

FEV1 revesed >200 mL and increased by 12%

Question 7

56 year old woman is evaluated for a 2 year history of episodic cough and chest tightness. Her symptoms began after a severe respiratory tract infection. Since then, she has had cough and chest discomfort after similar infections, typically lasting several weeks before resolving. She feels well between episodes. She is otherwise healthy and takes no medications. Physical examination reveals no abnormalities and spirometry is normal.

Next step?

Answer 7

Methacholine challenge testing

This patient’s history is consistent with, but not typical of, asthma

cough-variant asthma*** with normal testing btwn episodes, need to induce it

Question 8

You give a pt you suspect has asthma the Methacholine challenge. What results would suggest asthma?

Answer 8

FEV1 will drop by 20%

Question 9

complex clinical syndrome characterized by variable airflow obstruction, airway inflammation, bronchial hyper- responsiveness

Answer 9

Asthma

Question 10

Pathophysciology of asthma

Answer 10

Persistent inflammation–> infiltration of airway by inflammatory cells–> Hypertrophy of airway smooth muscle + Thickening of basement membrane (lamina reticularis)–>

Hyperplasia and hypertrophy of submucosal glands–> Goblet cell hyperplasia and hypertrophy–> Hyperplasia of microvascular dilation–> Loss of epithelial cells

Question 11

26 year old with poorly controlled asthma complains of increased cough. What would you expect to find in the sputum?

Answer 11

Charcot-Leyden Crystals

They consist of lysophospholipase, an enzyme synthesized by eosinophils, and are produced from the breakdown of these cells. **eosinophilic inflammation or proliferation

Question 12

What are signs and symptoms of Vocal cord dysfunction?

Answer 12

have throat or neck discomfort, wheezing, stridor, and anxiety. The disorder can still be difficult to differentiate from asthma; however, affected patients do not respond to usual asthma therapy.

Get Laryngoscopy

Question 13

Key things to determine when making asthma dx

Answer 13

Episodic sxs of airflow obstruction or airway hyper-responsiveness are present

Airflow obstruction is at least partially reversible

Alternative diagnoses are excluded

Question 14

Methods to establish ashtma diagnosis

Answer 14

Detailed medical history

Exam focusing on upper respiratory tract, chest, and skin

Spirometry: assess obstruction/reversibility, > 5 yr. Reversibility: increase in FEV1 >12 % and 200 ml from baseline

Additional studies to exclude alternate diagnosis

Question 15

Possible DDx for asthma in adults

Answer 15

 COPD (e.g., chronic bronchitis or emphysema)

 Congestive heart failure

 Pulmonary embolism

 Mechanical obstruction of the airways (benign/malignant tumors)

 Pulmonary infiltration with eosinophilia

 Cough secondary to drugs (angiotensin-converting enzyme (ACE)

inhibitors)

 Vocal cord dysfunction

Question 16

Possible DDx for asthma in infants for upper airway

Answer 16

 Upper airway disease: Allergic rhinitis and sinusitis

 Obstructions involving large airways

 Foreign body in trachea
 Vocal cord dysfunction
 Vascular rings or laryngeal webs

 Laryngotracheomalacia, tracheal stenosis, or bronchostenosis

 Enlarged lymph nodes or tumo

Question 17

DDx in young children or infants for asthma for small airways

Answer 17

 Viral bronchiolitis or obliterative bronchiolitis

 Cystic fibrosis
 Bronchopulmonary dysplasia
 Heart disease

Question 18

46 yo male comes to ED; acute breathlessness, chest pain, cough. No radiation of pain, but hear high pitched sounds on expiration (family hx asthma)

PE: nasal polyps, sinus tenderness and respiratory hear bilateral rhonchi w/ prlongued expiration. Use accessory muscles.

Has increased IgE in blood. See opacity in frontal sinuses and hyperinflation on CXR

FEV1 is less then 80% of normal and no ST changes on EKG

What’s going on to cause this?

Answer 18

EArly allergic reaction in the airway including bronchial constriction, edema, mucous plugging: dude has asthma

Question 19

is a clinical syndrome characterized by episodic reversible airway obstruction, increased bronchial reactivity, and airway inflammation. Environmental exposure in sensitized individuals may trigger the process.

Answer 19

Asthma

Question 20

Pathophysiologically the allergic response in the airway is the result of a complex interaction of

Answer 20

mast cells, eosinophils, T lymphocytes, macrophages, dendritic cells, and neutrophils. Inhalation challenge studies with allergens reveal an early allergic response (EAR).

Question 21

Clinically, the manifestations of the EAR in the airway include

Answer 21

bronchial constriction, airway edema, and mucous plugging.

***mast cell-derived mediators

Question 22

Four to ten hours later after EAR, , one sees the late allergic response (LAR), which is characterized by

Answer 22

cellular infiltration into the airway and is most likely caused by cytokine-mediated recruitment of lymphocytes and eosinophils.

Degranulation of the mast cell also plays an important role.

Question 23

Preformed mast cell mediators, such as histamine and proteases, are released, leading to

Answer 23

Bronchocnx: immediate and early phase reaction!

Question 24

What is the pathway of the allergy response

Answer 24

Allergen–> to lymphoid tissue–> will produce IgE–> go and sensitize and coat a mast cell

THEN

reexposure to allergen will crosslink IgE on mast cell–> degranulation of histamine, tryptase and LTC4

Question 25

What is goind on in the Immediate early reaciton

Answer 25

Mintues: degranulation–> relase histamine, Leukotrines, cytokines and proteins=

Bronchoconstriction (causes chemotaxis and cell influx)

Question 26

What happens during late phase reaction?

Answer 26

Hours later–> cytokines/chemokines/Mediators cause

Inflammation

Question 27

What are some asthma triggers?

Answer 27

Allergic, Viral respiratory infections, Excersice, aspirin, irritants, weather changes

Question 28

A 15-year-old boy on the high school track team develops difficulty breathing associated with wheezing when running in the winter. What would be helpful to prevent symptoms?

Answer 28

• Premedication 15 minutes before exercise with a SABA is typically the first-line therapy
• Cover nose and mouth with scarf or face mask in cold weather to humidify air

*** Cooler, drier air causes release of bronchoconstrictor mediators from airway mast

cells: cysLTs (LTC4, LTD4) and histamine

Question 29

If you have asthma and take aspirin, what can happen?

Answer 29

You will inhibit the Prostaglandin pathway that leads to bronchial dialation (PGG2 or PGH2) and push for the leukotriene pathway instead = Smooth mscl contraction adn bronchoconstriciton = wheezing!

Question 30

What can be helpful to reduce ashtma symptoms in regards to humidity

Answer 30

Dust mite is one of the most common indoor allergens, except in locations where humidity is consistently less than 50%. When dust mite allergen is significantly reduced, patients have demonstrated improvement in allergic rhinitis symptoms and bronchial hyperresponsiveness.