Inciter

Forsed position 

Characteristically 

Non characteristically 

Auscultation

The loosened breathing, the prolonged inspiration, dry whistling and moist wheezes

Strict breathing

Dry  wheezes

Percussion 

Box sound 

Pulmonary sound

“Mute” light 

Characteristically 

Not characteristically

                                  Treatment of the patients

Medical Care

The goals of asthma therapy are to prevent chronic and troublesome symptoms, maintain normal or near-normal pulmonary function, maintain normal physical activity levels (including exercise), prevent recurrent exacerbations of asthma, and minimize the need for emergency department visits or hospitalizations, provide optimal pharmacotherapy with minimal or no adverse effects, and meet the family's expectations for asthma care.

Medical care includes treatment of acute asthmatic episodes and control of chronic symptoms, including nocturnal and exercise-induced asthmatic symptoms. Pharmacologic management includes the use of control agents such as inhaled corticosteroids, inhaled cromolyn or nedocromil, long-acting bronchodilators, theophylline, leukotriene modifiers, and recently introduced strategies such as the use of anti-IgE antibodies. Relief medications include short-acting bronchodilators, systemic corticosteroids, and ipratropium. Nonpharmacologic management includes measures to improve patient compliance and adherence. For all but the most severely affected patients, the ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity to provide a healthy (or near healthy) lifestyle appropriate to the age of child.

A step-down approach based on the asthma severity classification system emphasizes the initiation of high-level therapy to establish prompt control and then decreasing therapy (National Asthma Education and Prevention Program Expert Panel Report II, 1997). Treatment should be reviewed every 1-6 months; a gradual stepwise reduction in treatment may be possible. If control is not maintained despite adequate medication and adherence and the exclusion of contributing environmental factors, increased therapy should be considered. Long- and short-term therapy is based on the severity of asthma, as follows:

ü Mild intermittent asthma 

ü Long-term control: Usually, no daily medication is needed.

ü Quick relief: Short-acting bronchodilators in the form of inhaled beta2-agonists should be used as needed for symptom control.

The use of short-acting inhaled beta2-agonists more than 2 times a week may indicate the need to initiate long-term control therapy.

Mild persistent asthma 

Long-term control: Anti-inflammatory treatment in the form of low-dose inhaled corticosteroids or nonsteroidal agents (eg, cromolyn, nedocromil) is preferred. Some evidence suggests that leukotriene antagonists may be useful as first-line therapy in children. Recently, the use of montelukast was approved for children aged 2 years and older.

Quick relief: Short-acting bronchodilators in the form of inhaled beta2-agonists should be used as needed for symptom control. Use of short-acting inhaled beta2-agonists on a daily basis or increasing use indicates the need for additional long-term therapy.

Moderate persistent asthma

Long-term control: Daily anti-inflammatory treatment in the form of inhaled corticosteroids (medium dose) is preferred. Otherwise, low- or medium-dose inhaled corticosteroids combined with a long-acting bronchodilator or leukotriene antagonist can be used, especially for the control of nocturnal or exercise-induced asthmatic symptoms.

Quick relief: Short-acting bronchodilators in the form of inhaled beta2-agonists should be used as needed for symptom control. The use of short-acting inhaled beta2-agonists on a daily basis or increasing use indicates the need for additional long-term therapy.

Severe persistent asthma 

Long-term control 

Daily anti-inflammatory treatment in the form of inhaled corticosteroids (high dose) is preferred. Other medications, such as a long-acting bronchodilator leukotriene antagonist or theophylline, can be added.

Patients with moderate-to-severe asthma who react to perennial allergens despite inhaled corticosteroids may benefit from omalizumab treatment. Two 52-week pivotal Phase III clinical trials were designed to study asthma exacerbation reduction in 1071 patients with asthma (aged 12-76 y). The coprimary endpoint of each study was the number of asthma exacerbations per patient during the stable-steroid phase and the steroid-reduction phase. Patients were randomized to receive subcutaneous omalizumab or placebo every 2-4 weeks. Inhaled corticosteroid doses were kept stable over the initial 16 weeks of treatment (stable-steroid phase) and tapered during a further 12-week treatment period (steroid-reduction phase).

In both pivotal clinical trials, when used as an add-on therapy to inhaled corticosteroids, omalizumab reduced mean asthma exacerbations (ie, asthma attacks) per patient by 33%-75% during the stable-steroid phase and 33%-50% during the steroid-reduction phase. Reduction in asthma exacerbations was confirmed by improvements in other measurements of asthma control, including symptom scores (eg, nocturnal awakenings, daytime asthma symptoms).

Quick relief: Short-acting bronchodilators in the form of inhaled beta2-agonists should be used as needed for symptom control. The use of short-acting inhaled beta2-agonists on a daily basis or increasing use indicates the need for additional long-term therapy.

Acute severe asthmatic episode (status asthmaticus) 

Treatment goals are the following: 

Correction of significant hypoxemia with supplemental oxygen: In severe cases, alveolar hypoventilation requires mechanically assisted ventilation.

Rapid reversal of airflow obstruction by using repeated or continuous administration of an inhaled beta2-agonist: Early administration of systemic corticosteroids (eg, oral prednisone or intravenous methylprednisolone) is suggested in children with asthma that fails to respond promptly and completely to inhaled beta2-agonists.

Reduction in the likelihood of recurrence of severe airflow obstruction by intensifying therapy: Often, a short course of systemic corticosteroids is helpful.

Achieving these goals requires close monitoring by means of serial clinical assessment and measurement of lung function (in patients of appropriate ages) to quantify the severity of airflow obstruction and its response to treatment. Improvement in FEV1 after 30 minutes of treatment is significantly correlated with a broad range of indices of the severity of asthmatic exacerbations, and repeated measurement of airflow in the emergency department can help reduce unnecessary admissions. Use of the peak flow rate or FEV1 values, along with the patient's history, current symptoms, physical findings, to guide treatment decisions is helpful in achieving the aforementioned goals. In using the PEF expressed as a percentage of the patient's best value, the effect of irreversible airflow obstruction should be considered. For example, in a patient whose best peak flow rate is 160 L/min, a decrease of 40% represents severe and potentially life-threatening obstruction.

                                      Consultations

Consider consultation with an allergist; ear, nose, and throat (ENT) specialist; or gastroenterologist. An allergist may help with further evaluation and management when the history and physical examination findings suggest significant allergies (especially systemic involvement and allergies to dietary products). An ENT specialist may help in managing chronic sinusitis. A gastroenterologist may help in excluding gastroesophageal reflux.  

                                   Diet

When a patient has major allergies to dietary products, avoidance of particular foods may help. In the absence of specific food allergies, dietary changes are not necessary. Unless compelling evidence for a specific allergy exists, milk products do not have to be avoided.

                                  Activity

One of the goals of therapy is to adequately control exercise-induced asthmatic symptoms so that physical activity is not restricted.

                             Medication

Current treatment of asthma includes the use of relievers, such as beta-adrenergic agonists, systemic corticosteroids, and ipratropium, and controllers, such as cromolyn, nedocromil, inhaled corticosteroids, long-acting beta-agonists, theophylline, and leukotriene modifiers.

Drug Category: Bronchodilator, beta2-agonists

 These agents act as bronchodilators, used to treat bronchospasm in acute asthmatic episodes, and used to prevent bronchospasm associated with exercise-induced asthma or nocturnal asthma. Several studies have suggested that short-acting beta2-agonists such as albuterol may produce adverse outcomes (eg, decreased peak flow or increased risk of exacerbations) in patients homozygous for arginine (Arg/Arg) at the 16th amino acid position of beta-adrenergic receptor gene compared with patients homozygous for glycine (Gly-Gly). Recently, similar findings are reported for long-acting beta2-agonists (eg, salmeterol).

Albuterol sulfate (Proventil, Ventolin)   This beta2-agonist is the most commonly used bronchodilator that is available in multiple forms (eg, solution for nebulization, metered-dose inhaler (MDI), oral solution). This is most commonly used in rescue therapy for acute asthmatic symptoms. Albuterol is used as needed, and prolonged use may be associated with tachyphylaxis due to beta2-receptor downregulation and receptor hyposensitivity.

Pediatric:

Oral inhaler: 90 mcg per inhalation, 2 inhalations q4-6h; more inhalations may be used in severe, acute episodes; more frequent dosing can be used to treat acute symptoms

 Nebulizer: 2.5 mg via nebulization of 0.5% solution in 2-3 mL of sodium chloride solution q4-6h

Pirbuterol acetate (Maxair)  Available as a breath-actuated or ordinary inhaler. The ease of administration with the breath-actuated device makes it an attractive choice in the treatment of acute symptoms in younger children who otherwise cannot use an MDI. Strength is 200 mcg per inhalation.

Oral inhalation: 1-2 inhalations q4-6h; not to exceed 12 inhalations q24

Drug Category: Nonracemic form of the beta2-agonist albuterol

This nonracemic form of albuterol was recently introduced. One advantage is better efficacy; hence, lower doses have a therapeutic effect, and a significant reduction in the adverse effects associated with racemic albuterol (eg, muscle tremors, tachycardia, hyperglycemia, hypokalemia) is reported.

Levalbuterol (Xopenex) Nonracemic form of albuterol, levalbuterol (R isomer) is effective in smaller doses and is reported to have fewer adverse effects (eg, tachycardia, hyperglycemia, hypokalemia). The dose may be doubled in acute severe episodes when even a slight increase in the bronchodilator response may make a big difference in the management strategy (eg, in avoiding patient ventilation).