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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
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187
• Pulmonary embolism
• Tracheomalacia
• Vocal cord dysfunction
Chronic bronchitis Vocal cord dysfunction
Emphysema Congestive heart failure
Cystic fibrosis Pulmonary embolism
Viral bronchiolitis Eosinophilic pneumonia
Bronchial stenosis
Mechanical airway obstruction
Aspirated foreign body
Endobronchial tumor Systemic vasculitis
Superior vena cava syndrome Carcinoid syndrome
Substernal thyroid Allergic bronchopulmonary aspergillosis
Drug-induced cough
β-Blockers
Angiotensin-converting enzyme inhibitors
Differential diagnosis of asthma [Holgate S, Sewell J, Payne KD.Chapter 01. In:
Crapo J, editor. Bone’s atlas of pulmonary and critical care medicine. Philadelphia:
Current Medicine; 2005. ISBN: 1-57340-211-7] Caption adapted from original
Pathophysiology andEtiology
• An inammatory process of the airways that results in periodic, at least partially reversible airow obstruction.
• Bronchial hyperresponsiveness.
• Family history may be pertinent for asthma diagnosis.
• Many cells and cellular elements contribute to asthma, including:
• Neutrophils
• Mast cells
• Eosinophils
• Macrophages
• Activated T lymphocytes
• Epithelial cells
• Many asthma triggers exist, including:
• Environmental allergens: dust mites, molds, animal dander, cockroach
allergens, fungi, etc.
• Viral respiratory tract infections
• Hyperventilation
• Gastroesophageal reux disease
• Environmental pollutants, e.g., tobacco smoke
• Obesity
• Hypersensitivity to nonsteroidal anti-inammatory drugs (NSAID)
188
C. V. Pollack, Jr. et al.
Pathophysiology of asthma at steady state and during an exacerbation. The airways
of asthmatic individuals are characterized by pathological changes, including thickened basement membrane, collagen deposition and hypertrophic smooth muscle,
collectively called ‘airway remodeling’. Inammation is triggered by a variety of
factors, including allergens and respiratory viruses. These factors also induce
hyperreactive responses in the asthmatic airways, associated with mucus and cell
debris released into the lumen, oedema and bronchoconstriction, leading to airway
obstruction and related acute exacerbations. Although pathophysiological changes
related to asthma are generally reversible, recovery may be partial. [From article:
Research needs in allergy: an EAACI position paper, in collaboration with
EFA. Clinical and Translational Allergy. 2012;2(1):21.; https://doi.org/
10.1186/2045-7022-2-21, at http://link.springer.com/article/10.1186%2F20457022-2-21/fulltext.html; by Nikolaos G Papadopoulos, Ioana Agache, Sevim
Bavbek, et al., © Papadopoulos etal.; licensee BioMed Central Ltd. 2012; licensed
under Creative Commons Attribution License BY 2.0 http://creativecommons.org/
licenses/by/2.0] Caption from original
Presentation
Typical/“Classic”
• Wheezing, coughing, shortness of breath, chest tightness, tachypnea, tachycardia, respiratory distress, altered mental status.
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Atypical
• Cough-variant asthma, nonasthmatic eosinophilic bronchitis, and atopic
cough.
• Approximately 30 % of cough variant asthma that go untreated will result
in progression to asthma
Primary Differential Considerations
• Vocal cord dysfunction
• Allergic and environmental asthma
• Tracheal and bronchial lesions
• Foreign bodies
• Pulmonary migraine
• Congestive heart failure
• Diffuse panbronchiolitis
• Aortic arch anomalies
• Sinus disease
• Gastroesophageal reux
• Pulmonary embolism
• Cystic brosis
• Eosinophilia count >8 %, consider allergic bronchoplumonary aspergillosis,
Churg-Strauss syndrome, or eosinophilic pneumonia
189
History andPhysical Exam
• Categories of asthma severity are determined by the following factors:
• Reported symptoms over the previous 2– 4 weeks
• Current level of lung function: FEV1, FEV1 (FVC values)
• Number of exacerbations requiring oral glucocorticoids per year
• Asthma Severity categories:
• Intermittent
• Mild persistent
• Moderate persistent
• Severe persistent
• Family history of asthma is often common for diagnoses of asthma, allergies,
eczema, and/or nasal polyps.
• Social history is frequently helpful to ascertain for environmental smoke
exposure. As mentioned under Incidence/Epidemiology, lower socioeconomic status may be associated with more severe asthma.
190
C. V. Pollack, Jr. et al.
Classication of asthma severity. Severity of asthma is classied into four
groups according to symptoms and lung function measurements. This method of
classication is important because therapy for asthma takes a stepwise approach
according to the disease severity. Generally patients have poor perception of the
severity of their asthma because they tend to adapt their lifestyle to accommodate their symptoms. This in turn leads to poor control of the disease as well as
poor quality of life. Classifying the disease in this stepwise fashion allows the
targeting of therapy according to the severity of the disease. FEV1—forced
expiratory volume in 1 second; PEFR—peak expiratory ow rate. [Gnanakumaran
G, Holgate S.Asthma in Adults. In: Lieberman P, Blaiss M, editors. Atlas of
Allergic Diseases, 2e. Philadelphia: Current Medicine; 2005] Caption from
original
Findings That Conrm Diagnosis
• Arterial blood gases and pulse oximetry for severity and response to
treatment.
• Eosinophil counts >4 %, absence is not exclusionary.
• Spirometry before and after short-acting bronchodilator.
• Bronchoprovocation test.
• High-resolution computed tomography (HRCT).
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191
Expiratory HRCT technique. A 9-year-old girl with suspected asthma. a Normal
inspiratory HRCT scan. b Expiratory HRCT shows visible differences in lung attenuation (mosaic pattern) due to obstructive small airway disease, which proved to be
asthma. Air-trapping is better depicted on expiratory scans [Garcia-Peña P, Lucaya
J.HRCT in children: technique and indications. European Radiology Supplements.
2004 Mar 1;14(4):L13–30.] Caption from original
Factors That Suggest Diagnosis
• Serum immunoglobulin E levels greater than 100IU frequently an allergic
reaction, may not be asthma but other conditions.
• Elevated blood eosinophils.
• Non-specic IgE >150IU.
• Family history.
• Allergies.
Factors That Exclude Diagnosis
• Laboratory assessments and studies are usually used to exclude other
diagnoses.
192
C. V. Pollack, Jr. et al.
Evaluation ofExacerbations
• Pulse oximetry: Inability to maintain pulse ox between above 92% suggests
impending respiratory failure.
• PEFR or FEV
measurement: PEFR is effort-dependent but can be used to
1
compare severity of exacerbation and response to therapy to previous care
episodes. FEV
is more accurate but is often logistically challenging to obtain
1
in the acute setting
Ancillary Studies
Laboratory
• ABG: progression of severity is typically hyperoxemia → hypoxemia →
hypercarbia.
• Pulse oximetry.
• WBC: may be high due to stress release and/or to concomitant infection.
Electrocardiography
• Indicated in patients at risk for cardiac disease, dysrhythmias, myocardial
ischemia.
• Transient ST-T wave changes in severe asthma.
• Tachycardia typical.
Imaging
• Chest x-ray is not necessary unless there is suspicion of pneumonia, pneumothorax or pneumomediastinum, foreign body aspiration, comorbid illness,
diabetes, AIDS, renal failure, or cancer.
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Other Studies
• Peak Flow
• Spirometry
• Lung function study
• Provocative testing
• Diffusing capacity for carbon monoxide (DLco)
• Allergy testing
Special Populations
Age
Pediatrics
• Asthma is not an uncommon cause of chest pain in children.
• Severity classication in children is key.
• Even children with mild asthma can have severe exacerbations.
• Controller medications are based on the severity of the symptoms and
exacerbation.
193
• Nonspecic symptoms in infants or young children may have a history of
recurrent bronchitis, bronchiolitis, or pneumonia.
• Review for family history or allergy and medical history of early injury to
airway.
• Infants are vulnerable to respiratory failure.
194
C. V. Pollack, Jr. et al.
Pediatric indications for asthma drugs [Chang C. Asthma in Children and
Adolescents: A Comprehensive Approach to Diagnosis and Management. Clinical
Reviews in Allergy & Immunology. 2012 Aug;43(1-2):98–137.] Caption from
original
• The management of an acute asthmatic in a child is not substantially different
than that utilized for the adult patient.
• Inhaled anticholinergics in children should be utilized as recue medications.
Early administration of steroids is effective and recommended in all cases.
• The use of chest radiographs in pediatric asthma should be reserved for infants
or children who present with wheezing for the rst time.
• Children are more likely to have cough-variant asthma, in which coughing is
a more predominant presenting symptom than wheezing. The cough generally
responds to bronchodilator therapy.
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Elderly
• The elderly have high prevalence of other obstructive lung disease. The
elderly may have increased sensitivity to adverse effects of β
-agonists and
2
inhaled corticosteroids.
Pregnancy
• Treat asthma aggressively during pregnancy. The National Asthma Education
and Prevention Program Working Group Report on Managing Asthma During
Pregnancy: Recommendations for Pharmacologic Treatment (2004; U.S.
Department of Health and Human Services) can be found at the following
link:
http://www.nhlbi.nih.gov/health-pro/guidelines/archive/asthma-management-
pregnancy-guidelines
Co-morbidities
• Rhinitis and rhinosinusitis management
• Allergic sensitivity and allergen exposure
• Psychological dysfunction
• Paradoxical vocal cord dysfunction
• Asymptomatic gastroesophageal reux
• Obstructive sleep apnea
• Connective tissue disease
• Dermatologic conditions
• Immunologic and hematologic disease
• Metabolic disorders
• Obesity
• Obstructive lung disease
• Pregnancy
• Respiratory infection
195
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Altered mental status may signal respiratory failure.
• Correct use of medications such as inhalers and nebulizers.
• Monitor peak ows to assess severity and response to treatment.
196
C. V. Pollack, Jr. et al.
Mimics
• Sinusitis
• Myocardial ischemia
• Gastrointestinal reux
• Congestive heart failure
• Not all wheezing in infants and young children is asthma
Time-Dependent Interventions
• Immediate initiation of inhaled β2- adrenergic agonist.
• Nebulized treatment.
• Supplemental oxygen.
• Administration of subcutaneous epinephrine unless concerned about coronary artery disease or hypertension.
• Intubation in respiratory failure.
• Corticoteroids should be given early, as they require 4–6 hours to show
benet.
Overall Principles ofTreatment
• Treatment is based on asthma severity.
• Routine monitoring of symptoms and lung function.
• Patient education is essential.
• Recognize and control trigger factors (environmental factors).
• Controlling comorbid conditions that contribute to asthma severity.
• Pharmacologic therapy.
• Reduction of personal impairment and reduction of risk.
• Preventative approach with regularly scheduled check-ups and family/patient
education.
• Awareness, recognition, and treatment of these atypical asthmas is
important.
• Many base their management of asthma in children upon the National Asthma
Education and Prevention Program (NAEPP) Expert panel guidelines (
www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/
full-report).
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