BRONCHIAL ASTHMA

AKSHAYA M P
ROLL : 13
BRONCHIAL ASTHMA
Definition
• Bronchial asthma is a disease due to
hyperreactive airways characterized by the
reversible diffuse airway obstruction due to
bronchospasm and inflammatory oedema .It
manifests by widespread narrowing of the
airways causing paroxysmal dyspnea , wheezing
or cough.
 Pathophysiology
Airway obstruction is caused by
• 1.edema and inflammation of mucous membrane lining the airways .
• 2.excessive secretion of mucus , inflammatory cells and cellular debris
• 3.spasm of the smooth muscle of bronchi.
 classification
• Asthma has been classified as
a. atopic (lgE mediated, triggered by allergens)
b. nonatopic (nonlgE mediated, triggered by infection),
c. mixed,
d. exercise induced or aspirin induced.
• Inhalation of an allergen leads to a biphasic response with early and late
reactions ultimately causing bronchoconstriction.
Triggers of Episodes of Asthma
• Viral infections. Viral infections in young children and exercise in older
child or adult appear to be more frequent triggers of airway
narrowing.
• Viral infections interfere with the integrity of mucosal surfaces by
opening up tight intraepithelial cell junctions and induce shedding of
epithelium.
• Role of exercise. Exercise induced asthma occurs in genetically
susceptible individuals with hyper-reactive airways. The loss of water
from the respiratory tract induces mucosal hyperosmolarity, which
stimulates mediator release from mast cells.
• Weather change. Sudden change in the weather might result in (i) loss
of heat and water from lower airways and
• (ii) sudden release of airborne allergens in atmosphere, resulting in
exacerbation of asthma.

• Emotional factors. Emotional stress operated through the vagus

nerve, initiates bronchial smooth muscles contractility.

• Role of food. Allergy to food proteins or additives in food might have a

minor role in the pathogenesis of asthma.These should be
incriminated only on a very strong association with the illness.

• Endocrine factors. Some endocrine changes including puberty may

increase symptoms of asthma.
Clinical Features
• The clinical features of asthma are variable.
• Symptoms vary from simple recurrent cough to severe wheezing.
• The symptoms occur with change in season, aggravated by exercise
and more at night.
• Acute asthma may usually begin with a cold, or bouts of spasmodic
coughing.
• In early phase of the episode, the cough is nonproductive.
• The patient becomes dyspneic, with prolonged expiration and
wheezing.
• Accessory muscles of respiration are excessively used.
• The child sweats profusely, may develop cyanosis and becomes
apprehensive and restless and appear fatigued.
• In severe episodes the child may show air hunger.
• The chest is hyper-resonant because of excessive air trapping.
• As the obstruction becomes severe, the airflow decreases markedly.
• As a result the breath sounds become feeble Wheezing which was
earlier audible may disappear. This is an ominous sign.
• Absence of wheezing in the presence of cyanosis and respiratory distress
should not be considered as an evidence of clinical improvement.
• As the child improve, the airflow increases and wheezing may reappear.
With remission, the wheeze disappears.
• Severe hypoxemia in asthma results in cyanosis and cardiac
arrhythmias.
• Pulsus paradoxus indicates severe illness.
• Mucus plugs occluding the bronchial tree may cause collapse of small
segments of the lung.
• Persistence of hyperinflation of the chest even after subsidence of the
asthmatic attack signifies that the apparent relief from bronchospasm
will be short lived.
• In chronic intermittent cases the chest becomes barrel shaped
DIAGNOSIS
• A prolonged whistling sound heard at the mouth during expiration is
called a wheeze.
• Recurrent attacks of wheezing indicate bronchial asthma.
• Although intermittent attacks of coughing may be due to recurrent
viral infections, the diagnosis of bronchial asthma should be
considered.
• Cough, which is associated with asthma generally, worsens after
exercise.
• Sputum is generally clear and mucoid but expectoration of yellowish
sputum (attributed to large number of eosinophils) does not exclude
he diagnosis of asthma.
• Chronic spasmodic cough may suggest occult asthma.
Investigations
• the important parameters in spirometry include PEFR, FEV1 , FVC and FEV 25- 75
• All parameters are decreased in asthma . Fev1 used for documentation of
severity of asthma
• Fev25- 75 is effort dependent so most sensitive indicator of airway obstruction
• PEFR can be measured with peak expiratory flowmeter whereas for other
parameters spirometer is used
• PEFR is used as diagnostic tool in doubtful cases as well as in monitoring of
treatment .
• Abnormality in PEFR suggestive of asthma include a diurnal variation of more
than 20 %, less than 80% of predicted and improvement of more than 20% after
bronchodilator therapy
Based on severity of asthma
• ABSOLUTE EOSINOPHIL COUNT-
• Significance of eosinophilia for distinguishing between allergic ,
vasomotor or infectious nature of chronic resp disease is limited.
• When Eosinophilia present bronchial obstruction generally respond well
to antispasmodic therapy and the condition is often reversible.
• The eosinophil count maybe low in cases associated with infection.
• Steroid mediction in asthma causes eosinophilia.
Chest x ray film
• Shows bilateral and symmetric air trapping in case of asthma.
• Patches of atelectasis of varying sizes due to mucus plugs are not
unusual.
• Main pulmonary artery is prominent due to pulmonary hypertension
• Bronchial cuffing may occur due to the presence of edema fluid in
perivascular and peribronchial interstitial space
• Extensive areas of collapse or consolidation should suggest an
alternative diagnosis .
• Chest xray film may often be normal
ALLERGY TEST
• Skin test and radioallaergosorbant allergent specific IgE (RAST)have
limited usefulness
• Few children need skin test to identify sensitivity to differnet antigens
since the role of desensitization therapy is not established
Differential diagnosis
• Bronchiolitis. Bronchiolitis always occurs within the first 2 yr, usually
within the first 6 months of life. It is commoner in winter or spring
months. Generally there is a single attack. Repeated attacks indicate
viral infection associated wheeze or asthma.
• Hyperinflation of chest with scattered areas of infiltration may be
seen on chest X-ray.
• Asthma may start at any age; more than 3 episodes are usual and
wheezing is prominent. Infants diagnosed as bronchiolitis with family
history of allergy, having atopic eczema or whose IgE levels are
elevated are likely to develop asthma.
Congenital malformation
• causing obstruction, e.g. vascular rings such as aberrant right
subclavian artery or double aortic arch, bronchogenic cysts and
tracheomalacia should be excluded in differential diagnosis.
Aspiration of foreign body
• Wheeze, if present is generally localized. The history of foreign body
aspiration may be forgotten.
• An area with diminished air entry, with or without hyper resonance
on percussion especially in children, may be due to obstructive
emphysema because of a check-valve type of obstruction due to the
foreign body.
• Most children develop frequent infections in the lung around the
foreign body.
 Hypersensitivity pneumonitis.
• An acute or chronic lung disease may be observed following inhalation of
organic dust such as molds, wood or cotton dust, bird droppings,fur dust,
grain or following exposure to certain chemicals or drugs such as epoxy
resins, PAS and sulfonamides.
• In the acute form of illness, these children show from fever, chills, dyspnea,
malaise, aches and pain, loud inspiratory rales (crackles) at bases of lung
and weight loss.
• X-ray chest shows interstitial pneumonia. Bronchial markings are prominent.
• The levels of IgE antibodies to the specific antigen are increased. The skin
test shows Arthus phenomenon with local hemorrhage, edema and local
pain within 8 hr of the test. Diagnosis is established by lung biopsy.
Cystic fibrosis
• Children with cystic fibrosis may present with recurrent wheezing but
over a period of time they develop clubbing. There may be clinical
evidence of malabsorption.
• X-ray film may show evidence of hyperinflation, peribronchial cuffing
and pneumonia.
• Diagnosis is established by estimating sweat chloride levels
Clinical presentation
HISTORY
• The history in a child with suspected asthma centers on: Presence of symptoms
• Typical symptom patterns
• Risk factors
• Precipitating factors or conditions (ie, atopy) Symptoms 80 % of children with
asthma < 5 year of age.
• Most common symptoms: Coughing and wheezing Asthmatic Cough:
characteristics? Nocturnal cough
• Seasonal cough * After specific exposures (eg, cold air, exercise, laughing, or
crying)
• Lasts more than three weeks
• Typically dry
symptoms
• Wheeze? A high-pitched sound produced when air is forced through
narrow airways. The characteristics of wheezes in asthma:
• Polyphonic (varied in pitch), reflecting the heterogeneous distribution of
affected airways.
• Expiratory When airflow obstruction becomes severe, wheezing can be
heard on both inspiration and expiration.
• If harsh expiratory monophonic wheeze, consider central airway
obstruction eg, tracheomalacia.
If inspiratory monophonic wheeze, consider Upper airway obstruction (eg,
vocal cord dysfunction) (eg, Seasonal symptoms Symptoms that are worse in
certain pollen seasons are characteristic of atopic asthma
Additional history
• – Personal history of other atopic diseases
• Family history of asthma or other atopic diseases (eg, allergic rhinitis,
atopic dermatitis, and food allergy) ·
• Environmental history
• Past medical history
• Medication use, medical utilization.
• School attendance, and psychosocial factors.
PHYSICAL EXAMINATION
• Generally normal if performed when the patient does not have an
acute exacerbation.
• · Abnormal findings in the absence of an acute exacerbation may
suggest: > Severe disease > Suboptimal control > Associated atopic
conditions.
Signs
• Dry cough
• Signs of respiratory distress · An increased anterior-posterior
diameter of the chest due to air trapping
• Decreased air entry or wheezing “ A prolonged expiratory phase
Signs of rhinitis, conjunctivitis, and sinusitis (nasal discharge, inflamed
nasal mucosa, sinus tenderness, dark circles under the eyes)
PHYSICAL EXAMINATION
• Allergic salute : a transverse nasal crease due to frequent itching.
• Halitosis due to chronic rhinitis, sinusitis, and mouth breathing. ·
Eczema/atopic dermatitis
• Nasal polyps.
Thank you