Clinical Manifestations of Clinical Manifestations of AsthmaAsthma

The classic symptoms of asthma are The classic symptoms of asthma are wheezingwheezing , , coughcough & & shortness ofshortness of breath( with chest tightness ).breath( with chest tightness ).

During periods of relatively normal During periods of relatively normal lung function , patients are likely to lung function , patients are likely to have no physical findingshave no physical findings

Wheezing:Wheezing: Wheezing is the most common finding during acute Wheezing is the most common finding during acute

airway obstruction, & the chest may be airway obstruction, & the chest may be hyperresonant on percussion.hyperresonant on percussion.

Cough:Cough:The cough can be nonproductive or raise copious The cough can be nonproductive or raise copious

amounts of sputum ( particularly in the presence of amounts of sputum ( particularly in the presence of infection ) infection )

EosinophilsEosinophils & their debris may cause a & their debris may cause a yellowyellow discoloration of sputum , even when infection is discoloration of sputum , even when infection is absent absent

Occationally , cough is the only manifestation of Occationally , cough is the only manifestation of asthma.asthma.

Shortness of breath:Shortness of breath: Dyspnea tends to vary greatly over time , Dyspnea tends to vary greatly over time ,

depending on the severity of airflow obstruction. depending on the severity of airflow obstruction.

Chest tightness :Chest tightness : commonly occurs with dyspnea & may be commonly occurs with dyspnea & may be

confused with angina pectoris .confused with angina pectoris .

Most patients associate their chest tightness with Most patients associate their chest tightness with the sensation of being unable to take in a full & the sensation of being unable to take in a full & satisfying breath .satisfying breath .

Physical signs of asthma :Physical signs of asthma : (in the (in the chest)chest)

During an attack the chest in held near position of full During an attack the chest in held near position of full inspiration & percussion note may be inspiration & percussion note may be hyperresonant.hyperresonant.

Breath sound are Breath sound are vesicular with prolong expiratory vesicular with prolong expiratory phasephase..

Bilateral expiratory & may be inspiratory Bilateral expiratory & may be inspiratory ronchi.ronchi.

In very sever asthma the chest may be In very sever asthma the chest may be silentsilent, , because because of insufficient air flow.of insufficient air flow.

No physical signs between attack except in patients No physical signs between attack except in patients with chronic asthma which there is usually expiratory with chronic asthma which there is usually expiratory rhonchirhonchi

Sever asthma starting from childhood may cause Sever asthma starting from childhood may cause

pigeonpigeon chest deformity (pectus carinatum) chest deformity (pectus carinatum)

According to the clinical features we According to the clinical features we can divide asthma into the can divide asthma into the following:following:

1- Episodic asthma (usually atopic).1- Episodic asthma (usually atopic).

2- Chronic asthma (non atopic).2- Chronic asthma (non atopic).

3- Acute sever asthma (status 3- Acute sever asthma (status asthmatics).asthmatics).

• History of allergy is very important.History of allergy is very important.• An extremely common feature of asthma is nocturnal An extremely common feature of asthma is nocturnal

awakening with dyspnea & wheezing .awakening with dyspnea & wheezing .

Episodic asthma (atopic):Episodic asthma (atopic):

No respiratory symptoms between episodes.No respiratory symptoms between episodes.

Paroxysms of dyspnoea & wheeze may Paroxysms of dyspnoea & wheeze may occur at any time, may be sudden onset.occur at any time, may be sudden onset.

Paroxysms may last hours, days or weeks, Paroxysms may last hours, days or weeks, may be mild, moderate or severe.may be mild, moderate or severe.

Triggers are : allergens, cold, exercise & Triggers are : allergens, cold, exercise & respiratory infections (specially viral).respiratory infections (specially viral).

Chronic asthma (non atopic) :Chronic asthma (non atopic) : symptoms are: wheeze , cough , dyspnoea & symptoms are: wheeze , cough , dyspnoea &

chest tightness.chest tightness. cough & wheeze at night (an extremely cough & wheeze at night (an extremely

common feature of asthma is nocturnal common feature of asthma is nocturnal awakening with dyspnoea and/ or wheezing).awakening with dyspnoea and/ or wheezing).

Episodes of sever acute asthma.Episodes of sever acute asthma.

Recurrent episodes of chest infection with Recurrent episodes of chest infection with productive cough are common productive cough are common

(It may be difficult to differentiate from (It may be difficult to differentiate from chronic bronchitis).chronic bronchitis).

Acute sever asthma (status Acute sever asthma (status asthmaticus)asthmaticus)

This is a life- threatening attack of asthma .This is a life- threatening attack of asthma .

-patients are usually extremely distressed, usually -patients are usually extremely distressed, usually adopts an upright position, fixing his shoulder adopts an upright position, fixing his shoulder girdle to assist the accessory muscle of respiration .girdle to assist the accessory muscle of respiration .

-The patient usually have -The patient usually have dyspnoea,tachypnoea ,wheeze , dry cough, dyspnoea,tachypnoea ,wheeze , dry cough, sweating ,tachycardia & pulses paradoxes (a large sweating ,tachycardia & pulses paradoxes (a large fall in blood pressure during inspiration & the pulse fall in blood pressure during inspiration & the pulse may be impalpable due to reduced cardiac return may be impalpable due to reduced cardiac return as a consequence of sever hyperinflation).as a consequence of sever hyperinflation).

-In sever cases: central cyanosis, silent chest (no -In sever cases: central cyanosis, silent chest (no wheeze) & bradycardia may occur.wheeze) & bradycardia may occur.

Triggers of asthma (not Triggers of asthma (not causes) :causes) :

1- 1- Exposure to allergensExposure to allergens: such as home dust, fungal : such as home dust, fungal spores, gases , fumes or wood dusts.spores, gases , fumes or wood dusts.

2- 2- Cold exposureCold exposure (cold air). (cold air).3- 3- Exercise.Exercise.4- 4- Smoking: Smoking: -Smoking during pregnancy increases the risk of -Smoking during pregnancy increases the risk of

developing atopic asthma in infancy.developing atopic asthma in infancy. -Passive exposure to cigarettes smoke immediately -Passive exposure to cigarettes smoke immediately

following birth increase the risk of developing following birth increase the risk of developing asthma.asthma.

5-5- drugs: drugs: B- blockers (even when used topically or eye B- blockers (even when used topically or eye drops), aspirin (and other NSAID)drops), aspirin (and other NSAID)

about 10% of asthmatic patients develop about 10% of asthmatic patients develop bronchospasm when given aspirin. bronchospasm when given aspirin.

6- 6- Infection:Infection: viral & bacterial infection of respiratory viral & bacterial infection of respiratory tract (viral more than bacterial).tract (viral more than bacterial).

7- 7- Anxiety Anxiety & psychological factors:& psychological factors: Sever anxiety or stress can exacerbate asthma.Sever anxiety or stress can exacerbate asthma.

ALLERGENSALLERGENS

Investigation in asthmaInvestigation in asthma

1/ CXR.1/ CXR.

2/ pulmonary function test.2/ pulmonary function test.

3/ skin hypersensitivity tests.3/ skin hypersensitivity tests.

4/measurement of allergic status .4/measurement of allergic status .

5/ blood gases5/ blood gases

1- Chest X- ray1- Chest X- ray Normal Normal between attacks.between attacks.

During an attack looks During an attack looks hyperinflated.hyperinflated.

In chronic cases looks similar to the hyperinflation In chronic cases looks similar to the hyperinflation caused by emphysema.caused by emphysema.

In chronic cases a lateral view may show In chronic cases a lateral view may show pigeonpigeon chest deformity.chest deformity.

There may be segmental or lobar There may be segmental or lobar collapsecollapse due to due to obstruction of a large bronchus by thick mucus obstruction of a large bronchus by thick mucus (mucus plug).(mucus plug).

Pneumothorax:Pneumothorax: a rare but may be fatal a rare but may be fatal complication of asthma.complication of asthma.

Rarely in sever cases CXR may show mediastinal or Rarely in sever cases CXR may show mediastinal or subcutaneous emphysema. subcutaneous emphysema.

2- Pulmonary function tests2- Pulmonary function tests FEV/VC <70%FEV/VC <70% FEV, VC and PEF all are reduced, they should be FEV, VC and PEF all are reduced, they should be

recorded for diagnosis & follow up .recorded for diagnosis & follow up .

PEF rate should be recorded twice daily to all PEF rate should be recorded twice daily to all patients admitted to hospital by a peak flow patients admitted to hospital by a peak flow meter & a chart arranged which will show marked meter & a chart arranged which will show marked diurnal variation.diurnal variation.

The lowest values recorded in the morning & The lowest values recorded in the morning & called (morning dipping). called (morning dipping).

Morning dipping Morning dipping :: PEF over nigh fall (morning PEF over nigh fall (morning dipping) & subsequent rise during the day in dipping) & subsequent rise during the day in patients with asthma.patients with asthma.

Reversibility test :Reversibility test :

in asthma usually there is an in asthma usually there is an improvement in FEV1 or PEF improvement in FEV1 or PEF following administration of a following administration of a bronchodilator .bronchodilator .

Reversibility test is defined as a 15% Reversibility test is defined as a 15% or more increase in FEV1 20 min. or more increase in FEV1 20 min. after inhalation of a after inhalation of a ββ-agonist-agonist

Measurement of bronchial Measurement of bronchial reactivity :reactivity :

can be of value in diagnosing asthma & in can be of value in diagnosing asthma & in assessing the effects of treatmentassessing the effects of treatment

this can be achieved by administering this can be achieved by administering increasing concentration of substances increasing concentration of substances such as such as histaminehistamine by inhalation until by inhalation until there is a 20% fall in FEV1, or PEF. there is a 20% fall in FEV1, or PEF.

Patients with asthma show evidence of Patients with asthma show evidence of broncho-constriction as much lower broncho-constriction as much lower concentrations than normal subjects.concentrations than normal subjects.

3- Skin hypersensitivity test :3- Skin hypersensitivity test : By By intradermal injectionintradermal injection of common of common

allergens to differenciate atopic from non-allergens to differenciate atopic from non-atopic .atopic .

In atopic there is positive skin test .In atopic there is positive skin test .

4- Measurement of allergic status :4- Measurement of allergic status : 1- elevated sputum &/or peripheral blood 1- elevated sputum &/or peripheral blood

oesinophil .oesinophil .2- elevated serum 2- elevated serum IgE IgE level.level.3- skin test (simple & provide rapid 3- skin test (simple & provide rapid

assessment of atopy).assessment of atopy).

DIAGNOSIS OF ALLERGIC DIAGNOSIS OF ALLERGIC CONDITIONCONDITION

SKIN TEST SENSITIVITY

POSITIVE SKIN TEST

WHEAL & FLARE REACTION

5- Blood gases :5- Blood gases :

PaO2 is diminished .PaO2 is diminished . PaCO2 is normal or diminished due PaCO2 is normal or diminished due

to hyperventillation .to hyperventillation .