Recurrent episodes of coughing, +/- wheezing, breathlessness and chest tightness

These episodes are usually associated with widespread but variable airflow obstruction that is OFTEN reversible either spontaneously or with treatment

1. Airborne allergens

2. Viral respitatory infections - implicated during infancy

tobacco smoke

air pollution

occupational exposures

diet low in antioxidants and omega3 fatty acid

IgE dependent release of mediators from mast cells

-histamime

-tryptase

-leukotrienes

-prostaglandins

+++less defined=NSAIDS, cold air, exercise

1. Airway edema/inflammation

2. airway hyperresponsiveness

3. airway remodeling

Spirometry: repeated measurements

-FEV1 dec

-FEV6 (sub for FVC)

-FVC (preserved or dec)

-FEV1/FVC dec

+++tested before and after SABD to assess reversibility

1. FEV1>200 ml and 12% change from baseline

2. some show reversibility after 2-3 wks on ICS

-need follow up spiro

Spirometry

flow loops

lung vol

airway resistance

DLCO

Complete PFTs

ABG

Sputum eosinophilia

FeNO measurements

Bronchoprovocation

Allergy testing

serologies

GERD testing

CT sinus

Monitoring tool, not diagnostic for asthma

green (80-100%) good

yellow (50-80%) caution

Red (<50%) danger

Methacholine is adminstered in incremental doses up to max dose of 16 mg/ml

20% dec in FEV1, up to 4mg/ml =positive  for bronchial hyperresponsiveness

Avoid performing test is FEV1 less than 65-70% at baseline

-allergic rhinitis and sinusitis

-FB

-VCD

-Vascular ring or laryngeal webs

-laryngotracheomalacia, tracheal stenosis, bronchostenosis

-large  nodes, tumor

-viral bronchitis/brinchiolitis

-CF

-Bronchopulmonary dysplasia

-CHD

ABOA

Eosinophilic bronchitis

Post infectious cough

GERD

PND/ Sinus disease

tumors

cardiac

VCD

In acute setting

Bronchiectasis

aspergillus (fungal)

occupational lung disease

Once diagnosis is established next:

1. Identify percipiating factors

2. identify comorbid that may aggravate asthma

3.classify asthma severity using impairment and risk domains

4. assses the patients knoledge and skills for self management

1. Symptoms 2x a week

2. <2nocturnal awakenings

3. use of SABA fewer than 2xa week

4. no change in activities

5. one, or no exacerbations requiring PO steroids

6. FEV1 b/w exacerbations that is normal

1. Symp >2x a week

2. 3-4 nocturnal awakenings per mo

3. use of SABA > 2 x a week not daily

4. minor interference with ADLs

5. FEV1 normal (>80% predicted)

6. 2 or more exacerbations requiring PO steroids per year

1. Symptoms daily

2. Nocturnal awakenings more than once a wk

3. daily need for SABA

4. Some limitations in nl activities

5. FEV1 b/w 60-80% predicted

6. FEV1/FVC reduced below normal

1. continuous symptoms

2. nocturnal awakenings nightly

3. need for SABA multiple times daily

4. extreme limitation in activity

5.FEV1 <60% predicted

6. FEV1/FVC reduced below normal

7. 2 or more exacerbations requiring oral steroids per year

Monoclonal ABX that binds to IGE

Must have ALLRGIC ASTHMA and >12 yo

mod-severe persistant asthma

High IGE

(+) allergy testing

SQ injection based on BMI

Steroid sparing

XOLAIR

(Omalizumab)

1. severe air flow obstruction

2. persistent severe airflow obstruction

3. 2 or + ED visits/yr

4. any hx of intubation or ICU

5. pt feels danger or fear of asthma

6. FEMALE, NONWHITE, nonuse of ICS

7. Smokers + drugs

8. depression, stress, low socioeco

9. attitudes about medication use

1. Reduce impairment

2. reduce risk

3. periodic assessments

1. Basic facts

2. Roles of meds and differeneces in meds

3. Patient skills

1. death

2. fixed airway obstruction

3. status asthmaticus

stage 1: SaO2 no, hypervent, PO2

Stage 2: Hypervent Hypoxia--> close monitor IRU

Stage 3: PCO2 nl "false", resp muscle fatigue, hypoxia=ICU

Stage 4: PCO2 high, PO2 low = ICU

Signs/symp:

snoring

witness apnea

EDS

insomnia

non-restorative sleep

GERD

morning headache

<5/hr = normal

5-20 = mild - mod

20-40 = mod to severe

>40 = very severe

Test of upper air resistence + arousal

snore + arousal

Respiratory event related arousal

>15/hr abnormal