ASTHMA

Syndrome characterized by generalized airway obstruction that occurs due to bronchial hyperreactivity.

Etiology:
1. Allergens (in children and adults <35 years), acting on atopy – predisposing
– House dust
– Pollen, mold, animal allergens – hairs, feathers, down
– Occupational allergens – dust, lint
2. Factors infectious
– Viruses – syncytial, parainfluenza, rhinoviruses
– Bacteria – streptococcus, staphylococcus, haemophilus influentzae
3. Irritants
– Smoke, toxic gases, hydrocarbons cold
4. Psychological factors
– Stress, psychological trauma, increased emotional sensitivity, tendency to aggression (a certain type of personality)
5. Effort – the crisis is induced by effort
6. F drugs – aspirin, penicillin
7. F food – food additives, alone, fish, strawberries, egg, soy
8. F inflammatory – bronchial inflammatory processes that cause eosinophilic bronchial wall impregnation
F Risk:
– Family CNTA
– Personal CNTA allergy – allergic rhinitis, allergic dermatitis
– Occupational exposure to allergens
– Bronchial hyperreactivity (atopic)
– Nasal Polyposis
Classification by etiology:
– Allergic Asthma
– Asthma infectious
– Infectious-allergic asthma
– Effort-induced asthma
– Aspirin intolerant asthma – crisis occurs at 30min after ingestion analgesia
– Asthma professional
Classification by severity – classification GINA (Global Initiative for Asthma)
1. Intermittent Asthma
– Intermittent symptoms (<1/sapt)
– Exacerbations brief (hours / days)
– Nocturnal symptoms <2/luna
– Normal spirometry between episodes of exacerbation
2. Persistent asthma
a) Easy – symptoms> 1 / s, <1/day, nocturnal symptoms> 2/luna, normal spirometry between episodes of exacerbation, FEV> 80%
b) Moderate – Daily symptoms, exacerbations affect daily activity / sleep, nocturnal symptoms> 1 / s, FEV = 60-80%
c) Sever – Daily symptoms, frequent exacerbations, frequent nocturnal symptoms, FEV <60%
Pathogenesis:
Nervous mechanism:
Parasympathetic innervation predominantly cholinergic (acetylcholine – receptor alpha – bronchoconstriction)
parasympathetic innervation to the detriment of adrenergic (adrenaline and noradrenaline-receptor beta – bronchodilation)
Cells involved: mast cell, eosinophils, neutrophils, macrophages
The disease has an immunologic mechanism that occurs due to allergen-conflict immunocompetent cells
Allergen – mast – immunoglobulin E – boom mast cell release of chemical mediators (histamine, serotonin) take place the following processes:
1. Bronchial mucosal edema
– Airway obstruction
– Increases resistance to flow
– Decrease expiratory vol
– Lung hyperinflation
– Increases respiratory labor
– Decreased lung compliance to
2. Bronchoconstriction
3. Accumulation in the bronchial wall of eosinophils, neutrophils, macrophages
– Inflammation
– Degradation of bronchial epithelium
– Stimulating the nerve endings with increased bronchoconstriction through the nervous mechanism

Clinical picture:
The disease has evolved in crisis episodic character separated by asymptomatic periods
Asthma:
– Dyspnea sharp, hissing, with slow breathing, prolonged expiration, wheezing
– Duration of dyspnea is variable access, cadand spontaneous or therapeutic
Phases:
1. Prodrome: aura asthma – sneezing, runny nose, dry nose and oropharyngeal, tearing, headache, coughing
2. Phase breathlessness – dyspnea expiratory type bradypnoea
– Appears at night
– Is accompanied by major anxiety, feeling of fullness chest and breathlessness, orthopnea position, irritating cough
– Clinical Ex: sick pale, cyanotic lips, turgid jugular, anterior trunk bent to favor diaphragm movement, prolonged expiration, whistling, difficult, slow breathing – 13-15/min, small amplitude excursions cost, decreased vesicular murmur, rales romflante and wheezing, crepitation – pigeon noise, hypersonority,
– Thoracic Rx: hiperexpansionat chest, ribs leveled, hipertransparenta lung, diaphragm leveled
3. Catarrhal stage: liberating coughing, sputum lining the patient spit a viscous, pearl, which cytological examination include:
– Springs Cruschmann – clusters of mucus
– Charcot-Leyden crystals – proteins and lipids
– Body Creole – desquamated cells, mucus
– Eosinophils
After expectoration breathing becomes easier, rales diminish innasprit vesicular murmur, can produce polyuria crisis
After 3:00 respiration and normal pulmonary auscultation

Status asthmaticus:
Access severe shortness of breath that lasts at least 24 hours, refractory to treatment, and which threatens the life duration and severity patient.
Causes:
– Abuse of Sympathicomimetic
– Suppress sudden corticosteroid
– Infections severe resp
Clinical picture:
– Dyspnea sharp, tachycardia, adinamie, polipnee, disturbances of consciousness, cyanosis gradually installed, perioronazal and extremities
– Ex clinically – large chest distension, nearly equal diameter, sweating, anxiety, MV very diminished

Laboratory picture:
1. Ventilatory tests:
Spirometry – obstructive type respiratory failure – FEV, IT, CV – low, CPT – N, VR, CRF – high
2. Ex radiological – just in crisis
3. Allergy tests – for bronchial hyperreactivity
a) inhaled – inhaled allergens of various potential for triggering an asthma attack
– Change VEMS with + 15% compared to normal looks like is the incriminated allergen
b) dermal – suspensions of different allergens inoculated by sc injection scarifiere ant or the face of the forearm

Charts:
1. For asthmatic malaise
2. For complications
– Immediate, during the crisis (subcutaneous emphysema, mediastinal emphysema, spontaneous pneumothorax, rib fractures)
– Time – infectious (pneumonia), chronic pulmonary heart,
– Iatrogenic:
a) Abuse of Sympathicomimetic – asthmatic malaise, tremors, irritability, nervous, and driving rhythm Tulbi
b) Miofilin – insomnia, irritability, arrhythmias
c) Corticotherapy – peptic dd, dg bleeding, diabetes, hypertension, osteoporosis, immunosuppression, corticosteroid dependent after OLT, shingles. Cushing

Treatment:
1. Prevention:
– Preventing exposure to allergens
– Increased immunity to causal allergen – specific and nonspecific hypo-sensitization
2. Protective drugs – drugs that prevent the crisis but have effect during the crisis:
– Sodium cromoglycate – cromolyn, Intal – is administered 15-20 min before exposure to allergens, prevent mast cell destruction and elimination of chemical mediators
– Ketotifen Claritin, loratadine, desloratadine (Aerius, Xyzal)
3. Symptomatic:
 sympathomimetic
a) not selected – adrenaline, ephedrine – acts on receptors alpha, beta1, beta2
b) Semiselective – acts on beta1 and 2 – isoprenaline, orciprenaline
c) selection – the R beta 2 – terbutaline (Brycanil), Salbutamol (Ventolin), fenoterol (Berotec), salmeterol (Serevent), combinations – fluticonazol + salmeterol (Seretide)
Ef secondary
– Anxiety, palpitations, tachycardia, angina, sudden death

 Parasimpaticolitice bronchodilators – Anticholinergic:
– Atropine
Ipratropium bromide (Atrovent)
 Methylxanthines – bronchodilators
– Theophylline – Teotard
– Aminophylline – Miofilin
Of abuse – theophylline intoxication: anxiety, loss of appetite, nausea, irregular heartbeats, seizures
Therapeutic effect – theophylline-emia <10mg/dl,> 20mg/dl – intoxication
 cortisone – decreases bronchial edema, antisecretory, antispasmodic
– In emergency HHC iv – effective immediately
– Prednisone – per os – environmental effect – days, hours
– Effect retardation – weeks – administration i.m. methylprednisolone, triamcinolone, betamethasone
– Spray – Aerosol – beclomethasone (Becotide) fluticonazona (Flixotide)
 leukotriene modulators
– Montelukast (Singulaire)
– Zafirlukast
– Zileutan
Treatment Crisis:
1. Oxygen administered wetting flow probe endonasal 5-6 l / min
2. Beta2 sympathomimetics – Inhaler – Salbutamol
3. Aminophylline – Miofilin iv or per os
4. Corticosteroids – HHC iv followed by a short course of prednisone per os (5 days)
Treatment of status asthmaticus:
1. Hospitalization in ICU
2. Monitoring every 15 min – fr resp, fr. Cord, TA; every hour – pH SGV, SGV gas meter, the 8/8ore – ionograma blood
3. HHC iv corticosteroids, prednisone after per os
4. Oxygen

5. Aminophylline iv

6. Avoid sedatives, hypnotics

7. Avoid penicillin
8. Avoid ox-therapy continue unchecked
Treatment of substance:
After staging:
1. Intermittent asthma:
– Beta2 inhaled short-acting sympathomimetics
– Eliminate risk f
– Preventative treatment before exposure to allergens – sodium cromoglycate
– Control 2 weeks
2. Persistent asthma
a) Easy – cromoglycate daily low dose inhaled corticosteroids in crisis, short-acting beta2 sympathomimetics, theophylline, leukotriene modifiers, control 2-4 weeks
b) Moderate – medium dose of inhaled corticosteroid, beta2 sympathomimetics with long action in crises, theophylline, leukotriene
c) Sever – high dose inhaled corticosteroids, long-acting beta2 mimetic simp, theophylline,