Bronchial asthma(BA) Definition: chronic inflammatory disease of airways which is characterized by: Inflammation of bronchi -unusual inflammation because

e inflammatory cells in bronchi are eosinophils, Tlymphoctes, mast cells and it is not caused by infection. Inflammation maybe caused by combination of genetic and environment factor or both. Result in bronchial hyperactivity and involve bronchial spasm and edema leads to bronchial obstruction. # spasm and edema are reversible. Airflow limitation -with typical clinical manifestation episode of attack of caough with dyspnea(chest tightness) usually occur at night. -between attacks : normal -spontaneously reversible. Aetiology i. Genetic ii. Environmental : responsible for development of asthma @ inductors iii. Emotional stress ; provoke attacks -other e.g: cold air, dust ( these are environmental factors which are called triggers NOT inductors) Genetic -many associating factors: a) Atopic syndrome -ability of individual to develop regularly antibody of Ig E in response to different environmental stimuli. -found in 25-30% of healthy people but not all develop BA but maybe urticaria seasonal rhinitis. b) Abnormal cytokine production -gene chromosome 5 responsible for production of cytokines. c) Primary hypersensitivity of bronchi -sensitivity to foreign body irritates receptor. -receptor more sensitive than normal. Hyperventilation can be trigger of BA. d) Idiocratic asthma. It is not allergy but sensitivity to some substances due to enzymopathies. -e.g: aspirin; genetic factor and abnormal metabolism of prostaglandin. Inductors -main mechanism: allergy reaction due to exposure to allergen. 80% has allergy to house dust( mite has chemical subst) pollen domestic pets( cat,dogs) by their saliva, urea or skin protein. Fungal Occupational allergy( more 200 materials) Triggering factors -cold air -viral infection -atmosphere pollution( sulfur dioxide) -emotional upset --blockers -strong fumes -NSAID

Pathogenesis: Atopic syndrome: a) Allergy of immediate type. -immediate contact with allergen induce reactionIg E degranulation of mast cell biological active substance(BAS) o PG C4 o PG D2 o Leukotriene o Histamine Attack bronci and bronchial wall edema and spasm attack. # this is allergic mechanism. Non-allergic mechanism o Abnormal production of PG, thromboxane, platelete activating factor(PAF) cause activity of macrophage increase in bronchial wall. o Aspirin and other salicylate o Asthma due to physical exertion which causes primary hypersensitivity of bronchial wall o Decrease of glucocorticoid concentration patient predispose to asthma. CLASSIFICATION by WHO in 1992 I. Allergic II. Non-allergic III. Mixed aetiology( allergic and non allergic) IV. Unknown aetiology V. Status asthmaticus( complication of asthma) Allergic @ extrinsic asthma Divided into: a. atopic asthma -presents with attacks of dyspnea b. allergic asthma / extrinsic allergic asthma -has allergy but not atopic syndrome -[Ig E] normal @ decrease but allergy is present. -difficult to distinguish.Symptoms are the same but usually diagnose as allergic or atopic asthma. c. Allergic bronchitis -mechanism involved are same as atopic asthma except: Atopic asthma Attacks of dyspnea Allergic bronchitis Equivalent of suffocation or dyspnea Attack of cough, wheeze n chest tightness

Mechanism: bronchial obstruction If moderate/mild not sufficient to produce dyspnea only cough n wheezes If severe causes dyspnea *both atopic n allergic bronchitis are same.

d. Seasonal rhinitis with asthma Hay fever with asthma respond to definite pollen Main complaint for both: a. Has asthma but bronchial spasm is minimal b. Sneezing, blocked nose but not severe bronchial spasm(Hay) c. Mild bronchial hypersensitivity n bronchial spasm. Non allergic(intrinsic) endogenous i. Idiocratic/idiosyncratic -aspirin induced asthma -tartazin(yellow colored tab) ii. Asthma with physical exertion -air hyperventilation triggers attack because cold air may irritate receptor iii. Primary hypersensitivity of bronchi Mixed aetiology -combination of atopic and aspirin induced asthma Unknown etiology -dont know the cause(idiopathic) Status asthmaticus -complication of asthma either allergic or non allergic Diagnose: status asthmaticus for temporary diagnosis, later when patient recover or become better, investigate patient has allergic or not. CLASSIFICATION According to severity I. Mild- transient asthma -mild symptoms occur rarely Less than once weekly Nocturnal symptoms less than once monthly Spirometry near normal almost 80 PEFR ~ normal(80% of normal) Variability .Not more than 10-15% in healthy people. Increase more 20% increase variability. Variability between 15-20%(in step 1) II. Mild persistent -system as mild as 1st step but more frequent. -once or twice perweek -1-2 monthly(nocturnal) -FEV1 = 80% -variability normal or slightly increase ( but < 20%) III. Moderate -symptom> 2 weekly(maybe everyday) -at night> 2 monthly -FEV1 decrease(60-80%) -variability increase >20-30% IV. Severe -frequent exacerbation

-symptom everyday(many times/day) -at night frequent -restriction of physical activity - FEV1 =<60% -variability>30% According to phase 1) Exacerbation 2) Remission Diagnosis: BA, allergic bronchitis step 2 , exacerbation. Clinical manifestation I. anamnesis -family history -previous episode of allergy n urticaria -smoking -drug taken(aspirin) -seasonal rhinitis -occupational II. Complaints -reversible bronchial spasm ( min to hours and then disappear) -attack of dyspnea -attack of shortness of breath correspond to definite allergen or triggers -severity of complain Feeling of suffocation Incomplete exhalation Wheezes heard by patient itself Cough: during day usually and white sputum at end of attack If not very severe case without dyspnea only cough. Chest tightness -sensation between attacks Exacerbation severe episode of bronchial spasm(rapid reversible) n edema(not rapid but complete reversible) Remission no complain.

III. Physical findings(during exacerbation)

-cyanosis -involvement of additional respiratory muscle -chest wall movement decrease on both side -shorter expiration, hyperinflated lung shallow expiration. -percussion(depend on attack):-normal or hyperesonance in emphysema( if hyperesonance constant, emphysema not disappear) -breath sound with prolong expiration -additional sound: polyphonic wheezes..* in COPD permanent wheezes but in asthma only during attack. -increase respiratory rate -body posture fix upper limb n leaning forward -confusion if attack severe -emotional disturbance -loss of consciousness in very severe case

-common features: More common at night because parasympathetic more active at night causes bronchoconstriction Allergy to house dust mite and pillow which contains a lot of dust. IV. Investigations I. Lung function test -bronchial obstruction: Decrease FEV1 Decrease PEFR Decrease FVC Decrease FVC index. -increase variability II. Bronchodilator -to distinguish asthma and COPD -repeat measurement after 15 sec e.g salbutamol/berotec ; improvement >15%: asthma( bronchial spasm) but if less 15%: COPD *induce bronchial obstruction by allergen contact is dangerous. III. Spirometry IV. Blood and sputum analysis Blood: -increase eosinophil in peripheral blood. Sputum o Increase eosinophil o Charcot-Leyden(destruction of eosinophil) o Curshman spiral ( very viscous sputum, similar white worm because has diameter and figure like bronchial tree) V. Chest X-ray -between attack no findings -during attack hyperventilation similar to emphysema ( dark lung) maybe disappear after attack. VI. Skin prick test -identify allergen -SC different allergen and see skin reaction to minimal concentration of allergen. -important to young patient because they have 2-3 allergen( not many) treat patient with hypersensibilization to suppress hyperactivity to allergen and only for patient with 1-3 type of allergens. VII. Immunological study -increase Ig E Subvariant of BA. 1. aspirin induced asthma: a. typical triad i. attack of asthma ii. rhinitis and polyps iii. additional reaction to aspirin and natural salycilate(cabbage) b. develop gradually c. usually diagnose at age 30-40 years old d. typical to male patient e. characterized by severity

i. moderate to severe ii. status asthmaticus is common. 2. asthma on physical exertion a. attack only in respond to physical exertionhyperventilation b. attacks are rare c. usually mild to moderate d. patient may overcome asthma by physical exertion i. firstly light exercise then increase level of exercise step by step. 3. occupational asthma a. exacerbated by contact with work or job b. disappear during holiday * patient with mild asthma either excess or lack of estrogen send to gynae n therapeutic department.