Reactive airway diseases_2018_pmm
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Airway diseases presenting with behavior of Reaction to any trigger have been in increase. We intend to visit available resources for better understanding of RAD - in Children and adults
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Reactive airway diseases_2018_pmm
- 1. Dr. Parthiv Mehta Hon. Chief, Pulmonary- Critical Care, UNMICRC Medical Director, Central United Hospital Medical Director, Mission Life India Ahmedabad - GUJARAT parthivmehta@Hotmail.com REACTIVE Airway Diseases
- 2. Asthma COPD Viral Wheeze (Children) Emphysema Hyper Ventilation Syndrome Infective (bacterial) Asthma Allergic Bronchopulmonary Aspergillosis (ABPA) Bronchiectasis Nonsmoking Fixed Obstruction Obliterative Bronchiolitis Eosinophilic Bronchitis CF Chronic Cough 1. Wardlaw AJ et al. Clin Exp Allergy. 2005;35:1254ā1262. Spectrum of AIRWAY DISEASES
- 3. What is Reactive Airway Disease? Reactive airway disease (RAD) is used to describe different conditions. People with RAD have bronchial tubes that overreact to some sort of irritant. The term is most commonly used to describe a person who is wheezing or having a bronchial spasm, but who has not yet been diagnosed with asthma.
- 4. RAD used more often for young children, who are younger than 5 ā before stamping it as ASTHMA! RAD is not the same as RADS. RADS is caused by excessive exposure to some sort of corrosive gas, its fumes or vapours. RADS occurs just one time and is not chronic. What is Reactive Airway Disease?
- 5. RAD ā Clinical Pathology ā¢ Hyper ā sensitive (Reactive) Bronchial tubes (BHR) ā¢ Excess mucus in the bronchial tube ā¢ Swollen mucous membrane in the bronchial tube (Inflammation) FORGET NOT, We areā¦ REVERSIBLE
- 6. RAD ā Clinical Presentation ā¢ Wheezing ā¢ Coughing ā¢ Shortness of breath or difficulty breathing Remember, We areā¦ EPISODIC - INTERMITTENT
- 7. How Do I Catch RAD?
- 9. Investigations for RAD / Asthma Inflammation 1 2 3
- 10. Episodic Symptoms ā¢ Skills of clinician to acquire vital information through patient's medical history and physical examination.
- 11. Episodic Symptoms ā¢ Age of onset ā¢ Symptom free period ā¢ Family history ā¢ Triggers ā¢ Use of Relievers ā¢ Exacerbations
- 12. ā¢ Most often after an infection. ā¢ Itās caused by some irritant that triggers the airways to overreact and swell or narrow. Pet hair or dander Smoke Dust and Pollen Exercise Perfume/Strong odours Stress Changes in the weather Food RAD ā Pre-disposing FactorsEpisodic Symptoms - TRIGGERS
- 13. Episodic Symptoms ā¢ Age of onset ā¢ Symptom free period ā¢ Family history ā¢ Triggers ā¢ Use of Relievers ā¢ Exacerbations
- 15. Reversibility ā¢ āPresenceā of Airflow limitation - Obstruction ā¢ āVariationā in Airflow ā¢ āImprovementā upon usage of āRELIEVERSā Peak Flow Meter Spirometer Osillometer
- 16. Peak Flow Meter ā¢ Peak expiratory flow (PEF), also called peak expiratory flow rate (PEFR) is a person's maximum speed of expiration ā¢ Directly correlates with āavailable apertureā of airway ā¢ Measures the airflow through the bronchi and thus the degree of obstruction in the airways ā¢ Effort Dependent R e v e r s i b i l i t y
- 17. Peak Flow Meter ā¢ Simple ā¢ Handheld ā¢ Easy to perform and interpret ā¢ āDO IT YOURSELFā Weighing Scale Thermometer Sphygmomanometer R e v e r s i b i l i t y
- 18. R e v e r s i b i l i t y ā¢ RAD / Asthma is suspected when there is >/= 20% diurnal variation on >/= 3 days a week or for 2 weeks in a PEF ā¢ Wide range of ānormal' values and high degree of variability >> Not āthe recommended testā to identify asthma Peak Flow Meter Good tool to MONITOR RAD/Asthma Higher the FLOW Lesser the SEVERITY
- 19. Investigations for Asthma Inflammation Supportive / Differentials 4
- 20. Spirometer
- 21. Spirometer ā¢ Spirometry is a vital test to establish āAirway Obstructionā and its āReversibilityā objectively and accurately. R e v e r s i b i l i t y
- 22. Spirometer ā¢ Reversibility : Significant reversibility is indicated by an increase of > 12 % and/or 200 ml in FEV1 after inhaling a short-acting B2 agonist ā bronchodilator. R e v e r s i b i l i t y
- 23. Spirometer ā¢ Performing Reversibility: ā Spirometry test (with at least 2 reproducible flow volume loops) ā Intake of a fast acting bronchodilator (often Salbutamol) through inhalation ā 15 minutes pause ā Second (Post Bronchodilatation) Spirometry test (with at least 2 reproducible flow volume loops) R e v e r s i b i l i t y
- 24. ā¢ Impulse Osillometery: ā Conventional Spirometry: Effort Dependent Spirometer
- 25. ā¢ Impulse Osillometery (IOS): Very useful for diagnosis of RAD / Asthma, especially in children where dependency of Spirometry and flow volume loop is questionable. ā IOS uses small amplitude pressure oscillations to determine the resistance of the airway. ā It is largely independent of effort does not require coordination, but does require cooperation of patient. Spirometer Episodic Symptoms
- 26. Inflammation ā¢ Inflammation in airways is MUST to confirm RAD / Asthma. ā¢ Airways ā Upper and Lower ā¢ Eosinophilic >> Neutrophilic ā¢ Modalities: ā Direct: Sputum - Eosinophilia ā Indirect: Markers - Exhaled NO, ECP, EPX
- 27. Sputum ā¢ Sputum is induced by proper coughing or using inhalations of 3% of hypertonic saline. ā¢ Sample: should look more opaque and/or dense and unlike saliva. ā¢ Cell differential counts are performed. Inflammation
- 28. Sputum ā¢ Eosinophilia in sputum: Directly linked with the underlying eosinophilic airway inflammation. Management employing sputum monitoring has been found useful in preventing exacerbations and hospitalizations. Inflammation
- 29. Exhaled Nitric Oxide ā¢ Nitric Oxide (NO) is produced in discrete concentrations in the healthy human airway (Respiratory epithelium, Nose, upper and lower airways) where it is important in physiological functions such as maintaining airway patency. ā¢ It is responsible for airway inflammation and is also the product of airway inflammation. So, Evaluation of NO as āSurrogate marker of Eosinophilic Inflammationā is gaining acceptance. Inflammation
- 30. Exhaled Nitric Oxide ā¢ Nitric oxide analyzers are used to measure exhaled nitric oxide (FENO). Inflammation
- 31. Exhaled Nitric Oxide ā¢ NO is over produced in asthmatic individuals. ā¢ Potential of FENO to predict exacerbations of asthma has been examined in various studies and levels were found to be elevated before the fall in lung functions or the development of clinical symptoms of asthma exacerbations. ā¢ NO is increased in inflammation of lung e.g. asthma. If bronchospasm without inflammation, NO is not increased i.e. it is not Asthma. Inflammation
- 32. Exhaled Nitric Oxide ā¢ Ingestion of foods containing nitrates, smoking status, ambient nitric oxide level, nasopharyngeal contamination, airway infections and drugs such as leukotriene modifiers may affect the actual collection and quantification of exhaled nitric oxide. ā¢ Patients are asked to take nothing by mouth for one hour before sample collection. Inflammation
- 33. Markers of Inflammation ā¢ Important especially for diagnosis of Asthma in Children ā¢ Currently, the noninvasive clinical assessment of airway inflammation in young children is limited. ā¢ The detection of raised blood eosinophil levels or evidence of eosinophil activation proteins in blood or urine, such as Eosinophil Cationic Protein (ECP) or Eosinophil Protein X (EPX), can be used in addition to the examination of nasopharyngeal secretions. Inflammation
- 34. Markers of Inflammation ā¢ In the near future it is likely that tidal breathing methods for measuring exhaled nitric oxide (NO) and other gases will be validated for use in the younger children. ā¢ The analysis of other constituents of breath, such as exhaled proteins, is currently being investigated as potential indicators of airway pathology. Inflammation
- 35. Supportive / Differentials ā¢ Allergy test ā¢ Blood test ā¢ Radiology: Chest X-Ray, CT Scan ā¢ Endoscopy: Upper-Lower Respiratory, Upper GI ā¢ 2D Echo
- 36. Allergy Test ā¢ Allergy test : ā This test is to look for the trigger factors causing asthma. ā Useful to diagnose occupational asthma and seasonal asthma by detecting the triggers causing the attack. ā Supports diagnosis of Asthma ā Identification of allergen triggers can assist in formulating an avoidance strategy. ā A trial of allergen avoidance may be diagnostic and therapeutic. Supportive / Differentials
- 37. ā¢ Skin tests: ā Main tool in diagnosing allergies all over the world ā Different allergy profile can be known by the skin allergy tests. ā¢ Patch test (used mainly for diagnosing contact dermatitis) ā¢ Scratch test ā¢ Skin prick test ā¢ Intradermal test ā¢ Skin end point titration ā¢ Parasite- kustner test (Passive transfer test). Allergy Test Supportive / Differentials
- 38. ā¢ Mechanism of skin allergy testing: ā Cells and antibodies responsible for allergies are present under the skin as well as other parts of the body. ā If an allergen to which patient is allergic is applied to the skin a reaction occur and a wheal is formed. ā The size of the wheal is measured to grade the severity of allergy. Allergy Test Supportive / Differentials
- 39. ā¢ RAST (Radio allegro sorbent technique): ā Detects allergen specific IgE in serum. ā The results of the tests correlate well with the skin allergy tests. ā One sample of the serum can be used to test many allergens. ā Benefits: can be used where the skin allergy tests cannot be performed like young children, severe atopic dermatitis, dermatographism, history of extreme sensitivity, patients afraid of multiple injections. Allergy Test Supportive / Differentials RAST is not influenced by drugs while skin tests are suppressed by anti allergic drugs and steroids. There is no risk of anaphylaxis with RAST.
- 40. ā¢ X-Ray Chest : ā Preferred for routine evaluation ā Helps to establish other diagnosis ā¢ Eosinophilic Lung Disease ā¢ Churg Strauss Syndrome ā¢ Cystic Bronchiectasis ā¢ Interstitial Lung Disease ā¢ Congestive Cardiac failure ā Must for Exacerbation or Uncontrolled ā¢ Consolidation ā¢ Pneumothorax Radio-Diagnostics Supportive / Differentials
- 41. ā¢ CT Scan: ā Useful tool for differentiating other āasthma alikeā or co-existing morbidities for ānon- respondersā. ā Role of CT scan has been established ā¢ with suspicion of bronchiectasis ā¢ occupational asthma ā¢ parenchymal infiltrates ā¢ suspicion of Allergic Bronchopulmonary Aspergillosis and/or invasive aspergillosis Radio-Diagnostics Supportive / Differentials
- 42. ā¢ CT Scan: Bronchial wall thickening Bronchiectasis / Bronchial dilatation Radio-Diagnostics Bronchial wall thickening Bronchiectasis / Bronchial dilatation Supportive / Differentials
- 43. ā¢ Laryngoscopy and Bronchoscopy: Inspection: Allows visual inspection of the upper and lower airway. ā Help to rule out Vocal cord dysfunction, Laryngomalacia or Tracheomalacia as an important differential diagnosis Lavage: Broncho Alveolar Lavage (BAL) is an important investigation for differentiation of infection and inflammation. Biopsy: Performing Endo-Bronchial biopsy (EBLB) or Trans-Bronchial biopsy (TBLB) ā Will help to establish type of inflammation in airway, parenchymal infiltration and infection as well as structural changes in parenchyma. ABPA v/s Invasive Aspergillosis, DILD Endoscopy Supportive / Differentials
- 44. Normal Abnormal Laryngomalacia Tracheomalacia Endoscopy Supportive / Differentials Nearly 20% of patients with refractory asthma referred for tertiary care have coexisting VCD. Medical utilization is higher in patients with VCD compared with age/sex-matched asthma patients.
- 45. ā¢ Upper GI Scopy: ā Gastro-oesophageal reflux (GERD) is common in patients of chronic or ādifficultā asthma ā nearly twice to normal individuals. ā Though it is hard to identify potential responders amongst asthmatics having GERD and treatment often has little effect on asthma symptoms, it is important to diagnose GERD. Endoscopy Supportive / Differentials
- 46. ā¢ Echocardiogram: ā 2D Echocardiogram is important to differentiate āCardiac Asthmaā i.e. with Cardiac causes like Left Ventricular dysfunction or pericardial effusion from āBronchial Asthmaā. ā An effective tool to provide appropriate support in the form of anti-failure therapy. ā Patients with COPD shall develop Cor-Pulmonale on long run. Echo Cardiogram Supportive / Differentials
- 47. RAD / Asthma Algorithm
- 49. Criteria for the diagnosis of RAD / Asthma ā¢ Demonstration of obstruction (FEV1/VC < 70%) and FEV1 increase by >15% (at least 200 ml) with respect to the initial value, measured at least 15 min after the inhalation of four puffs of a short-acting beta2 agonist agent, e.g., 400 Āµg of Salbutamol ā¢ Or: FEV1 worsening by >15% during, or within 30 minutes after, physical exercise (exertional asthma), possibly with an increase of the specific airway resistance by at least 150% ā¢ Or: FEV1 improvement by >15% (or by at least 200 ml, if the initial value is below 1300 ml), after daily high-dose administration of an inhaled corticosteroid (ICS) for a maximum of four weeks ā¢ Or: in patients with normal pulmonary function despite a typical history for asthma, demonstration of non-specific bronchial hyper-reactivity by means of a standardized, multilevel inhalational provocative test and of a more than 20% circadian variation in PEF with measurements taken over 3 to 14 days
Editor's Notes
- A fundamental challenge that clinicians face in managing pediatric airway diseases is establishing a differential diagnosis. RAD or Asthma is typically recognized on the basis of its classical presentation that includes variable airflow obstruction and airway hyperresponsiveness; however, these clinical features are also observed in patients with other airway disorders, such as viral-induced wheeze, chronic cough, and bronchiectasis, in addition to allergic bronchopulmonary aspergillosis and/or cystic fibrosis.