bronchial and cardiac asthma

Question 1

definition BA and CA

Answer 1

BA
Dyspnea episodes accompanied by wheezing resulting fr Narrowing of bronchi due to bronchospasmas a result of hyperresponsiveness of bronchial smooth muscle. Wheezes are distant

CA
Dyspnea episodes accompanied or not by wheezing occurring in associated with pulm congestion/edema Etio: Various heart disease- congenital heart disease, valvular disease, rheumatic disease, thromboembolism

Question 2

history BA CA

Answer 2

BA
Previous periodic attacks of asthma-
Cardiac risk factors (diabetes, HT,

CA
family history of allergic diseases (eczema, rhinitis, urticaria)
smoking)-previous history of angina. MI or valvular heart disease- infectious endocarditis

Question 3

Time of onset/Age BA CA

Answer 3

BA
Usually in early morning Middle aged/ young people

CA
Usually in middle of night (orthopnea and paroxysmal nocturnal dyspnea) Middle aged, elderly-maybe in young (congenital)

Question 4

symptoms BA CA

Answer 4

Expiratory dyspnea and cough with expec of small sticky, stringy sputum

Exp and insp dyspnea and cough with expectoration of foamy, watery frothy secretion, maybe blood stained

Question 5

Signs

Answer 5

Tripod posture Chest barrel shaped or pigeon Only prolonged exp

Orthopnea (forced posture), normal chest, asphyxia Prolonged both in insp and exp (half sitting position

Question 6

chest shape

Answer 6

Barrel chest

Normal chest

Question 7

auscultation

Answer 7

Wheezing > prominent than crepitation

Crepitation (base of lung) > prominent than wheezing

Question 8

CVS exam

Answer 8

no cardiomegaly (except advanced stages with RV failure-dt pulm HT cor pulmonale)

Cardiomegaly with heaving apex beat-raised JVP, pedal edema, gallop rhythm, murmur, decreased S1 and BP, tachycardia If affection of chambers, valves give murmurs (org/func)

Question 9

chest x ray

Answer 9

Normal or hyperinflation

Cardiomegaly with prominent pulm artery shadow

Question 10

ecg

Answer 10

Sinus tachycardia P-pulmonale RV hypertrophy

LV hypertrophy LA hypertrophy MI

Question 11

echocardio

Answer 11

Normal/enlarged RV

Systolic/diastolic dysfunc/congenital or valvular lesions

Question 12

response to treatment

Answer 12

Best to bronchodilators

Nitrates, diuretics, ACE-I‘s

Question 13

basic treatment according to steps

Answer 13

1. 1st: Stop contact with origin, and use inhalants of beta-2 agonists (ventalin) and NSAIDS (intal, keto)
2. 2nd: Inhalation beta-2 agonists (short acting) every day and anti-inflammatory drugs eg intal, tyled
3. 3rd: All drugs in 2nd step + inhalation of glucocorticosteroids 200-300microgramms eg becodisk + bronchodilators (long activating) eg salmetarol
4. 4th: All drugs in 3rd step + inhalation of glucocorticosteroids 800-1200microgramms + bronchodilators (long activating) + systemic/parallel glucocorticoids.

Question 14

complications

Answer 14

• Pneumodiastinum
• Emphysema
• Pneumopericardium
• Subarachnoid hemorrhage
• Cor pulmonale, acute right heart failure
• Acute respiratory failure
• Status asthmaticus
• Pneumothorax , acute emphysema
• Thromboembolism of pulmonary artery
• Associated lung infections
• Exhaustion and dehydration- shock
• Growth retardation in children

Question 15

Metabolic & anaphylactic types of severe asthma
- Anaphylactic- short, acute term
- Metabolic (anaphylactoid) – long term

Answer 15

Metabolic & anaphylactic types of severe asthma
- Anaphylactic- short, acute term
- Metabolic (anaphylactoid) – long term

a) Pathogenesis

There are 3 stages of immune reaction:
1. 1st: sensitization (involves primary exposure of Ag and production of Atb)

2. 2nd : pathochemical (involves 2ndary exposure of Ag and release of mediators)
3. 3rd: pathophysiological (result of mediator actions on resp system)

Mediators:
- Leucotrienes
- Protein mediators (that increase vascular perm)
- PGD2 (bronchoconst, vasodilators)
- Eosinophilic chemotaxic factors
- Platlet activiating factors
- Histamine

3 main mechanisms to airflow obs in BA:
- Edema of wall of respiratory system
- Bronchospasm
- Mucous oversecretion

Question 16

diagnostic criteria

Answer 16

• Blood picture (eosinophilia, leucocytosis)
• Sputum (has eosinophils, Kurshmann‘s spirals, Charcot-Leyden crystals)
• Spirometry (decreased FVC, FEV:FVC decrease) - signs of broncho obstruction
• X-ray (wide IC spaces, horizontal ribs)
• Arterial blood gas (decrease CO2 tension < 36mmHg)
• Immune system test (inhalation/injection with allergens cause local reddish skin, edema, rash)

Question 17

dy/dx of severe asthma and common atack of dyspnea

Answer 17

Stages of status asthmaticus
1. I stage (relative compensation).
Severe cough. Orthopnea. Tachypnea. Inability to speak in sentences. Added muscles are involved. Distant wheezes. Cyanosis. Bandbox sound. Ausc.: no sound over the low lobes, hash breathing over the upper parts.
Tachycardia(120/min.). Nerve excitation, hallucinations.

2. II stage (decompensation, silent lung).
   Severe dyspnea. Inability to speak. Superficial respiration. Orthopnea. Tachypnea. Pale-grayish skin. Bandbox sound. Ausc.: no sound over the hole lobes, small amount of rales over the small part of the lungs. Tachycardia (140/min). Pulsus paradoxus. Hypotension. Mental status changes (confusion).
3. III stage (hypercapnia coma).
   Patient is unconscious. Diffuse cyanosis. Superficial respiration. Chain- Stock’s breathing. Ausc.: no sound over the hole lobes (―silent chest‖). Tachycardia(140/min.). Pulsus filliformis. Arrhythmia. Hypotension. Gallop rhythm.

Question 18

severe asthma and common atack of dyspnea

Answer 18

Criteria
Status asthmaticus Common dyspnea attack
1. onset of attack
Anytime Second half of night

2. sputum expectoration
   No Present
3. alteration of bronchi
   Block of bronchi Temporary narrowing
4. dyspnea
   > than few hours Temporary expiratory dyspnea
5. coma
   Hypoxemic coma Absent
6. CNS disorder
   Present Absent
7. Drug effect
   No effectiveness of beta stimulator, bronchodilators and Xanthanine
   Effective

Question 19

Emergency care & intensive therapy

Answer 19

Emergency care & intensive therapy
- Rehydration eg glucose solution 3-4L daily
- Correction of electrolyte balance
- Heparin: improve rheological blood and sputum
- Euphyllines 6mg/kg
- Glucocorticoids: depending on stages 1mg/kg
- Oxygen therapy
- In 2nd stage, do artificial lung ventilation with bronchial lavage