Obstructive Lung Disease: Asthma and Bronchiectasis

Chronic inflammatory disorder of the airways with reversible symptoms - genetic component that predisposes for the development

Asthma

Asthma is usually due to...

Immunological reaction (airway inflammation, increased mucus production, airway hyperresponsiveness, variable airway obstruction)

Asthma - airway remodeling:

Hypertrophy of bronchial smooth muscle and deposition of subepithelial collagen

Asthma triggers:

Allergic/atopic, non allergic/nonatopic, occupational, exercised-induced bronchoconstriction, drug-induced

Types of asthma include:

Atopic/allergic and nonallergic/nonatopic

Begins in childhood + family h/o asthma

Associated with eczema, allergic rhinitis, food allergy

Atopic/allergic asthma: IgE mediated (MC)

Tends to occur in adults - marked by neutrophilic inflammation

Nonallergic/nonatopic asthma

Nonallergic/nonatopic asthma includes:

Drug induced, occupational, exercise-induced, cough variant

ASA, NSAIDs - bronchoconstriction via increased leukotrienss

Drug induced asthma

Starts during exercise or within 3 minutes after ends, peaks 10-15 min, resolves within 1 hour

Exercise induced asthma

In cough variant asthma, the patient does what instead of wheezing?

Coughs

asthma symptoms:

Wheezing, cough, chest tightness, dyspnea

Usually upon exhalation, usually absent between asthma exacerbations

Wheezing

Asthma PE findings:

Decreased air entry or expiratory wheezing on auscultation, eczema/atopic dermatitis, signs of rhinitis, conjunctivitis, and sinusitis

Acute asthma attack PE findings:

Depressed LOC, wheezing (absent in 30%, called "silent chest", concerning for very limited airflow)

Pulmonary function testing:

Spirometry with pre and post therapy (albuterol inhalation) readings

Decreased FEV1/FVC ratio (<70-75%) demonstrates...

Obstruction

>12% increase of FEV1 (and >200 ml in adults) with bronchodilator therapy demonstrates...

Reversibility

This test is helpful if there are symptoms of asthma and a normal spirometry test

Bronchoprovocation testing

Asthma - skin testing for allergens if...

Persistent

Asthma goals of treatment:

Optimize control of symptoms, reduce risk of asthma exacerbations, minimize adverse effects from meds

Well controlled asthma =

No limitations due to breathing

Optimizing control of asthma symptoms:

Decrease intensity and frequency of asthma symptoms, decrease symptoms, < 2 days/week acute relief meds, < 2 nights/month, optimized lung function, maintain normal activity levels

Reducing future risks of asthma include:

Asthma exacerbations, suboptimal lung development, loss of lung function over time, adverse effects from meds

Risk factors for exacerbations include:

Poor adherence to meds, incorrect inhaler techniques, low lung function/poor PFTs, smoking/vaping

Specific goals for reducing risk:

Prevent exacerbations, prevent decreased lung growth/loss of lung function, optimize meds

Components of asthma management:

Patient education, control of asthma triggers, monitoring for changes in symptoms or lung function, pharmacologic therapy

Monitors severity and progression of disease (asthma)

Peak flow monitoring (PF)

Change in PF will occur prior to...

Impending attack

Asthma - PF - approx 20% reduction from personal best indicates...

Poor control

Asthma - PF - 20 to 50% reduction needs...

Quick relief medication

Asthma - PF - >50% reduction needs...

Immediate medical care

There are some asthma triggers that can's or shouldn't be avoided - so we need to teach patients how to...

Adjust meds to avoid exacerbations in these cases

Assessing asthma severity serves as a guide for...

The intensity of therapy needed for control

Daytime asthma symptoms occurring 2nor fewer days/week, two or fewer nocturnal awakenings/month, no interference with normal activities

Intermittent asthma

Daytime symptoms more than 2x/week, but less than daily, approx 3-4 nocturnal awakenings/month, but less than weekly, minor interference with normal activities, 2 or more exacerbations requiring PO steroids within 12 months

Mild persistent asthma

Daily symptoms of asthma, nocturnal awakenings as often as once per week, occasional limitation of normal activity, FEV1 >\= 60 and <80% of predicted, and FEV1/FVC below Normal

Moderate persistent asthma

Asthma symptoms daily throughout the day, nocturnal awakenings nightly, extreme activity limitation

Severe persistent asthma

Asthma types of therapy:

Immediate relief and long-term control

Which guidelines should we use for asthma?

NAEPP

Intermittent asthma (step 1) treatment:

SABA (short acting beta 2 agonist) for relief of symptoms PRN

Mild persistent asthma (step 2) treatment:

Low dose ICS daily + SABA PRN

Alternative option of steroid must be avoided for mild persistent asthma:

LRTA daily + SABA PRN

Moderate persistent (step 3) treatment:

Low dose ICS + LABA combination in single inhaler (budesonide-formoterol = symbicort) can be used for both: maintenance and reliever therapy (MART)

Severe persistent asthma (step 4 or 5) treatment:

Medium or high dose of ICS + LABA

Some patients, despite good medication adherence, modification of environmental exposures, and management of comorbidities, continue to have poor asthma control =

Treatment - resistant severe asthma

Treatment-resistant severe asthma patients may benefit from...

Adding a biologic agent (glucocorticoids on rare occasion)

Asthma - routine visits every....... Depending on severity and adequacy of control

1-6 months

Well controlled asthma =

Daytime symptoms no more than 2x/week and nocturnal awakening no more than 2x/month, SABA no more than 2x/week, PEF/FEV1 normal, PO steroids and ER no more than 1x/year

Acute asthma exacerbation treatment:

Assess FEV1 or PEF, supplemental oxygen and pulse ox, nebulized SABA and ipratropium bromide (duoneb), oral or Iv steroids, IV rehydration, IV magnesium, NIPPV/BiPAP (be prepared to intubate)

When to refer to pulmonary or asthma/allergy specialist?

Poor response to therapy or requiring higher doses steroids or in the last year >\= 2 courses of oral steroid or any hospitalization

Condition characterized by chronic permanent dilation and destruction of bronchi and bronchioles

Bronchiectasis

Bronchiectasis: infectious insult - persistent severe inflammation -

Destruction of smooth muscle and elastic tissue - excessive mucous production as inflammatory response

Bronchiectasis - results in...

Impairment of drainage of bronchiole secretions (recurrent lung infections)

Bronchiectasis causes:

Cystic fibrosis (MC), primary ciliary dyskinesia, obstruction, allergic bronchopulmonary aspergillus, pulmonary infections, systemic disease, lung damage secondary to smoking

What is the most common cause of bronchiectasis?

Cystic fibrosis

Bronchiectasis symptom history:

Chronic cough, dyspnea, wheezing, copious amounts of purulent sputum, history of recurrent infections or underlying lung disease

Bronchiectasis PE findings:

Dyspnea and wheezing, crackles at the bases

Bronchiectasis diagnosis:

Sputum culture, CT, CXR, bronchoscopy

Bronchiectasis - What is the most common infection in non-CF patients?

H. Influenzae

Bronchiectasis - what is the most common infection in CF patients?

Pseudo. Aeruginosa

What is the diagnostic test of choice for Bronchiectasis?

CT

Bronchiectasis - what can be seen in the CT?

Dilated tortuous airways (signet ring sign and tram-track)

Bronchiectasis acute exacerbations treatment:

ATB (for those without culture information, broad spectrum empiric ATB like Fluoroquinolone), chest PT, bronchodilators

Bronchiectasis chronic disease treatment:

Long term maintenance and surgery

Bronchiectasis long term maintenance:

Exercise and improved nutrition, airway clearance therapy, vaccinations, nebulized bronchodilators + inhaled hyperosmolar therapy, ATB prophylaxis

Bronchiectasis surgery for...

Recurrent infections, severe hemoptysis, or focal disease