Today we had an interesting discussion on Asthma and it's potential mimicers, here is a synopsis:
- Diagnosis:
- FEV1/FVC less than0.75-0.8 with 12%+ improvement with beta-agonist
- More than 20% variation in peak expiratory flow (PEF)
- Methacholine challenge: PC20 (Concentration required for a drop in FEV1 of 20%) less than 4mg/ml
- Measures of poor control:
- Daytime symptoms more than 4/wk and night time symptoms more than 1/wk
- Missing days of work/school
- Decreased physical activity
- Frequent exacerbations
- FEV1 or PEF less than 90% of personal best
- Need for fast-acting beta2 agonist more than 4 doses/wk
- Sputum eosinophils more than 2-3%
- Treatment of Asthma exacerbation:
- Markers of severe disease/impending respiratory collapse:
- Work of breathing: use of accessory muscles
- Hypoxia (asthma is really a problem with ventilation, when oxygenation starts to decrease that's a worrisome sign)
- Pulsus paradoxus greater than10mmHg
- Silent chest!
- Inhaled beta agonists: short acting beta 2-agonists (salbutamol, albuterol) and short acting anti-cholinergics (iptratropium) MDI with aerochamber
- Prednisone: 40-60mg Prednisone daily or if unable to take PO consider IV solumedrol for 10-14 days.
- Adjuncts: MgSO4 2mg IV, Leukotriene receptor antagonists
- Intubation if needed
- Abx if evidence of pneumonia
- Complications of asthma that may present as worsening/non-responding asthma:
- Churg-Strauss: Medium-small vessel vasculitis that presents with worsening asthma, eosinophilia and ANCA positive in 40-60%. Other signs of vasculitis include: leukocytoclastic vasculitis (palpable purpura), mononeuritis mulitplex and less commonly RPGN.
- ABPA: Allergic bronchopulmonary aspergillosis. Major diagnostic criteria:
- Hx of asthma
- New pulmonary infiltrate
- Immediate skin sensitivity to aspergillus precipitins
- Precipitating serum antibodies to A. fumigatus
- Peripheral eosinophilia (500/mm3)
- IgE (1000ng/ml)
- Increased serum antibodies IgG, IgA, IgE
- Central bronchiectasis
- Cryptogenic Organizing pneumonia (previously called BOOP):
- A non-specific pulmonary inflammatory process manifesting as inflammation of the distal bronchioles, alveolar ducts/walls. Characterized by fever, malaise, chronic cough, areas of infiltration in CXR
- Terminology: Organizing pneumonia of determined cause and if it is "idiopathic" it is referred to as organizing pneumonia of undetermined cause or COP
- Causes of organizing pneumonia: infections (including: mycoplasma, PJP, HIV, cryptococcus), drugs (amiodarone, cocaine, bleomycine), malignancy.
- Can also occur in the context of CTD: SLE, sjogren's, dermatomyositis, etc.
- Mimicers of Asthma:
- Paradoxical vocal cord motion: the vocal cords move in during inspiration. Can be triggered by stress, exercise, airway manipulation, irritant inhalations. Presents with upper airway stridor, throat tightness, hoarseness cough. Treat with reassurance and asking the patient to "pant"
- Laryngospasm: Can be induced by URTI, presents with aphonia and choking sensation. Use of continuous positive airway pressure and heliox may help.
- "Cardiogenc wheeze": Don't miss the patient who presents with wheeze secondary to pulmonary edema (cardiogenic or non-cardiogenic)!
2 comments :
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