INTERNAL MEDICINE LEC.

#4 PART #2, 04-03-2013

P. S. DOCTOR SAID THAT HE WOULD SPEAK QUICKLY TO LET US UNDERSTAND AND ANSWER THE QUESTIONS IN THE EXAM , SO THINGS HE DIDN 'T MENTION YOU CAN GO BACK TO THE SLIDE TO READ THEM !

BRONCHIAL ASTHMA
Definition and Characteristics It is a chronic inflammatory disorder of the airways , its phenotypes or Causing recurrent/intermittent episodes (attacks) of: Wheezing Breathlessness Chest tightness Cough particularly more at night Those Symptoms are worse at night and/or in the early morning. when we test their lung function the Variable airflow limitation that is at least partly reversible either spontaneously or with treatment, in another words when we give them bronchodilator drug they usually go back to normal. Airway hyper-responsiveness to a variety of stimuli; for example when they smoke they show symptoms Wheezing, Chest tightness & Cough. The Scope of the Problem -USA There is no good studies about asthma in Jordan but it's very common, in USA it Affects 14 -15 million people, 6% of children under 18 years of age and adults having wide range of age , Inner city children have

highest rates bcz of pollution, Rates higher among females, Rates higher among blacks. This study has been made to know what is population's experience with asthma for example 35.1% of population have family member of asthma and almost 6% themselves have asthma, So asthma is a common disease, it's unusual that there is some body don't know anything about asthma almost 25% or less.

causative factors of asthma are: Genetic : those who are born with atopy, and others bcz of Environmental factors : allergy, viruses, diet, antibiotics and smoking. Pathophysiology of asthma It's complicated multiple cells, multiple pathways and multiple cytokines are involved in the end all of these lead to : Inflammation of airway Airway hyper responsiveness Airflow obstruction Bronchial injury

in this picture we can notice the difference between the normal and asthmatic airways; where the asthmatic one is narrowed, there is mucus hyper secretion, smooth muscles hyperplasia, so it's narrowed but not a mechanical narrow it's due to thickening of the walls because of a disease so the bronchodilators alone will not solve the problem.

Consequences of events of Asthma: in the figure beside, there is a stimulus like allergies to flowers or grass in spring season which lead to acute airway inflammation which with time become chronic inflammation and injury to the airway and with frequent inflammation lungs will try to protect themselves by remodeling of the airways, so it's not a benign disease.

in the figure beside, the lungs function was measured by FEV1, the curve above is determining the lung function of normal person it drops with age , but in the lower curve for the asthmatic one which drops worse with age , indicating that it's not a benign reversible disease. We can notice that the curve is a step wise manner , the steps usually indicate acute exacerbation of the asthma; whenever there is worsening of the disease or acute exacerbation they use more function of the lungs. Asthma is an inflammatory airway disease, has it's won stimulus, cause airway hyper responsiveness, has
symptoms, not benign in all patients some of them progress and lose their lung function with time.

popularly asthma is known as chronic lifelong disease, if asthma onset occurs at younger ages 5 years for example the majority of them will be remission and some of them will persist, but if it occurs at late stages the majority will persist and some of them will resolve or remission. So the Onset of the disease will detect what will happen at the end.
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Risk Factors for Asthma Perinatal exposure to tobacco smoke, parents when they smoke near their children they increase their risk of asthma. so take this advice from Dr. "It's not a benign thing to somebody to smoke in a KIA car with his wife and 5 children!!" Atopy is associated with inherited elevation of total IgE mediated to specific things like olive, house dust mite, ... ect. Indoor Air Triggers, inside the house the most common is the house dust mite ; which live on the dust we could see when sun shine go through the window, we can inhale it to inter our airways and other parts of our body, a lot of people are allergic to this but it's very difficult to get rid of it bcz it's everywhere! There are people allergic to Cockroaches, Animal dander (cats and dogs), Environmental tobacco smoke outdoor Air Triggers, olive is a common tree in Jordan bcz it's easy to deal with so it presents everywhere and there are somebody allergic to it. Additional Triggers: Viral upper respiratory infections GERD (Gastroesophageal reflux disease) Sinusitis and rhinitis Diet, allergic to food Cold air Drugs, regarding the dentists almost the NSAIDs are used, some patients of asthma die from one tablet or one injection of NSIAD, Beta blockers for those with heart failure.

Asthma Diagnosis usually it is clinical diagnosis just doing : History and patterns of symptoms. Physical examination, office spirometry. Measurements of lung function. Measurements of allergic status to identify risk factors to a certain patient. Symptoms and Signs Variety of symptoms *wheeze *shortness of breath *chest tightness that *cough worse during night or early in the morning and also there is something called provoked by triggers Asthma symptoms tend to be: *Variable and intermittent, go up and down *Worse at night and early morning , and there is seasonal variation to those with seasonal allergy *Provoked by triggers, because of their airway hyper responsiveness to factors like smoke, perfume ,.. ect. Additional Elements in History Personal or family history of: Asthma, Atopic condition: eczema, allergic rhinitis Worsening of symptoms after: *Exposure to recognized triggers *Taking aspirin, NSAID, b-blockers. it's important as a dentist to ask the patient is he has allergy to one of them. *Exercise, they are ok but when they run they start coughing especially in children.
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In examination some patients look normal don't have any signs that doesn't mean they don't have asthma, they may be normal during the day but get worse at night! but you should hear wheezes. Differential Diagnoses what looks like asthma? those who have the same signs and symptoms of asthma: COPD; this is a similar disease but in heavy smokers with 50 or more years of age, who have more than 20 years back of smoking. Gastro-esophageal reflux disease (GERD); they have cough during night. Cystic fibrosis; sputum production Vocal cord dysfunction;

Diagnostic Tools
Peak flow monitoring by patients, a small instrument measures the speed of the air exhalation of the patient, for example measure the peak flow at morning it's 300 then at night it becomes 600 which is the variability that is typical to asthma. Pulmonary function testing (spirometry) 1- Obstructive pattern Forced Vital Capacity (FVC) Forced Expiratory Volume in 1 second (FEV1) FEV1/FVC < 70% to say that this patient is asthmatic. 2- Reversible airflow limitation FEV1 increases by 15% after inhalation of a rapid-acting beta-2-agonist that means the patient who has obstruction or he can't exhale all air from his lungs is given a bronchodilator then measure the obstruction again , if he gets better by more than 15% then he is asthmatic.

Clinical Control of Asthma Asthma at the past was a difficult disease to treat but now with discovery of newer medications especially inhaled corticosteroids we can control asthma, in a large number of patients they are completely normal they have: No (or minimal)* daytime symptoms No limitations of activity No nocturnal symptoms No (or minimal) need for rescue medication Normal lung function No exacerbations _________ Minimal = twice or less per week So it can be controlled , diagnosed and treated appropriately. # Usually we classify asthma according to the characteristics mentioned in the table above; Controlled, partly controlled or Uncontrolled. then we can make adjustment to the medication accordingly. But the main goal of us to get the patient to the left sided column (controlled).

Asthma Management
Although there is no cure for asthma Appropriate management most often results in the achievement of control, if it cured it will cure spontaneously.

Controller Medications
1- Inhaled glucocorticosteroids , which is the most important one. 2- Leukotriene modifiers, it's name is montelukast in the market it can be effective especially children 3- Anti-IgE , they are expensive can be very effective with some patients. 4- Theophylline
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5- Systemic glucocorticosteroids , used in severe cases. Long-acting inhaled 2-agonists

Reliever Medications
those medication are given to the patient in emergencies when we want a rapid response: 1- Rapid-acting inhaled 2-agonists : available in the hospital which is Salbutamol , available as tablet, syrup or inhaler. 2- Systemic glucocorticosteroids , used in acute exacerbation. **a picture of inhalers we use : ** the table below just to know that there is step up step down approach for the pulmonologist to help them decide to increase or decrease the dose of a drug.

Asthma Exacerbations It's the same asthma but sometimes it get acute to worse those have : Episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness Characterized by decreases in expiratory airflow Potentially life-threatening and treatment requires close supervision there were patients who were dead because of asthma in the hospital! So Asthma is not a completely benign disease like many people think! Manage Asthma Exacerbations we use the same medication used to manage the chronic asthma but more intensively, for example instead of giving inhaler we give metaboliser or IV.
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ORAL HEALTH CHANGES IN PATIENTS WITH ASTHMA Increased rate of caries development Reduced salivary flow Oral mucosal changes Gingivitis Orofacial abnormalities (adenoid face) Increased upper anterior and total anterior facial height Higher palatal vaults Greater overjets Higher prevalence of posterior crossbites

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THE HAPPY END

Done by : Baraa'h Al-Salamat