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Reactive Airway Dz

"reactive airway disease" and "asthma" mb used interchangeably but are not necessarily the same thing

interesting: http://www.herbaltherapeutics.net/EclecticProtocols-Asthma.pdf

Reactive airway disease
a general term
doesn't indicate a specific diagnosis
mb used to describe a history of coughing, wheezing or shortness of breath of unknown cause
may not be asthma
use of the term reactive airway disease reflects the difficulty in establishing a diagnosis of asthma
esp during early childhood
tests to diagnose asthma generally aren't accurate before age 6 (bronchial challenge test?)
usu involves wheezing, allergic rxns
use of this term and others may result in delay of asthma dx, beware
not all children who wheeze have asthma
most children younger than 3 years who wheeze are not predisposed to asthma
~30% of infants who wheeze go on to develop asthma

Reactive Airways Dysfunction Syndrome = RADS
a term proposed by S.M. Brooks and colleagues in 1985
sx like asthma after a single exposure to irritant
vapor, fume, or smoke
some call it occupational asthma

SYMPTOMS
range in severity from mild to fatal
coughing, wheezing, and dyspnea.[5]

ETIO IN ADULTS
exposure to high levels of chlorine, ammonia, acetic acid, sulphur dioxide
chlorine can cause longterm airway damage

DDX
extensive

ASTHMA DX CRITERIA
At least 5 years of age
Episodic symptoms of airflow obstruction or airway hyperresponsiveness
Reversible airflow obstruction of at least 10% of predicted forced expiratory volume in one second (FEV1) after use of short-acting beta2-agonist
Alternative diagnoses have been excluded
2009 The American Thoracic Society and the European Respiratory Society-->new official standards on asthma

ETIO
environmental stimuli-->allergen-antibody interaction-->mediators-->airway inflammation
-->smooth muscle hyperresponsiveness, edema, and increased mucous production-->incr work of breathing
mast cells-->mediators-->edema, mucous secretion, and bronchospasm
mediators: histamine, tryptase, heparin, leukotrienes, platelet-activating factor, cytokines (ILs, TNF)
eosinophils, lymphocytes also release mediators

KIDS UNDER 3
more susceptible to pulmonary complaints
some think all infants have highly responsive airways dt incr IgE under 2, viral (rhino), heredity
intrapulmonary airways are small
any lower airway infection-->diminished airway function
poor collateral ventilation, decreased elastic recoil pressure, and a partially developed diaphragm

SX IN KIDS
fever and bronchospasm NOT assoc with a more severe clinical course
fever w infx-->good prog

HYGIENE HYPOTHESIS AND OTHER ETIO CONSIDERATIONS
early exposure to infections and allergens mb protective vs later asthma
breastfeeding mb protective up to 24 mo of age dt TGF-B1 in human milk
maternal environmental tobacco smoke during pregnancy/year 1 MAY predispose children to RAD

ASTHMA
common in Western countries than in developing countries
more prevalent in English-speaking countries
peak prevalence of asthma is in those aged 6-11 years

GENETICS OF ASTHMA
ADAM33 gene on the short arm of chromosome 20 involved? research ongoing
7% risk if neither parent has it
20% with one asthmatic parent
64% if both

PEDIATRIC ASTHMA
approx 50% of all ED and clinic visits for asthma are children younger than 18 years
chronic, multifactorial, lower airway disease that affects 5-15% of children
2.7 million children in the United States alone
ED visits peak in the fall
School holidays-->decrease in hospitalization
Asthma prevalence increasing worldwide
dt air pollution?
higher prevalence in poverty stricken urban areas
correlation with cockroach allergen? mb imp in inner city

STATUS ASTHMATICUS
on the rise
increase in hospital admissions esp in under 4yo
kids on corticosteroids go to the ED less

ASTHMA PREDICTIVE INDEX
algorithm to determine the risk factors for developing persistent asthma sx
in kids under 3 with 4+ episodes in prior year
incl either (1) one of the following:
parental hx of asthma
a physician diagnosis of atopic dermatitis
evidence of sensitization to aeroallergens
or (2) two of the following:
evidence of sensitization to foods
≥4% peripheral blood eosinophilia
or wheezing apart from colds

OBESITY AND ASTHMA
mb assoc
adipokine: resistin mb negatively predictive of asthma??

RAD
1/3 of kids under 18 affected
13 million health care visits annually in the United States
mortality rates increasing
more common in black and Hispanic children
no correlation exists with income or education level from a retrospective review
male-to-female ratio is 1.5:1


HX: ASK ABOUT THESE
Initiation of symptoms (More than a few days decreases the chance of quick reversal in the ED because of prolonged inflammation and mucous plug formation)
Upper respiratory infection (URI) symptoms, fever, and production of phlegm
Precipitating factors
Use of an bronchodilator inhaler; how often it was used in the past 24-48 hours prior to the ED visit; how often it was used over the past week or month
How many inhalers were used in the past month
How many puffs are being administered with each use and if the inhaler is being used with a spacer
Compliance with use of corticosteroid inhaler (Ask if it was used daily despite any symptoms of wheezing)
Date of last ED visit; how severe the current episode is compared with previous episodes9
Date of the last hospital admission
Number of admissions in the past year; number of intensive care unit admissions
History of intubation and how long ago it was
Recent use of oral steroids
Factors that usually initiate symptoms
Whether this is a typical episode
Presence of any underlying cardiac, GI, or immunologic diseases
Other current medications
Exposure to tobacco smoke and allergens (ie, cat dander)
Ability to tolerate fluids
Recent mental status changes
Baseline peak expiratory flow rate (PEFR)
History of atopic dermatitis or other allergic skin conditions10
Dry cough or wheezing that is often worse at night
History of recurrent wheezing and dyspnea
Wheeze or cough after active playing
Relationship to emotional expressions
Relationship to menses
Physical

Fever
Tachycardia
Tachypnea, dyspnea
Wheezing
Coughing
Flushing, cyanosis
Flaring of nasal alae
Presence of nasal polyps and nasal secretions
Intercostal retractions
Poor feeding
Diaphoresis
Distant breath sounds, hyperresonance (Beware of "silent chest," too little air movement to hear wheezing.)
Pulsus paradoxus (mild asthma pulsus paradoxus = 10, moderate = 10-20, severe >20)
Altered mental status
Decreased peak expiratory flow rate
Inspiratory-to-expiratory ratio (An increased inspiratory-to-expiratory ratio is a bad sign.)
Allergic shiner (ie, dark semicircles of skin under the eyes)
Transverse nasal skin fold from repeatedly rubbing the nose
Increased anteroposterior diameter or pectus carinatum
Murmur
Clubbing
Subcutaneous emphysema

RATING ASTHMA
Mild asthma: the child can speak in sentences and is not short or breath at rest, slight increase in respiratory rate but no accessory muscle usage
Moderate asthma: the child is short of breath while talking and speaks in short phrases, respiratory and heart rate increased, loud wheezes throughout expiratory phase
Severe asthma: the child is short of breath at rest, very agitated, sitting upright and not speaking or using only one single word, wheezes throughout inspiration and expiration
Respiratory arrest imminent if child is drowsy and wheezes are absent

ASTHMA TRIGGERS
Infection -Respiratory syncytial virus (RSV) most commonly isolated from infants and preschool-aged children; Mycoplasma pneumoniae most commonly isolated from school-aged children
Tobacco smoke
Pet dander, cockroach and dust mite allergen
Molds
Pollen
Exercise
Weather changes
Stress
Drugs
A precipitant of bronchiolitis is respiratory infection, usually due to RSV.
Gastroesophageal fistula
Mediastinal mass (external compression of the airway)
Cystic fibrosis

ASTHMA
case discussed in Stansbury class
two formulas, one general tonic, the other the bronchodilator for acutes
brainstorming possible ingredients:

TONIC
take minimum 3mo before followup
make a tea of the good ones
crataegus
mast cell stabilizers:
tanacetum = feverfew, tumeric,
allium if prone to infx, (also astragalus, reishi)
glycyrhizza, zingiber, scutellaria baicalensis (chinese)
khella = Ammi visnaga
petasites
ginkgo for enhanced circ
hydrastis = goldenseal, drying and antimicrobial
eleuthero
achillea
zingiber general anti-inflam
euphrasia = eyebright, she doesn't think it's so good for lungs but good neck up
lungwort? loberia pulmonaria

BRONCHODILATOR
equal parts first four with a touch of cayenne to activate
lobelia heavy hitter, can cause nausea
foeniculum eases nausea
ephedra heavy hitter
thyme if need drying
cayenne
eucalyptus chest rub as complement

SOURCES

Stansbury lecture

James T. Li, M.D. @ Mayo Clinic
http://www.mayoclinic.com/health/reactive-airway-disease/AN01420

http://en.wikipedia.org/wiki/Reactive_airway_disease

http://emedicine.medscape.com/article/800119-overview

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