Obstructive airway or lung disease is characterized by obstruction to airflow seen as decreased expiratory airflow that primarily involves the bronchi, bronchioles and/or alveoli. It is seen in asthma, chronic bronchitis, emphysema, COPD, bronchiectasis, alpha 1 antitrypsin deficiency and bronchiolitis obliterans.
I) Reactive airway disease and asthma: Reactive airway disease is a poorly defined condition, often used synonymously with asthma.”Reactive airway disease” does not mean that the patient necessarily has asthma. Pulmonary function tests and methacholine challenge test can confirm if a patient has asthma, in doubtful cases. “Reactive airway dysfunction syndrome”, is the development of an asthma-like syndrome with acute wheezing, most often with no past history of asthma, resulting from a single exposure to an extreme irritant like fumes, dust storms etc. Methacholine sensitivity of airways is seen in reactive airway dysfunction syndrome.
Asthma: Asthma is characterized by chronic airway inflammation and airway hyperresponsiveness showing a marked airway narrowing on exposure to triggers like viruses, dust, pollen,mould,cold air, exercise etc. It presents with episodes of wheezing, chest tightness, dyspnea and coughing that occurs as a response to one of the triggers. Reversible bronchoconstriction is seen. It is caused by a Th2 immune response and cytokines IL4,5,9 and 13, along with eosinophilic infiltration and release of IgE and mediators such as histamine that mediate the pathological processes. An early and late response is seen that leads to progressive inflammation and airway damage. Airway remodelling occurs with frequent asthma exacerbations.
Maternal smoking, delivery by C-section and the use of antibiotics in pregnancy increase the risk of asthma in offspring. Asthma is often associated with atopy, allergic rhinitis and eczema. RSV infections in infancy may predispose to asthma in adolescence.
*Normal value of FEV1 in adults is >80% and in children is >90%
**PEF is peak expiratory flow
Challenge tests such as methacholine challenge are done in adults when the clinical suspicion of asthma is high but spirometry is normal. Peak expiratory flow can be measured practically anywhere by a peak flow meter. Peak expiratory flow rate or PEFR correlates with the cross-sectional area, even though the actual site of obstruction in asthma is in the bronchi and bronchioles. Normal range of PEFR for men is 500-700 L/min and for women is 380-550 L/min. Asthma exacerbations can be graded as mild (> 70% PEFR), moderate exacerbations (40-69% PEFR) or severe exacerbations (<40% PEFR).
Class | Description | Treatment |
Intermittent | Symptoms< twice/week; nighttime symptoms <twice/month; no significant spirometry or PEFR changes | Rescue inhaler/short acting beta 2 agonist/ low dose inhaled formoterol |
Mild persistent | Symptoms 3-6/week; nighttime symptoms 3-4/month; no significant spirometry or PEFR changes | Daily low-dose inhaled corticosteroid preferred; Long acting beta 2 agonists, low dose inhaled formoterol,theophylline, cromolyns or leukotriene modifiers can be added |
Moderate persistent | Daily symptoms ; nighttime symptoms 5 or more/month; FEV1 60-80% of normal, >30% variability in PEFR | Daily low to medium dose inhaled glucocorticosteroid plus long acting beta 2 agonist; Cromolyns or leukotriene modifiers can be added. Can shift to high dose glucocorticosteroids if needed |
Severe persistent | Continuous symptoms; frequent nighttime symptoms, FEV1 <60% of normal, >30% variability in PEFR | Daily high dose inhaled corticosteroid plus long -acting inhaled beta 2 agonist; Oral glucocorticosteroid, theophylline, leukotriene modifiers or long acting oral beta 2 agonist can be added |
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