Asthma Treatment at Home
A 6-year-old boy presents to his physician with end-expiratory wheezing scattered throughout the lung fields. He is noted to have nasal flaring, tachypnea, and intercostal retractions. These symptoms are triggered by changes in the weather. He has a family history of asthma and atopic dermatitis. He has never been intubated or admitted to the pediatric ICU. His last hospitalization for asthma was 6 months ago. He takes medication for asthma only when he starts to wheeze. Definition. Asthma is a reversible obstructive airway disease that affects both small and large airways. There are three components of an asthma attack (I) bronchospasm, (2) mucus production, and (3) airway edema. The obstruction caused during the asthma attack causes increased airway resistance and decreased forced expiratory volumes and flow rates. In addition, the lungs are hyperinflated there is premature airway closure, increased work of breathing, and changes in the elastic properties of the lungs. Presentation....
Of a volatile permeant (31) and metabolism of the permeant as it diffuses through the skin (32). The models have been used successfully to examine the transdermal delivery of a number of drugs, e.g., nitroglycerine (33), estradiol, rolipram (34), and theophylline in preterm infants (35).
The physical signs and CXR suggest emphysema. This is confirmed by an obstructive ventilatory impairment with hyperinflation, air trapping, and reduced diffusion. In bronchial asthma, there would typically be marked bronchodilator response, and the patient with chronic bronchitis would present with chronic sputum production. Tuberous sclerosis presents radiographically as hyperinflation and lower zone infiltrates, but clinically is a systemic disease with a clinical triad of mental retardation, seizure disorder, and dermal angiofibromas called adenoma sebaceum. Pulmonary disease is rare (it is seen in less than 1 of cases) and presents with pneumothoraces and hemoptysis. In this case with emphysema, complications include respiratory failure. Increased IgE levels are associated with allergic bronchial asthma obstructive sleep apnea and clubbing do not have an increased association with this condition. CT scan is the most sensitive imaging modality to...
Activation of the Th2 pathway can lead to immediate hypersensitivity, an IgE-dependent form of allergy. The reaction is initiated when IgE antibodies that are bound via their Fc region to the IgE receptors, principally on mast cells, bind their specific antigens ( allergens ). Crosslinking of the IgE receptors on these cells stimulates the activation and release of mediators from these cells. IL-4 from Th2 lymphocytes strongly promotes the synthesis of IgE the Th2 cytokines IL-5 and GM-CSF stimulate eosinophil differentiation and activation and IL-4 acts on mast cells. IgE, eosinophils, and mast cells are involved in host defense against the extracellular helminthic parasites. On the other hand, a dysregulated Th2 response leads to chronic inflammation, asthma being a prime example.54
The airway epithelium is a target of inflammatory, environmental, and physical stimuli in diseases such as asthma and bronchopulmonary dysplasia. Damage to the epithelium may compromise both the physical barrier and key metabolic functions. Repair involves the migration and spreading of cells over the basement membrane and the proliferation of new epithelial cells. Each step can be modulated actively by growth factors secreted by constitutive cells within the airway, or suppressed by mediators secreted by inflammatory cells that have migrated into the airway. Understanding these steps is essential to gaining insight into the repair process in airway epithelium.
The patient has had steroid-dependent chronic bronchial asthma for many years and has no history of foreign travel or contact with a TB patient. He has a history of occasional hemoptysis. CBC eosinophilic Oxygen saturation low. Very high titers of specific IgE antibodies against Aspergillus present (specific marker for the disease) sputum cultures positive for Aspergillus skin tests to Aspergillus antigens positive. PFTs obstructive picture (due to underlying asthma). Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder that primarily affects the central bronchi immediate and Art hits-type hypersensitivity reactions are involved in its pathogenesis. The onset of the disease occurs most often in the fourth and fifth decades, and virtually all patients have long-standing atopic asthma. Untreated ABPA leads to proximal bronchiectasis, p.189
A4 enzyme system, drugs that are metabolized through this system (Rifampin, barbiturates, carbamazepine, certain statin drugs, amiodarone, benzodiazepines, sildenafil (Viagra), theophylline, and certain selective serotonin reuptake inhibitors) may increase repaglinide metabolism (19). Although in vitro data indicate that repaglinide metabolism may be inhibited by antifungal agents (such as ketoconazole and miconazole) or antibacterial agents (such as clarithromycin), systematically acquired data is not available on increased or decreased plasma levels with other cytochrome P-450 3-A4 inhibitors or inducers.
Corsaro, D., Valassina, M., Venditti, D., Venard, V., Le Faou, A., and Valensin, P.E. (1999) Multiplex PCR for rapid and differential diagnosis of Mycoplasma pneumoniae and Chlamydia pneumoniae in respiratory infections. Diagnosis in Microbiology and Infectious Disease 35, 105-8. The use of PCR to detect infectious organisms as a cause of asthma.
Panic and the phobias make a significant contribution to the burden of disease. The original Burden of Disease study only included panic disorder, while the estimation of the burden of disease in Australia in 1999 56 included panic, agoraphobia and social phobia but not the specific phobias. These three disorders accounted for 28000 Disability Adjusted Life Years lost, 1.1 of the total burden of disease in Australia, and 8 of the burden of all mental disorders. Put in context, the burden of panic and phobias was half the burden of asthma and four times the burden of insulin-dependent diabetes and comparable to the burden of prostate cancer.
Cough is a dominant and persistent symptom of many inflammatory lung diseases, including asthma, COPD, viral infections, pulmonary fibrosis and bronchiectasis. Chronic cough can also be idiopathic in nature where no obvious causal mechanism is evident. Cough is the most common complaint for which medical attention is sought and although effective treatments for cough are not available, narcotic agents, such as the opioid codeine, are often used. However, such agents have only limited beneficial value due to the associated side effects such as constipation, nausea, vomiting and drowsiness. Therefore, the identification of novel therapies, devoid of central activity, for the treatment of chronic cough would be of significant therapeutic benefit and greatly enhance the quality of life of patients who suffer from this condition 68 .
Early experiments using the relatively weak TRPV1 antagonist capsazepine provided pharmacological validation that capsaicin-induced bronchospasm in guinea pig bronchi did indeed involve the activation of TRPV1 12, 80 . Contractile responses to resiniferatoxin and capsaicin were unaffected by the neurokinin-1 (NKX) antagonist CP-96,345, partially inhibited by the NK2 antagonist SR 48968 but nearly abolished by a combination of the antagonists. These data suggest that resiniferatoxin and capsaicin both release tachykinins that act on both NKX and NK2 receptor subtypes in a TRPV1-dependent manner 80 . More recently a more potent and selective agent has been used to confirm these observations 81 . Neurogenic inflammation in asthmatic airways via retrograde release of peptides from sensory nerves via an axon reflex. C-fibres are activated via TRPV1 and cause reflex activation of cholinergic nerves. These nerves also release neuropeptides, including substance P (SP), which causes...
A severe, prolonged asthma attack that does not respond to conventional methods of treatment. 9. A child is having a status asthmaticus attack. His pulse becomes_ 10. A child having an asthma attack may have used an over-the- counter bronchodilator. If he has, he must not be given the medication_
Usually, at this early point we unconsciously begin to formulate a differential diagnosis in our minds and we begin to ask ourselves questions. When Mr. Burgman says his chest is tight does he mean that it is hard for him to take a breath because of the obvious bronchospasm, or does he mean that he has the constrictive feeling in his chest that people report with AMI Is he short of breath and wheezing because he has chronic obstructive pulmonary disease with respiratory failure, or because he is in pulmonary edema edema, rales at the bases, and his current array of medications that are aimed at congestive heart failure help us to feel confident that his respiratory distress is on the basis of pulmonary edema rather than chronic obstructive pulmonary disease with bronchospasm. Now we face the question of whether Mr. Burgman's problem is acute pulmonary edema alone, or whether it is acute pulmonary edema precipitated by AMI Clearly the history is potentially compatible with both. Before...
The history of wine has been documented as far back as 2000 bc. In Babylon, salves were mixed with wine to treat various skin conditions. The Ancient Egyptians are also recorded to have used it for the treatment of other ailments, including asthma, constipation, epilepsy, indigestion, jaundice and depression. Perhaps as a deterrent to self-medication, various bizarre and somewhat unlikely ingredients were added, including pigs' eyes, bats' blood, dogs' urine and crocodile dung (Pickleman 1990).
Sleep position, i.e., placing the infant on his or her back during sleep (unless medically contraindicated), may decrease occurrences of SIDS. Patients who have experienced IALTE should have home electronic monitoring of the heart rate, respiratory pattern, and oxygenation. These IALTE patients may also be treated with theophylline or caffeine.
The precise mechanism of nucleation and subsequent crystal growth is not fully understood. Frank (1949) suggests that if a molecule diffuses to the flat surface of a crystal it only has one binding surface, but if it arrives at a kink or step, it has more than one binding surface with which to anchor itself to the crystal. With screw dislocations, the crystal can continue to grow in a spiral staircase manner. Four models predicting crystal growth of theophylline monohydrate were presented by Rodriguez-Hornedo and Hsui-Jean (1991)
HPI The child, a known asthmatic, had come to the hospital by ambulance 15 minutes earlier with severe wheezing, intercostal retractions, nasal flaring, and marked dyspnea. He was given inhaled corticosteroids. Treatment Metaproterenol by inhalation until bronchospasms stop. Treat infection, acid-base electrolyte imbalance. Discussion In a severe case of asthma such as this, a preexisting infection is usually the precipitating event. Inhaled steroids have no place in the treatment of an acute attack, as is also the case with sodium cromolyn (cromolyn prevents the release of mast cell mediators, useful for prophylaxis). IV steroids may be given but may take several hours to take full effect (they block leukotriene synthesis by blocking synthesis of phospholipase A2). Inhaled beta-agonists are the mainstay of acute, emergent therapy (they activate adenyl cyclase and thereby increase cAMP, which relaxes bronchial smooth muscle). Adverse effects include arrhythmias, tachycardia, and...
The answer is a Fauci 14e pp 14511455 Massive lifethreatening hemoptysis is 100 cc of blood in 24 h The most common
The answer is d. (Fauci, 14 e, pp 194-197.) The most common cause of chronic cough in adults is postnasal drip due to sinusitis or rhinitis (allergic, vasomotor, irritant, perennial nonallergic). Patients typically complain of having to clear their throats or a feeling of something dripping in the back of their throats. Physical examination reveals muco-purulent secretions and a cobblestone appearance to the mucosa. Asthma is more of an episodic disease with wheezing, but occasionally patients complain of only cough. Gastroesophageal reflux disease (GERD) must be considered in patients who complain of heartburn or regurgitation. Other causes of chronic cough include bronchitis, congestive heart failure, and use of angiotensin converting enzyme (ACE) inhibitors. 135. The answer is e. (Seidel, 4 e, p 184, 371.) Clubbing is associated with cystic fibrosis, lung cancer, congenital heart disease, cirrhosis, colitis, and thyroid disease. Clubbing is due to the formation of new...
On a hot summer day in a large urban center located in the southwestern United States, an emergency room department reports an increase in admissions for asthma in children and young adults, but not among patients suffering from chronic bronchitis or ischemic heart disease. The most likely air pollutant responsible for the exacerbation of asthma is
Adenosine and dipyridamole increase blood flow to nonarteriosclerotic vessels, unmasking stenoses in other arteries with their vasodilatory action. These agents should not be used if an individual has asthma or severe obstructive lung disease, because bronchospasm can be worsened.
PE VS no fever tachypnea (RR 32) normotension. PE inspiratory and expiratory wheezes (due to bronchoconstriction, small airway inflammation) boggy and pale nasal mucosa accessory muscle use during breathing enlarged chest AP diameter hyperresonant to percussion. Treatment Inhaled, oral, and parenteral bronchodilators steroids cromolyn zafirlukast. Discussion A disease characterized by hyperreactivity of the airways and obstruction due to bronchospasm, edema, and mucus. Also known as reactive airway disease. p.316
In addition to the stimulation of airway C-fibres, capsaicin has also been shown to have effects on the inflammatory response as assessed in human cell-based assay systems. Thus, capsaicin has been shown to interact with TRPV1 expressed by BEAS-2B and other airway epithelial cells to cause the calcium-dependent production of cytokines and, conversely, calcium-independent cell death. The mechanisms of these cellular responses to capsaicin appear to proceed via distinct cellular pathways, but both pathways are initiated by TRPV1. These results demonstrate that capsaicin and related compounds, which are contained in pepper-spray products, can produce airway inflammation and cause respiratory epithelial cell death 91 . However, the role of the TRPV1 in airway inflammatory disease would depend on the presence of endogenous activators of this channel under physiological and pathophysiological conditions. In fact, it is quite possible that this situation does in fact exist in the disease...
Bethanecol has also been used to stimulate reflex bladder contractions in patients who have had suprasacral spinal-cord injuries (3). The contraindications include peptic ulcer disease, cardiac arrhythmias, bladder or bowel obstruction, bronchial asthma, and hyperthyroidism. In addition, acute circulatory arrest may be caused by intramuscular or intravenous injection. Other side effects include flushing, nausea, vomiting, diarrhea, bronchospasm, headache, salivation, sweating, and visual changes. Overall in several studies, BC has not been demonstrated to cause sustained physiologic bladder contractions in individuals with voiding dysfunction (4-7).
Ephedrine, combined with methylxantines, was used in the treatment of asthma for decades. A physician in Denmark noted weight loss in his patients taking this combination drug for asthma. The combination of 200 mg caffeine and 20 mg ephedrine given three times a day was subsequently approved as a prescription obesity medication in Denmark, where it enjoyed commercial success for more than a decade (116). In 1994, legislation in the United States declared ephedra and caffeine to be foods, eligible to be sold as dietary herbal supplements. The use of this combination as an unregulated dietary supplement for the treatment of obesity was accompanied by reports of cardiovascular and neuropsychiatric adverse events, leading to the FDA declaring ephedra, the herbal form of ephedrine, as an adulterant (117). Recently, courts in the United States have overturned the FDA decision to withdraw ephedra from the herbal market, at least in regard to ephedra doses of 10 mg or less, and the...
Over the last 5 years, Durlach et al.104 have shown that magnesium depletion is relative to neurodegenerative and neuromuscular disease, asthma, and mitral valve prolapse, which are reminders of the importance of maintaining magnesium levels in the elderly. For the elderly with Type 2 diabetes, the problem of magnesium depletion is very common, and the need to routinely establish a selective administration of magnesium to improve glycemic control and prevent chronic complications of diabetes is very important.105
As well as being expressed on the sensory innervation of the airways, TRPV1 is also expressed on airways epithelial cells, and activation of TRPV1 by particulate matter induces apoptosis, which may be an important mechanism for particulate matter damage to the airways 47 . Air pollutants are thought to cause a reduced immune function and lowered resistance to infection as well as hypersensitivity to allergens and may exacerbate asthma and chronic obstructive pulmonary disease (COPD). Environmental particulate matter can act like synthetic particles made from negatively charged polymers, which are thought to act by concentrating protons near proton-gated receptors. Particulate matter causes a slowly desensitizing activation of TRPV1, and the calcium influx leads to apoptosis in sensory neurons and lung epithelial cells 47 . The authors suggest that blocking TRPV1 receptors would be useful in alleviating particulate matter-induced inflammation and toxicity.
Churg-Strauss syndrome, named for Jakob Churg, a Polish-American pathologist (19101966) and Lotte Strauss, an American pathologist (1913-1985), has an incidence of about 3 per million. The typical patient is usually male and in the fifth decade of life. Classically the syndrome is a triad of rhinitis and asthma, eosinophilia, and systemic vasculitis. Because of its makeup, there are a number of theories about the underlying pathophysiology. It may be a progression of an allergic phenomenon, or a primary vasculitis that has an asthmatic component due to the involvement of eosinophils. Treatment is primarily with corticosteroids alone, although in life-threatening cases cyclophosphamide can be added. Due to its association, it may be difficult to taper pred-nisolone treatment when the vasculitic parts of the disease are in remission, as this may lead to asthmatic exacerbations.
In very serious cases, like tetanus or snakebite, if there is a good chance that the antitoxin might produce an allergic reaction (if the person suffers from allergies or asthma or has had horse serum before), inject promethazine or diphenhydramine 15 minutes before giving the antitoxin adults, 25 to 50 mg. children, 10 to 25 mg., depending on their size (see p. 387).
Preoperative therapy involving chest physiotherapy, smoking restriction, antibiotics, and bronchodilators can greatly reduce postoperative pulmonary complications. The severity of postoperative pulmonary complications can range from benign minor atelectasis, which is usually self-limiting, to a fulminant acute respiratory failure that carries a very high mortality. Accordingly, recognition and management of postoperative cardiac and pulmonary complications are essential for the vascular surgeon.
A history of smoking is associated with more than a three times increase in post-operative lung problems. Even stopping smoking for a short period of time reduces this risk substantially. In the long term, smoking is a major risk factor for global lung diseases, such as asthma and chronic lung disease. Reduced lung function is associated with an increase in post-operative lung problems, and may necessitate post-operative ventilation. In severe lung disease, weaning the patient from mechanical ventilation can be prolonged.
Recent studies have found that the most important factor is getting the blood pressure controlled, and this is more important than the means. 10 Similarly, most patients will need more than one medication. Several commissions have suggested that the first-line drugs should be low-dose thiazide diuretics or beta-blockers, in the absence of other factors. Beta-blockers, especially the cardioselective types, are good medications for many individuals. Data suggest that use of beta-blockers may reduce the incidence of strokes but not total mortality.11 They are especially good choices in patients with tachycardia, anxiety, migraine headaches, and angina. They should be avoided in asthmatics, patients with bradycardia or atrioventricular blocks, and diabetic patients using insulin who may become hypoglycemic. Beta-blockers can make the individual feel slow, tired, or depressed. Their effects on women's sexual function are not known.
The recruitment and activation of phagocytes in response to infections also may contribute to tissue damage owing to the exuberant local release of leukocyte granule enzymes and other proteins and generation of oxidants. Thus, the pyogenic response of neutrophils to bacterial infections can be partially deleterious, as with the chronic neurologic sequelae following bacterial meningitis in children. Likewise, eosinophil activation in response to helminthic infections and allergic diseases, such as asthma, can damage host cells.54
Glucocorticoids are used widely in the treatment of many chronic diseases, particularly asthma, chronic lung disease, and inflammatory and rheumato-logic disorders, and in people who have undergone organ transplantation. The risk that oral steroid therapy poses to BMD, among other side effects, has been known for some time. As a result, clinicians have eagerly substituted inhaled steroids in an endeavor to partially protect the patient from unwanted negative steroid effects. Recent evaluations of the effects of inhaled glucocorticoids on bone density in premenopausal women demonstrated a dose-related decline in bone density at both the total hip and the trochanter.47 Women asthmatics were enrolled who were using no inhaled steroids, using four to eight puffs per day, or using more than eight puffs per day at 100 g puff. No dose-related effect was noted at the femoral neck or the spine. Serum and urinary markers of bone turnover and adrenal function did not predict the degree of bone...
Is the accumulation of fluid in the pericardial sac in amounts sufficient to cause obstruction of blood flow back to the heart. Cardiac tamponade may follow trauma or surgery. It may be a complication of malignancy (i.e., lung, breast, lymphoma), chronic renal failure, or hypothyroidism. The patient has the classic signs of cardiac tamponade, including pulsus para-doxus, JVD, and distant heart sounds. Patients may also present with hypotension. ECG may show low voltage and pulsus alternans. Chest radiograph may show enlargement of the cardiac shadow. Pulsus paradoxus is an inspiratory drop (from expiration) in systolic blood pressure of 10 mm Hg (normal 10 mm Hg). Pulsus paradoxus may also be seen in severe asthma and constrictive pericarditis.
Frequently in all degrees of cold injury, the affected individual becomes sensitized to further exposure to cold. With milder injuries, sensitization to cold may persist only days or weeks, but in more severe injuries, cold sensitivity of the injured part may be permanent. Consequently, additional precautions must be taken by a person once injured by cold to prevent further injuries. In certain cases, true cold sensitivity or allergy may exist. Such persons may demonstrate urticaria or hives with intense burning, itching, and swelling when exposed to cold. Generally, this happens to persons who have had a cold injury. Rarely, however, this reaction may be a family trait or happen to a person who has plasma cryoglobulin or cold agglutinins. In such persons, cold exposure may cause a systemic reaction of generalized urticaria, asthma, and even shock.
Beginning of spring (marked exacerbation of clinical symptoms) until autumn winter (milder symptoms), even though for children the disease remains variably active the year around. Nevertheless, perennial cases that are persistent throughout the year are not rare, especially in patients living in warm subtropical or desert climates. Its predominance during the high pollen season highly strengthens the widely accepted hypothesis that VKC is an immuno-logically mediated hypersensitivity reaction to environmental antigens. The characteristic features of the two clinical forms of VKC, the giant papillae on the upper tarsal conjunctiva (tarsal VKC) or the gelatinous limbal infiltrates (limbal VKC), leave no doubt as to the diagnosis of vernal disease. All VKC forms are characterized by intense itching, tearing, mucous secretions and a severe photophobia that often forces children to live virtually in the dark. The commonly noted foreign body sensation is caused by conjunc-tival surface...
The answer is b. (Schwartz, 7 e, pp 211-212.) This patient is having an anaphylactoid reaction with destabilization of the cardiovascular and respiratory systems. Anaphylactoid reactions are most commonly caused by iodinated contrast media, -lactam antibiotics (e.g., penicillin), and Hymenoptera stings. Manifestations of anaphylactoid reactions include both the lethal (bronchospasm, laryngospasm, hypotension, dysrhythmia) and the nonlethal (pruritus, urticaria, syncope, weakness, and seizure). Epinephrine is the initial treatment for laryngeal obstruction and bron-chospasm, followed by histamine antagonists (H1 and H2 blockers), amino-phylline, and hydrocortisone. Vasopressors and fluid challenges may be given for shock. Conscious patients are usually stabilized with injected or inhaled epinephrine, while unconscious patients and those with refractory hypotension or hypoxia should be intubated.
A 38-year-old man is admitted with progressive shortness of breath and cough. He denies any fever, chills, or purulent sputum production. He wants to be evaluated to determine the reasons for his symptoms. On exam, he is afebrile and has decreased breath sounds with hyperresonant upper lung field more obvious on the right. ABGs on RA pH 7.35 Pco2 38 mm Hg Po2 78 mm Hg. Spirometry FVC 1.72 (70 of predicted) FEV1 1.34 L (60 of predicted) FEVi FVC 76 TLC 4.1 L (100 of predicted) TLC by helium dilution method 3.4 (71 ) DLCO 70 of predicted. There is no bronchodilator response. Chest radiographs are shown below in Fig. 19. b. Increase bronchodilator dosage and frequency
A 24-year-old male law student presents with a 3-wk history of increasing dyspnea. He has a history of chronic sputum production of about 100 cc of purulent material each day for many years. In the past, he was hospitalized for a left pneumothorax. He is on inhaled bronchodilator as an outpatient. CXR is shown below in Fig. 24. a. Increase bronchodilator therapy
Therefore, isotonic fluid is usually given to these patients to establish perfusion. Dextrose-containing solutions should be given to children who are hypoglycemic. 32-agonist therapy may help children with bronchospasm. Prophylactic antibiotics are not recommended unless the child has been exposed to contaminated water. It is imperative to establish an airway and deliver oxygen to prevent further hypoxia.
Antagonists, zafirlukast and later montelukast, in patients with asthma. The probable mechanism is the unmasking of an underlying but hitherto unrecognized vasculitis. A variant is allergic granulomatosis and angiitis, which is seen in patients with prior asthma and allergy for many years.
ID CC A 60-year-old male is referred to an allergist for late-onset asthma that has been unresponsive to bronchodilators and antibiotics. Discussion Churg-Strauss is an idiopathic systemic small- and medium-vessel granulomatous vasculitis (grouped with polyarteritis nodosa PAN , which does not involve lungs) characterized by a triad of late-onset asthma, a fluctuating eosinophilia, and an extrapulmonary vasculitis.
Both cognitive and behavioral interventions have been found to improve well-being in a variety of GMCs, including cardiovascular illness, chronic pain, AIDS, cancer, and asthma 141, 142 . However, few studies use CT to reduce depression coexisting with GMCs 142 . Larcombe and Wilson 143 , in a controlled study, showed CBT to improve depression in patients with multiple sclerosis. Kelly et al 144 demonstrated the effectiveness of group CBT and social support for depressed HIV-infected patients.
The solutions, reported in Table 2 of this reference, several of the compounds in the study (i.e, dopamine, glycine, urea, glyphosate, theophylline, aminopyrine, 2,4-d, and alachlor) were partially ionized. Equilibration was attained over 24 hours. These Kcw,rep values were placed in the excluded database because they were measured using PHSC.
Many roundworms in the intestines may cause discomfort, indigestion, and weakness. Children with many roundworms often have very large, swollen bellies. Rarely, roundworms may cause asthma, or a dangerous obstruction or blockage in the gut (see p. 94). Especially when the child has a fever, the worms sometimes come out in the stools or crawl out through the mouth or nose. Occasionally they crawl into the airway and cause gagging.
The diagnosis is made on clinical grounds. However, a nasal smear of patients with allergic rhinitis may be overabundant with eosinophils. In addition, a family history of asthma or eczema may be obtained. Treatment. The patient should avoid the allergen. Antihistamines and decongestants are useful in treating allergic rhinitis, especially if seasonal. Cromolyn nasal solution is useful in both seasonal and in perennial allergic rhinitis. Topical use of corticosteroids is the most effective treatment. If infection is suspected, a broad-spectrum antibiotic should be administered.
A 53-year-old female nonsmoker is being evaluated with symptoms of progressive shortness of breath. She has a past history of trauma to the right side of the chest. There is no history of asthma, sputum production, or recent chest pain. CXR is shown in Fig. 51. a. Obstructive limitation with bronchodilator response d. Obstructive disease with no bronchodilator response
Pneumonia is an acute infection of the lungs. It often occurs after another respiratory illness such as measles, whooping cough, flu, bronchitis, asthma or any very serious illness, especially in babies and old people. Also, persons with AIDS may develop pneumonia. If the person is wheezing, an anti-asthma medicine with theophylline or ephedrine may help.
Contraindications for the use of beta-blockers include a pulse less than 50, significant hypotension, decompensated heart failure, asthma or reactive airways disease requiring bronchodilators and or steroids, and second- or third-degree atrioventricular block.42 Diabetes, peripheral vascular disease, mild moderate asthma or chronic obstructive pulmonary disease (COPD), asymptomatic bradycardia, and compensated congestive heart failure are not contraindications to the use of beta-blockers.42
A 28-year-old G1, PO 26-wk pregnant woman is seen in the OB clinic. She has a past history of bronchial asthma that has been well controlled for the last year by inhaled steroids. She states that she has noted increasing shortness of breath for the last 3 days. On examination, she appears tachypneic and moderately uncomfortable. On physical examination, she has a pulse of 110 bpm normal temperature respirations 32 min blood pressure 160 90 mm Hg. Heart exam NSR without any gallop. A grade 2 6 systolic murmur in the pulmonic area is heard. Lung exam is clear to auscultation abdomen exam confirms a 26-wk gravid uterus. Laboratory data Hb 12 g dL Hct 36 WBCs 7.0 L with normal differential BUN 23 mg dL creatinine 0.9 mg dL sodium 136 mEq L potassium 4.2 mEq l. ABGs on room air pH 7.34 Pco2 34 mm Hg Po2 68 mm Hg. PEFR 450 L min. Chest x-rays are shown in Fig. 54. c. Acute exacerbation of bronchial asthma
Asthma for many years and has no history of foreign travel or contact with a TB patient. He has a history of occasional hemoptysis. Labs CBC eosinophilia. Oxygen saturation low. Very high titers of specific IgE antibodies against Aspergillus present (specific marker for the disease) sputum cultures positive for Aspergillus, skin tests to Aspergillus antigens positive. PFTs obstructive picture (due to underlying asthma). patients have long-standing atopic asthma. Untreated ABPA leads to proximal bronchiectasis.
- Chronic obstructive pulmonary disease (COPD) (25-50 ) Many patients with vascular disease are (or were) heavy smokers with significant COPD. Normally abdominal surgery leads to reduced lung volumes, with shallow tidal volumes, reduced or absent sighing, weakened cough and impaired gas exchange. Patients with COPD are at higher risk of developing post-operative pulmonary complications. Pre-operative preparations are therefore required with physiotherapy, bronchodilators and cessation of smoking to significantly reduce the risk of these complications.
Groups suggest that since propranolol blocks circulating tissue plasminogen activator (tPA), there is a direct effect on the aortic wall by diminished plasmin-mediated MMP activation and therefore reduced expansion rate. Whatever the pharmacological explanation, it would certainly appear that unless contraindicated (e.g., asthma, severe cardiac failure), a good argument can be made for the administration of propra-nolol while the aneurysm is under surveillance.
Current data summarized in this chapter suggest that airway inflammatory diseases (e.g. asthma and COPD) may respond to treatment with an effective and selective TRPV1 may play an important role in the enhanced sensitivity of the airways seen in asthma, COPD and chronic cough with the implication that antagonism of TRPV1 may have therapeutic potential. The enhanced sensitivity may be due to the release of inflammatory mediators such as BK and NGF upregulating the activity of TRPV1 leading to exaggerated functional responses. These effects can be elicited by agonists at the TRPV1 (e.g., capsaicin, H+, heat, RTX) and inhibited by agents that inhibit sensory nerve activity (e.g., capsazepine, cannabinoid agonists, andandamide). RTX, resiniferatoxin BK, bradykinin NGF, nerve growth factor AHR, airway hyperresponsiveness inhibitor of TRPV1 and to this end much work is being carried out to develop novel inhibitors 104 . Interestingly, capsaicin-sensitive nerve stimulation in subjects with...
A 43-year-old man with a history of substance abuse is admitted to the ICU with status asthmaticus and respiratory failure. Upon reaching the ICU, he has a cardiorespiratory arrest and requires CPR, intubation, and mechanical ventilation. BP was 160 100 mm Hg on admission, but post-CPR it remains at 80 60 mm Hg. An immediate IV fluid bolus is administered and a CXR (Fig. 79) is done. b. Severe status asthmaticus
Airway flow rates are also measured by spirometry, but the procedure is modified so that the patient is asked to exhale rapidly and forcefully after maximum deep inhalation. The volume of air exhaled is measured at one-, two-, and three-second intervals. Bronchodilators are then given to the patient and the procedure is repeated. Recordings are evaluated to identify the difference in airway flow rates with and without the aid of bronchodilators. Individuals with pulmonary obstructive disease have decreased airway flow rates. Variations from Normal. Spirometry is useful for diagnosing diseases such as chronic obstructive pulmonary disease, asthma, bronchitis, and emphysema. These diseases affect the pulmonary airways and are therefore classified as obstructive diseases. The effect of restrictive diseases, such as kyphosis, scoliosis, pneumothorax, and hemothorax, on the ventilation function of the pulmonary system can also be assessed via spirometry.
National Eczema Society, Hill House, Highgate Hill, London N19 5NA. Tel 020 7281 3553. Provides telephone advice and information support through a national network of regional telephone contacts and groups throughout the UK and a joint holiday programme with the National Asthma Campaign, with provision for children, teenagers and young adults. Also has a network of local volunteer contact persons.
Asthma is a common disease in children and the prevalence in the United States was estimated at 5 in 1992, a rise from 3 in 1982, with sharp declines noted from early childhood to adolescence. Which of the following factors is most strongly predictive of mortality due to asthma in children c. Asthma
The answers are 2-1 a, 2-2 d. (Behrman, 16 e, pp 1285-1287. McMillan, 3 e, pp 1214-1216. Rudolph, 20 e, pp 672-677.) Of the choices given, bronchiolitis is the most likely, although asthma, pertussis, and bronchopneumonia can present similarly. The family history of upper respiratory infections, the previous upper respiratory illness in the patient, and the signs of intrathoracic airway obstruction make the diagnosis of bronchiolitis more likely. Viral croup, epiglottitis, and diphtheria are not reasonable choices because there are no signs of extrathoracic airway obstruction. cated for acute exacerbations of chronic lung disease, which might present with fever, change in color of sputum, and increasing shortness of breath. Oral corticosteroids are helpful in some patients, but are reserved for those who have failed inhaled bronchodilator treatments.
An in-hospital workup of a 78-year-old, hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24 and a urinalysis with 18-25 WBCs and gram-negative bacteria. On call to the operating room he receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3 the patient develops a wound infection. e. Asthma a. Increasing the length of the preoperative hospital stay to prophylacti-cally treat the asthma with steroids
A 50-year-old male smoker is evaluated for chronic shortness of breath. On physical examination his vital signs are pulse 110 bpm temperature normal respirations 30 min with use of accessory muscles and pursed-lip breathing blood pressure 110 78 mm Hg. Other pertinent findings are heart exam apex beat (impulse) is medial to the midclavicular line with generalized decreased breath sounds on lung exam ABGs (FiO2 0.21) pH 7.38 Pco2 47 mm Hg Po2 67 mm Hg. PFTs spirometry FVC 2.80 L (67 of predicted) FEV1 1.56 (50 of predicted) FEV1 FVC 56 TLC 134 of predicted RV 170 of predicted DLCO 43 of predicted. There is no reversibility with bronchodilators. Chest radiographs are shown below in Fig. 18. a. Bronchial asthma with status asthmaticus
382, The answer is b, (I lard man, p 906.) Cimetidine reversibly inhibits cytochrome P450+ This is important itt phase I biotransformation reactions and inhibits the metabolism of such drugs as warfarin, phenytoin, propranolol, metoprolol quinidine, and theophylline. None of the other enzymes are significantly affected.
Issues related to the management of major respiratory problems comprise much of the backbone of Intensive Care, particularly problems concerning mechanical ventilation, acute (adult) respiratory distress syndrome and nosocomial pneumonia. While many other respiratory problems are also common, especially asthma, acute pulmonary oedema, community-acquired pneumonia and pulmonary thromboembolism, some may have uncommon causes or differential diagnoses. These uncommon aspects of common conditions, together with the more clearly uncommon conditions themselves, are therefore considered in this book and include asthma
Lung scans are most useful for the identification of pulmonary embolism. Tumors, chronic obstructive pulmonary disease, pneumonia, atelectasis, asthma, bronchitis, emphysema, asthma, and tuberculosis are best visualized with a conventional chest x-ray.
The child develops bronchospasms with wheezing (the bronchial tubes get smaller, spasmodically causing wheezing). The tissues of the larynx swell, causing the child to make a harsh, respiratory sound when he breathes. He also becomes hoarse. 3-12. ACUTE ASTHMA Asthma is a congestive pulmonary disease characterized by attacks of wheezing and difficult breathing. Smooth muscles that lie in the walls of the smaller bronchi and bronchiolus become increasingly responsive to a variety of stimuli (pollens, dusts, milk, shellfish, fumes, etc.). This causes edema in the bronchi and congestion of the lining membranes of the bronchi. Additionally, the membranes which line the bronchi secrete a great deal of mucus which is hard to dislodge (cough up). a. Signs Symptoms of Acute Asthma. Included are the following b. Treatment of Acute Asthma. An acute attach of asthma is treated as a respiratory emergency. Treat as follows (2) Administer bronchodilator medication. The drug...
If this type of poisoning is suspected, refer to Halstead's Poisonous and Venomous Marine Animals of the World and contact a poison control center. The fish involved include the puffer fish, scromboids (tuna species), ciguatera (large colored fish), and paralytic shellfish. Give basic life support and prevent self-injury from convulsions. The possible complications from this type of injury are allergic reactions, asthmatic reactions, paresthesia, numbness, temperature reversal phenomena, or respiratory arrest and circulatory collapse.
William Lambe, another London practitioner, followed a similar course in the early 1800s. Although obesity was not a problem for him, he did relieve himself of longstanding illness by removing meat from his table. He then applied the diet to the care of his patients, and succeeded in curing, he believed, many cases of asthma, tuberculosis, and other chronic complaints, even cancer. In his 1809 report on these personal and clinical experiences, he submitted that a strict vegetable regimen was adequate for health, that meat was unnecessary, and that what is unnecessary cannot be natural, and what is not natural cannot be useful. 18
Oral contraceptive pills are a very popular method of birth control. There are many OGP preparations most consist of a combination of estrogens and progestins, which, when taken daily, selectively inhibit pituitary function to prevent ovulation. The most severe complication is an increased incidence of vascular thrombotic events, either cerebral or myocardial. Other side effects include nausea, acne, weight gain, psychological depression, cholestatic jaundice, increased incidence of vaginal infections, headaches, and breakthrough bleeding. OCPs should be used cautiously in patients wirh asthma, diabetes, liver disease, and hypertension.
The types of reactions that can be seen following Hymenoptera stings include a typical, local reaction marked by transient pain, redness, and swelling a more extensive local reaction with swelling beyond the sting site a type I (immunoglobulin E-mediated) anaphylactic response with any combination of diffuse urticaria, angioedema, laryngeal edema, bronchospasm, or hypotension and a delayed, probably immune complex-mediated, reaction.60 Examples of such delayed reactions include serum sickness and very rare atypical phenomena such as hemolysis, thrombocytopenic purpura, and poorly understood neurologic syndromes such as Guillain-Barr syndrome or transverse myelitis.59 Multiple Hymenoptera stings can produce systemic poisoning. Of special interest in this regard are the Africanized honeybees (Apis mellifera scutellata), or killer bees. These bees are located from Argentina northward into the southern United States and differ from domesticated honeybees in that they attack aggressively...
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Coping with Asthma
If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.