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Internal medicine lec #4 part 1 Bronchial Asthma

19-3-2012

Dr. who gave this lecture is Basheer Khassawneh, MD, FCCP Bronchial Asthma is a common disease Sometimes in "TIME" magazine they talk about things that are common health problems that affect the society worldwide and Bronchial Asthma once made it to the cover page! Asthma is becoming more and more common

What is Bronchial Asthma? Do you know anybody with Bronchial Asthma? >> It is usually common! Definition helps you understand the disease, so it is an airway inflammation, and it is chronic not transient and goes away Causing recurrent episodes of symptoms, and this is what you see of asthma >> recurrent episodes of: o Wheezing o Breathlessness o Chest tightness o Dry cough o Cough particularly at night Symptoms are worse at night and/or in the early morning

Physiology of the disease: Variable airflow limitation, so they have a narrow airway that the air flow is limited And it is variable, so they have good\bad days, and good\bad hours

Reversibility in this obstruction becomes better spontaneously or with treatment "medication; bronchodilators for ex" Another property of asthma is Airway hyper-responsiveness to a variety of stimuli; which means when those patients are exposed to triggers, for example the wind outside and this cold air may cause people with asthma to start coughing and wheezing, dust, or strong smell The Scope of the Problem USA: -Affects 14 -15 million people, and it is a large number of people who have asthma -6% of children under the age of 18 years have asthma there, so it is also common in children, if you take a class or school 6% of the students would have true asthma and take medication for it -Inner city children have highest rates, so urbanized areas have more asthma than ruler areas -So we expect to see more asthma in more urbanized society, Amman, middle of Irbid, and Zarqa for example -Rates higher among females -In America rates higher among blacks, the Dr. doesn't think that here in Jordan <3 we have a huge ethnic diversity to judge! Family Members With Asthma 35.1% Past History of Asthma 5.8% Friends/Cowor kers With Asthma 29.4%

None 23.0%
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 Experience With Asthma: Public Survey They ask people around some Qs such as: do you have asthma? Did you have asthma? Do you have a family member having asthma? Do you know somebody who has asthma? As you can see in the chart above most of people either knows someone with asthma or they have it themselves

How the disease happens? It is a multifactorial disease (such as many internal med diseases) so there is no single defect that tells why you do have or don't have asthma Genetics plays a role through atopy "allergy", another effect of genetics has to do with cytokine dysregulation, and cytokines that are produced in the airways will have problems, excessive or reduced cytokines will help to produce asthma Environmental factors; Allergens, viruses' interactions, diet for example introducing early allergenic diet to children especially infants can cause asthma so parents should be very careful about what to feed their children in their early ages, and smoking either passive or active "for example kids who stay beside their smoking father or mother are more prone to respiratory tract infections than the others"

What happens at the cellular level? It is complicated and that's why its treatment is tricky, you will find histamine, leukotrienes, and cytokines who work on the epithelial and endothelial and cause inflammation And we have cytokines that works on macrophages and smooth muscles and cause inflammation So it is a multi-pathway disease >> for example in kids with asthma if you give them a drug that works on leukotrienes such as multi leukast they 4

usually improve because leukotrienes usually play an important and predominant role in asthma, BUT in adults it is not as effective as in children!

-Up until early 90s they used to think of asthma as a mechanical disease even physicians, asthmatics would have bronchoconstriction all they need is bronchodilators -As they started to take biopsies from asthmatic patients they realized that asthma is more than a bronchoconstriction -A lot of the lining epithelium in asthmatic airways is destroyed, and there is mucus plugging, if you take a lung biopsy from people who die from sever asthmatic attack will find a lot of mucus plugging, and bronchodilators cannot improve them at all :\ -And we have thickening, and an increase of the smooth muscles of the airways -It is not just a simple bronchoconstriction\ bronchodilation it is more than that, there will be lots of inflammation and this reflects our treatment of asthma patients Consequence of Inflammation in Asthma: -How do all of these pathways work? People with asthma history if they had a stimulus (Antigens, virus, pollutants, occupational agent) it will cause inflammation this inflammation might be acute episode >> 5

either goes away by itself or cause hyper-responsiveness and inflammation {the patient will have bronchoconstriction and cough etc} -Most of the patients will go into the "Chronic inflammation phase" which will cause injury such as edema and injury to the endothelium etc; to this injury body does repair what we call remodeling "repair with recurrent damage" which is important in Asthma -How do we see this repair in Asthmatic? A patient comes for example at the age to 20, he doesn't take medication, so he will have recurrent asthma repair inflammation and so on >> at the age of 30 he comes and says Dr. I used to have just a simple bronchodilator once in two weeks, then after few years I started to have regular use, but now I go to the emergency room and they give me steroids needles! NOW in his case it is a progressive disease, BUT usually it is not a progressive disease it is stable! A mild patient stays mild moderate stays moderate and so on, when do you cross these borders? >> When you have remodeling -So when we have changes on the cellular level only it is important to enforce management on patients so the Dr. tells his patients that if you don't want to take the medication now its fine but this simple medication won't help you after 3 or 5 years! -So Chronic inflammation with no medication lots of repair and inflammation and remodeling >> will lead to permanently altered lung function If you take a look at the lung function of a male non-smoker:

-From the age of 20-80 it slowly decreases but if you look at the asthmatic it is a rapid decrease because of remodeling and destruction of the airways! (So they lose their lung function with time) -Another important issue for public knowledge is that people say Asthma can go away this is true in children more than in adults, and it depends on the onset of which if it is at the early age "below 5 yrs" there is higher chance that the child when he grow up he will grow out of Asthma! -BUT for adulthood asthma the later Asthma will start the less likely this will occur (for example someone had asthma at the age of 25-30 it is unlikely asthma will go away) -The common Arabic terminology of the Bronchial Asthma is "al- rabo" and when you tell someone that you have Rabo he will believe that it will never go away which is true most of the adults will stay at this chronic phase, some of them will regress and some of them will progress, but most go into this stable chronic phase! Risk Factors for Asthma: o Allergy/Atopy which if familial we said people with eczema, conjunctivitis, or rhinitis makes it more likely to develop asthma! o Family history of asthma/allergy, so a child with parents having asthma is more likely to develop asthma than a child with healthy family! o Perinatal exposure to tobacco smoke, as we said before the Dr. thinks it is a crime for the parents to smoke inside the house and cause passive smoking to their children, because carcinogens will settle on the carpet and things in the house! o Early viral respiratory tract infections o Low birth weight o Environmental pollution o Low socio-economic status 7

o Passive smoking Atopy and Asthma: - Asthmatics are more atopic than non-asthmatics

Atopy (atopic syndrome) is a syndrome characterized by a tendency to be hyperallergic. A person with atopy typically presents with one or more of the following: eczema (atopic dermatitis), allergic rhinitis (hayfever), allergic conjunctivitis, or allergic asthma. Patients with atopy also have a tendency to have food allergies. Patients with atopy usually develop what is referred to as the allergic triad of symptoms, i.e., eczema (atopic dermatitis), hayfever (allergic rhinitis), and allergy-induced asthma (allergic asthma). They also have a tendency to have food allergies, and other symptoms characterized by their hyperallergic state. For example, eosinophilic esophagitis is found associated with atopic allergies. Atopic syndrome can be fatal for those that experience serious allergic reactions, such as anaphylaxis, brought on by reactions to food or environment. Wiki

-Some people come and ask for skin tests but they are usually not rewarding in asthmatics -They usually have multiple atopic reasons House dust mite for example and a number of things -House dust mite is the most common aer-allergen worldwide

-It lives in dust, it is everywhere, we are allergic to its feces we inhale it! {YUCK} -It is very hard to get rid of it, and very hard to avoid it Indoor Air Triggers: o Environmental tobacco smoke o Cockroaches o House dust mites - common o Animal dander - cats o Mold Outdoor Air Triggers: Here in Jordan <3 olives makes a problem because it is everywhere, and it produces strong air allergens o Particulate matter (air pollution) o Combustion products, maybe here in Jordan <3 it is not that much of a problem o Industrial emissions o Vehicle exhaust o Outdoor pollens >> Olive Additional Triggers: -1st problem as additional triggers for us as doctors are medications -Some patients with asthma they exacerbate by the use of aspirin o Viral upper respiratory infections o Exercise and hyperventilation o GERD

o Sinusitis and rhinitis o Diet o Cold air o Drugs o Aspirin, NSAID which are the most commonly used in Jordanian market and you as dentist want to give a patient a medication and you prescribe a NSAID for him and the exacerbate so you have to pay attention!, beta blockers Asthma Diagnosis: -It is usually diagnosed clinically by taking history and symptoms of the patient, as we said before they would have the Syndrome of Asthma (go back and review them) Symptoms and Signs: o Variety of symptoms o wheeze o shortness of breath o chest tightness o cough Asthma symptoms tend to be: o Variable and intermittent o Worse at night, and early mornings o Provoked by triggers, strong smells, cold air etc

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Additional Elements in History: Personal or family history of: o Asthma o Atopic condition: eczema, allergic rhinitis >> makes the case stronger to be asthmatic as well Physical Signs of Asthma: -They can be normal, especially if he came to you as a dentist During exacerbations: Wheezes! Differential Diagnoses: -COPD, Chronic obstructive pulmonary disease, which occurs in elderly, in smokers usually, so it can be very similar to asthma -Acid reflux, they would have recurrent cough -Post nasal drip, usually with cough early in the morning -And other things that can mimic asthma: o Cystic fibrosis o Tumor: Laryngeal, tracheal, lung o Bronchiectasis o Foreign body o Vocal cord dysfunction o Hyperventilation Diagnostic Tools: >> Peak flow monitoring, a small piece of plastic that measures the peak flow >> Pulmonary function testing (spirometry), asthmatic patient who has an obstructive defect "pattern" they would 11

have: FEV1/FVC < 70% and the Forced Vital Capacity will decrease, and less FVC in 1 sec "decreased FVC1" -And they have reversibility >> which means when we give them a bronchodilator in the clinic and I test them again they would be better and with better airflow -FEV1 increases by 15% after inhalation of a rapid-acting beta-2-agonist Asthma Management: Goals of management nowadays are better: No (or minimal) daytime symptoms No limitations of activity No nocturnal symptoms No (or minimal) need for rescue medication Normal lung function No exacerbations

>> This is almost a normal person and this is achievable by medications Levels of Asthma Control: Not that much important :\ BUT take a look next page

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Characteristic

Partly controlled (Any present in any (All of the following) week) Controlled None ( 2/ week) None > 2 / week Any

Uncontrolled

Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Need for rescue / reliever treatment Lung function (PEF or FEV1)

None

Any

3 or more features of partly controlled asthma present in any week

None ( 2 / week)

> 2 / week

Normal

< 80% predicted or personal best (if known) on any day 1 / year 1 in any week

Exacerbation

None

-Doctors should believe that there is no current cure for asthma, but most important to know that if you give them medications "symptoms wide" they can live a normal life ^^: -While the doctor was preparing for the lecture he opened google pix and searched Bronchial asthma and the most common thing that he found is ??? Someone holding an inhaler! >>> So inhalers are stigma for Asthma! <<< Q: why some people have mild, moderate and severe? A: Asthma is just like a pyramid the top is severe and the bottom is mild and people can have any of which! Most of the time people stay wherever they are but sometimes they can get worse :\

-So most of the people stick at the level they are at! And if they are not treated they can cross the borders and get worse 13

-So we said Asthma is an inflammation so you should give antiinflammatory drugs and the best one is Inhaled glucocorticosteroids; because it is locally delivered to the site of the disease with minimal systemic effect -Leukotriene modifiers, as we said a subset of patients benefit from that especially children -We have a new treatment which is: Anti-IgE , for people with atopic or allergic Asthma, very expensive -An old medication: Theophylline, less used these days -We use Systematic glucocorticosteroids, during exacerbations and patients who doesn't respond >>So the main treatment of Asthma is: inhaled corticosteroids<< And the mortality rate among patients who don't take inhaled corticosteroids is much higher than those who take it! Reliever Medications Asthmatic patients have airway hyperresponsiveness and bronchospasm so we should give them bronchodilators as well The common bronchodilator is: Salbutamol Anticholinergics: Ipratropium, is also a good bronchodilator especially when combined with salbutamol -Steroids also can work as bronchodilators

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Those are the various types of inhalers that we have! And they have combination of medication within those inhalers, steroids and bronchodilators

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The figure above illustrates the step therapy for asthma It is a traditional slide for asthma patients everywhere you go you will find it Although we don't follow these rules, but as you can see the general concepts are important For example all patients should be well educated about their disease, and environmental control As you can see all patients take inhaled corticosteroids but with variable doses! Asthma Exacerbations Asthma during exacerbations is similar to regular asthma; let's look to asthma as camping fire you just put water on it to stop it what if you have a big fire in the whole wood! The same concept you bring water to stop it but in a larger scale! Asthma during exacerbation is similar to regular asthma, for example instead of inhaled CS we give systemic CS Instead of 2-agonists every 6 hours I give it every 4 hours and so They may be treated in the hospital! For example if you had a patient in your clinic and he had asthmatic attack you give him O2 (the amount doesn't really matter) followed by CS >> if they had good response that is good if not you give them systemic CS and then they go to the hospital!

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There is an article in the magazine dentistry and medicine the Dr. advice us to look at it! it is about increased risk of caries in asthma patients and -Reduced salivary flow -Oral mucosal changes -Gingivitis -Orofacial abnormalities Increased upper anterior and total anterior facial height Higher palatal vaults Greater overjets Higher prevalence of posterior crossbites So there is an association between asthma and dental diseases! You should be aware if the patient has allergy to any component and if the local anesthetic is not good for him! As we said the attacks comes early in the morning so we tell them to go to the dentists in the afternoon! Take your medication before you go! Simple things make a big difference in management Qs? Dr. answered some Qs but they where general and he answered in general as well Dr. said Qs comes from the slides )( ..

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Internal medicine lec #4 part 2 Community Acquired Pneumonia -Dr. who gave this lec is Shaher M. Samrah, MBBS, FCCP -Types of pneumonia: Community Acquired Pneumonia (CAP) Hospital Acquired Pneumonia Pneumonia in Immune-compromised Host

19-3-2012

Pneumonia in Patients with HIV >> which is considered a special type of pneumonia

-What we are concerned about is CAP Epidemiology -The sixth leading cause of death -The most common infectious cause of death Mortality < 1% in the outpatient setting will die -But the mortality increases according to the severity; 5-12% for patients requiring hospital admission and 22-50% for patients requiring ICU admission Microbiology We think of a variety of bacterial and viral pathogens, but CAP most commonly caused by bacteria Streptococcus pneumoniae is the most common organism In sever dental caries patients with bad oral hygiene and lots of cavities they would have anaerobic infections other than Streptococcus pneumoniae 18

Take a look at this list of pneumonias:

Alcoholism Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter species, Mycobacterium tuberculosis Haemophilus influenzae, Pseudomonas aeruginosa, Legionella species, S. pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae Gram-negative enteric pathogens, oral anaerobes CA-MRSA, oral anaerobes, endemic fungal pneumonia, M. tuberculosis, atypical mycobacteria Histoplasma capsulatum

COPD and/or smoking

Aspiration Lung abscess

Exposure to bat or bird droppings Exposure to birds Exposure to rabbits Exposure to farm animals or parturient cats Influenza active in community

Chlamydophila psittaci (if poultry: avian influenza) Francisella tularensis Coxiella burnetti (Q fever)

Influenza, S. pneumoniae, Staphylococcus aureus, H. influenzae Bordetella pertussis

Cough >2 weeks with whoop or posttussive vomiting Structural lung disease (eg, bronchiectasis) Injection drug use Endobronchial obstruction In context of bioterrorism

Pseudomonas aeruginosa, Burkholderia cepacia, S. aureus S. aureus, anaerobes, M. tuberculosis, S. pneumoniae Anaerobes, S. pneumoniae, H. influenzae, S. aureus Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia)

Alcoholism, Aspiration, Lung abscess all of which you can see anaerobic organisms in the list! So not everyone with CAP has streptococcal infection, but you have to think about it because it is the most common microorganism 19

And you should think of the risk factor that is most likely to cause the disease! Previously they used to say that there is what we call typical and atypical pneumonia but they don't use it anymore because and the might go inside each other's classes and in the end the treatment is the same, because as well at least 10-40% Co-infection with one pathogen of the list Diagnostic Approach to CAP Clinical Evaluation >> we start with History we ask about symptoms, fever, chills, and so on Physical exam Simple laboratory tests Radiological Evaluation Chest X-Ray CT chest Microbiological studies Clinical Evaluation: (Symptoms) 90% patients will have cough regardless productive or dry Purulent sputum Dyspnea Pleuritic chest pain Fever and chills Physical Signs: Vital signs: Tachycardia, tachypnea, fever, hypotension Signs of consolidation: This means when the lung has an infection! Dullness, egophony, crepetations bronchial breath sounds, 66% 66% 50% 30-40%

Signs of pleural effusion: this means fluid around the lung 20

Stony dullness "Dr.s have a test by the finger they knock on the cavity or any place in the body you should hear resonance when you don't hear it they cavity is filled with something else fluid or so", diminished breath sound

Investigation: Depends whether it is an outpatient or inpatient We start with Routine tests performed on admission: Chest radiograph Complete blood count Urea, electrolytes and liver function tests, because there are microorganisms that produce liver dysfunction Oxygenation assessment: ABG You detect if the patient has hypoxia SaO2 <92% on admission How to detect pneumonia: pulse oximetry, or by ABG "arterial blood gas" features of severe pneumonia Radiological Evaluation By definition, Pneumonia requires the finding of infiltrate on chest radiograph The presence of infiltrate on CXR is the gold standard for diagnosing pneumonia Radiological findings: -Lobar infiltrate: One lobe or multi-lobar -Interstitial infiltrate, all of the lung infected 21

-Pleural effusion: Parapneumonic or empyema And they may have: -Lung abscess -So when a patient comes to you and you start detecting the dysfunction and see what the symptoms that he has are, cough, fever, and shortness of breath I ask for an X-ray and you will find lobar infiltrate -What other things that I can do to help me diagnose? Some people might ask for culture from this lung to see what is this microorganism?

This is pneumonia in the right upper lobe of the lung

Here we have the right lower lobe having more infection, but you feel bilateral infiltrate exist! >> Right lower + middle Lobes

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Here we can see the infection in the right lower lobe but there is effusion as well! >> Pleural Effusion

Here we have infiltrate on the left lower lobe, but there is some sort of fluid level! So cavity with fluid >> Lung abscess Microbiologic Diagnosis: Some people ask for sputum for culture which is good but should not guide you through diagnosis! Because you have to start treatment before, according to the risk factor

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So you don't have to wait for culture to start treatment unless you have moderate and severe cases and you want to make sure of the microorganism that is causing the infection! Microbial cause is not found in 2560% of cases You diagnosis Should be guided by: The severity of pneumonia Epidemiological risk factors The response to treatment So Sputum culture is not really needed! ~ 30% has unable to produce sputum Helps to broaden the empiric antibiotic therapy o Blood Culture sometimes it is recommended preferably before antibiotic treatment, so when you have a patient you take a blood culture from him before you start antibiotics to make sure that you are not treating a resistant microorganism o Pleural fluid if the patient had plural infusion! Gram stain and culture o And in some cases we make what we call Bronchoscopy (BAL, PB) , .. In rare infection and rare presentations, and risk cases for example when a patient comes and you suspect he has TB and you tell him to give you sputum which has a totally different treatment! Pneumonia is a systemic infection it is not local it reaches the blood! So you have to start antibiotics as soon as possible And at least order blood culture and it helps you later on

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For example when an outpatient comes we treat him without blood nor sputum culture so it depends on the severity and sometimes we don't use chest X-ray Serology: Sometimes you take a urine sample and you find antigens in it! So this helps to guide diagnosis but it doesn't guide treatment So you always have to treat Legionella for example And it helps in screening and epidemiological studies, BUT we don't wait for those to come back to decide treatment ^^: The antibiotics that we use in CAP cover those other organisms, such as Legionella, Pneumococcal antigens so usually the antibiotic covers the microorganisms included in the disease And sometimes you have other signs such as Legionella causes liver dysfunction for example and they have hyponatremia so in this case to make sure that Legionella is the cause and to rule out other dysfunctions we order a urine test or serum test It takes 4-6 weeks to get the results Which is not recommended to wait that much! As we said you have to decide where to treat out\in patient, and if the patient need to be in ICU We have some things that help us decide but we don't use them all For example: Pneumonia Severity Index (PSI) CURB-65 Pneumonia Severity Index (PSI)

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We have classes from 1-5, depends on the scores 1\2 >> outpatient 4\5 >> inpatients More than 5 >> they usually go to ICU Those are the scoring points:

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It is COMPLICATED and we don't use it often So we go to the other thing which is CURB 65 It is a summary of the risk factors and when we see them we say this patient has severe pneumonia and this doesn't C Confusion U Urea > 7 mmol/l R Respiratory rate > 30/min B BP: Systolic < 90 mm Hg Diastolic < 60 mm Hg Hypotension, renal failure, and confused patient! 65 Age > 65 Years

The older the patient the more severe his case will be! So if the patient had the things above he has severe pneumonia And if the patient had end organs involvement we say he has sepsis, it became systemic so there is risk factors in severe pneumonia that are really scary and we should take of them Studies play a role here because of the need of knowing the effect of the risk factors on the severity of the disease Criteria for Severe CAP The slides say minor and major not necessary, you know what the things you should think about to decide admission to ICU or not Major Criteria >> Invasive mechanical ventilation Patient that needs invasive ventilation Where to put him? 27

If the patient had Septic shock requiring vasopressors whatever the cause is It is very difficult to treat him in the floor Minor Criteria >> Respiratory rate > 30/min PaO2 / FIO2 < 250 Multi-lobar infiltrates Confusion Uremia (BUN > 20 mg/dl) Neutropenia Thrombocytopenia Hypothermia "the same as fever it is a bad thing that means the patient is no longer having defense no white cells defense to produce fever" Patients with very low oxygenation or having bilateral lung abscess they are at high risk of getting worse you're always concerned whether they'll need more oxygen CAP Treatment: Microbiological DX unknown in up to 50% Initiate therapy within 8 hours ((patient with pneumonia >> antibiotics)) Always think about co-infection and X-rays How to decide what kind of treatment you want to use?? >> If the patient was previously healthy, and did not use antibiotics "Previously healthy + No antimicrobials within the previous 3 months" Simple Macrolide is enough for example: eryhthromycin, Clarithromycin, Azithromycin 28

>> "Comorbidities or antimicrobials within the previous 3 months" -Respiratory fluoroquinolone: levofloxacin --lactam + macrolide The later we have to use two antibiotics because the microorganism pneumonia has 30% increased resistant Macrolide are not enough for severe pneumonia we have to use other antibiotics Inpatient Treatment-Non ICU Same as we said: Respiratory fluoroquinolone Levofloxacin, Moxifloxacin, Gemifloxacin -lactam + Macrolide Ceftriaxone, Cefotaxime Dental pneumonia! In cases of aspiration and lung abscess pneumoniae where anaerobic infection Which are found in the mouth dental caries, decays A patient that is alcoholic and is always sleeping, with bad oral hygiene which is a risk factor for two things: dental pneumonia, and infective endocarditic What are the antibiotics used in this case? Clindamycin (first-line therapy) covers anaerobic only Amoxicillin-clavulanate Metronidazole + Amoxicillin/Penicillin G

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We have vaccinations:

There is another thing which is Influenza virus Vaccine

In October or November to decrease mortality from such as infections And they are given to the staff as well

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It takes time to heal ... 4 weeks to resolve depends on the severity it is a reversible disease Most common pneumonia caused by bacteria It is infectious At the end the Dr. showed a pic of a casino in Las Vegas why I don't kn! Sorry for any mistake .. ~ " " - - : : ( ) ...

Life is short try not to waste it unhappy

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