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DIFFERENTIAL
DIAGNOSTICS
The Bronchobstructive syndrome (BOS) is a symptomocomplex, developing as a result of airflow obstruction of the bronchi due to narrowing or occlusion of airways. The most common clinical manifestations are expiratory breathlessness, dry whistling rales, prolonged expiration and decreased forced expiratory volume per 1 sec (FEV1) at spirometry.
Causes of BOS
1. Respiratory organ diseases : Infectious and inflammatory diseases ( such as chronic obstructive pulmonary disease (COPD), pneumonia, multiple bronchiectasis, bronchiolitis, mycotic lung lesions) Allergic diseases (e.g. bronchial asthma). Tumours of the trachea and bronchi. Postnasal syndrome (that is disease of the nose and paranasal sinuses): such as allergic rhinitis, infectious rhinitis, sinusitis, hypertrophy of tonsils) Bronchopulmonary dysplasia; tracheobronchial dyskinesia Bronchopulmonary malformations . Mucoviscidosis; Pulmonary vasculitis Hyperventilation syndrome ; Sleep-apnea and sleep-hypopnae syndrome;
Causes of BOS
2. Aspiration diseases (or aspiration obstructive bronchitis). They include the following disease Gastroesophageal reflux disease, tracheoesophageal fistula, gastroentestinal malformations diaphragmatic hernia. 3. Foreign bodies in the trachea, bronchi, esophagus 4. Cardiovascular diseases associated with left ventricular failure. 5. Diseases of the central and peripheral nervous system. 6. Congenital and acquired immunodeficiecy diseases 7. Some other conditions, such as: Traumas and burns. Poisonings. Exposure to various physical and chemical factors of the environment. Compression of the trachea and bronchi of the extrapulmonary origin.
DIAGNOSTICS FINDINGS
1. Clinical data, the anamnesis (medical case history). 2. Laboratory studies (including virologic and microbiological) 3. Examination of the patient by otorhinolaryngologist (ENT-specialist). 4. Respiratory function tests 5. Examination of the patient by allergologist 6. Chest X-Ray and X-Ray examination of the sinuses of the nose. 7. Bronchoscopy and bronchography 8. Fibre-optic gastroduodenoscopy 9. Electrocardiography (ECG)
Affection of the bronchial tree and the pulmonary parenchyma Presence of partly irreversible bronchial obstruction. It is - a distinctive feature of COPD from BA because in the latter obstruction is quite reversible Steadily progressing character of the disease leading to increased respiratory insufficiency. Reduction of FEV1 by more than 50 ml testifies to progression of bronchial obstruction
ASTHMA
Allergens
COPD
Cigarette smoke
Ep cells
Mast cell
Eosinophil
Neutrophil
Bronchoconstriction AHR
Reversible
Airflow Limitation
Irreversible
Source: Peter J. Barnes, MD
Loss of elasticity
Anamnesis data The onset in the Typically develops in (Medical history first half of life people over 35 findings) Presence of atopy, Risk factors play a burdened heredity major role in the initiation of the disease Extrapulmonary Present None manifestations of allergy
Aging Populations
12
Obstruction
Cough Sputum
Breathlessness
Paroxysmal, it typicaly subsides Constant, slowly progressing spontaneously or with the help of treatment
It is decreased in exacerbations It is decreased and is of the disease and it is constantly getting worse restored in remission
BA
Respiratory function tests Are reduced and restored according to disease severity Gain by more than 15%
COPD
Are steadily decreasing according to the stage of the disease Gain by less than 15 %
PEF variability > 20 %. Positive Histamine or methacholine bronchial provocation test Increased IgE in blood Eosinophilia of blood and sputum
Additional tests
Uncommon, only in a Common in patients severe exacerbations with III-IV stage of the of the disease disease Eosinophils prevailing Neutrophils prevailing High Low
Reversible obstruction BA
Reduction of a degree of Clinical manifestations are severity of BA is a usual secondary to FEV1 changes. phenomenon which is necessary to achieve on carrying out of adequate therapy
Controlled
None (twice or less/week) None
Partly controlled
More than twice/week
Uncontrolled
Three or more features of Any partly controlled asthma More than twice/week present in any week Any
Normal
< 80% predicted or personal best (if known) One or more/year One or any week
None
Stage II: Moderate Stage III: Severe Stage IV: Very Severe
COPD
I. Elimination of risk factors II. Bronchodilators 1. Anticholinergic agents 2. 2- agonists 3. Long-acting preparations of theophylline III. Inhaled corticosteroids (only if indicated) Indications: *Decreased FEV1 (less than 50%) and repeated exacerbations. The proved clinical effect IV. Rehabilitation
Control options
None
Anti-IgE treatment
Uncrontrolled
Exacerbation
FEV1/FVC < 70% FEV1/FVC < 70% 30% < FEV1 < 50% predicted FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term
oxygen if chronic respiratory failure. Consider surgical treatments
500-1000
400-800 250-500
> 1000
> 800 > 500
1. Symptoms become severe and 1. Severe cough appear frequently 2. Increased amount of sputum 2. Increased need for and change of its character bronchodilators 3. Dyspnea 3. Decrease of FEV1 and PEFR
Management of Exacerbation
Bronchial asthma COPD
1.Short acting bronchodilators: increase of the dose and frequency of drug intake; 2.various combinations of drugs are administered; 3.used nebulaser
3. Aminophylline
4. Oxygen-therapy. 5. Antibiotics are administered if any signs of an infection are present
-lactam Tetracycline -lactam/ lactamase inhibitor (Co-amoxiclav) Macrolides Cephalosporins 2nd or 3rd generation
Antibiotics
-lactam/ lactamase inhibitor (Co-amoxiclav) Fluoroquinolones Cephalosporins 2nd or 3rd generation