Asthma is characterized by a diffuse inflammation of the airways. Cause a plurality causative factors that lead to partial or complete, reversible bronchoconstriction. The symptoms include dyspnea, thoracic tightness, coughing and wheezing. Diagnosis is based on history, physical examination and lung function tests. The treatment includes control of triggering factors and drug therapy, usually with inhaled ?2-agonists and corticosteroids. The prognosis is good with treatment.
Asthma is characterized by a diffuse inflammation of the airways. Cause a plurality causative factors that lead to partial or complete, reversible bronchoconstriction. The symptoms include dyspnea, thoracic tightness, coughing and wheezing. Diagnosis is based on history, physical examination and lung function tests. The treatment includes control of triggering factors and drug therapy, usually with inhaled ?2-agonists and corticosteroids. The prognosis is good with treatment. Epidemiology Since the 70s, the prevalence of asthma has increased steadily. The disease now affects an estimated 235 million people worldwide. More than 25 million people are affected in the US. Asthma is one of the most common chronic diseases in childhood, affecting more than 6 million children in the United States. It is more common in boys before puberty and in girls after puberty. It also comes ever more common in non-Hispanic dark-skinned and Puerto Ricans. Despite the increasing popularity has recently experienced a decline in mortality. In the US, about 3400 deaths annually occur because of asthma. However, the mortality rate among black is 2 to 3 times higher than in white population. Asthma is the most common cause of hospitalization in children and the leading chronic disease that leads to absenteeism in elementary school. Asthma costs the United States an estimated annual 56 billion US $ in medical care and lost productivity. Etiology The etiology of asthma is multifactorial and depends on the interactions of many genes predisposing and environmental factors. Among the predisposing genes include the genes coding for T2-helper cells type 1 and 2 (Th1 and Th2), IgE, interleukins (IL-3, -4, -5, -9, -13), granulocyte-monocyte colony -stimulierender factor (GM-CSF), tumor necrosis factor-? (TNF-?) and the ADAM33 gene, which is intended to stimulate the proliferation of bronchial smooth muscle and fibroblasts or regulate the cytokine production. The environmental factors may include the following: allergen exposure diet Perinatal factors in older children and adults play an important role in the disease development proven allergens in the household (eg house dust mites, pets, cockroaches [translator’s note .: latter play in… German-speaking countries seem hardly matters]) and (in the environment, pollen). A poor in vitamin C, E and ?-3 fatty acids diet is also linked to asthma, such as obesity. Asthma is also associated with perinatal factors like low age or poor nutrition of the mother, premature birth, low birth weight and lack of breastfeeding in context. On the other side of early childhood exposure to endotoxins can induce tolerance and be protective. Air pollution is not clearly linked to the development of disease, but may favor exacerbations. The role of passive smoking during childhood is occasionally still controversial: some studies a protective and others with the pathogenesis of favorable effect has been described (Editor’s note .: so now, is highly likely that passive smoking favors asthma creation..). Genetic and environmental factors are together influence the balance between Th1 and Th2 cell lines. Toddlers can immune responses are born with a predisposition to allergy-and-inflammatory Th2, which are characterized by growth and activation of eosinophils and IgE production. Early childhood exposure to bacterial and viral infections and endotoxins can cause the body to Th1 responses, suppressing the Th2 cells and indicate a tolerance. The trend in industrialized countries towards smaller families with fewer children, a more hygienic home environment and the early use of vaccines and antibiotics could lead this Th2-suppressing, tolerance-inducing contact with children to lack. Thus, in part, the continuous increase of asthma in industrialized countries are explained (hygiene hypothesis). Reactive airway dysfunction syndrome (RADS) IContact with nitrogen oxides and organic solvents in closed spaces (z. B. colors, solvents, adhesives) to the development of the reactive airway dysfunction syndrome (RADS) play an important role, a syndrome in which persistent reversible airway obstruction in patients with no history of asthma is present (occupational asthma). RADS seems to differ from asthma and can occasionally a form of lung disease due to environmental factors be. However RADS and asthma have many clinical similarities (z. B. dyspnea, dyspnea, cough), and both can respond to corticosteroids. Pathophysiology of asthma seen in bronchoconstriction edema and inflammation of the airways airway hyperresponsiveness airway remodeling in patients with asthma are Th2 cells and other cell types – especially eosinophils and mast cells, but other CD4 + cells and neutrophils – to the extensive inflammatory infiltrate in the airway epithelium and involved in smooth muscle, which leads to airway remodeling (z. B. desquamation, subepithelial fibrosis, angiogenesis, and smooth muscle hypertrophy). Hypertrophy of the smooth muscle cells leads to a narrowing of the airways and increased reactivity to allergens, infections, irritants, parasympathetic stimulation (the proinflammatory to release neuropeptides such as substance P, neurokinin A and calcitonin gene related peptides leads) and other triggers of bronchoconstriction. Additional pathological mechanisms that lead to bronchial hyper-reactivity, include the loss of inhibitors of bronchoconstriction degrade (epithelium-derived relaxing factor, prostaglandin E2), and other substances which are known endopeptidases and endogenous bronchoconstrictors. Other typical findings in asthmatics that have to be seen as epiphenomena of airway inflammation are probably through secretion and peripheral blood eosinophilia moved bronchi. However, not all patients with asthma and eosinophilia. Triggers Common triggers of an asthma exacerbation are environmental and occupational allergens (numerous) infections Exercise Inhaled irritants feeling aspirin Gastroesophageal reflux disease (GERD) The infectious triggers in infants include RSV virus, rhinoviruses and parainfluenza virus infection. In older children and adults, infection of the upper respiratory tract (particularly by rhinoviruses) and pneumonia common infectious trigger. Physical exertion, especially in cold or dry environment can be a trigger. Often the inhalation of Atemwegsirritanzien, such as air pollution, cigarette smoke, perfumes and cleaning products. Sometimes trigger emotions such as fear, anger and excitement of exacerbations. ASA is a trigger in up to 30% of patients with severe asthma and <10% of patients. ASA-sensitive asthma is typically accompanied by nasal polyps with nasal blockage and laying of the sinuses. GERD is a common trigger in patients with asthma, possibly by esophageal acid-induced bronchoconstriction reflective or by micro-aspiration of gastric acid. However, treatment of asymptomatic GERD does not seem to be improved (z. B. with proton pump inhibitors) asthma. Allergic rhinitis is often the same front with asthma; is not clear yet whether the two diseases represent different manifestations of the same disease or allergic rhinitis whether an independent asthma triggers ist.Reaktion Are triggers present, these lead to a reversible narrowing of the airways and irregular ventilation of the lungs. In lung sections that are distal to narrowed airways, perfusion exceeds the ventilation, alveolar O2 -voltage drops and the alveolar CO2 -Voltage increases. Most patients can compensate by hyperventilating, but in severe exacerbations, diffuse bronchoconstriction leads to severe hyperinflation, causing the respiratory muscles is greatly mechanically disabled so that the work of breathing increases. Under these conditions, the hypoxemia deteriorated further and the PaCO2 increases. This resulted in a respiratory and metabolic acidosis may develop, which left untreated can lead to respiratory and cardiac arrest. In contrast to the classification hypertension (in z. B. a parameter (blood pressure), the severity of the disease and the effectiveness of treatment defined), asthma causes a number of clinical abnormalities and variations in test results. Unlike most types of hypertension, come and go, this is usually in asthma. Thus, the monitoring (and exploration) of asthma uniform terminology and defined benchmarks requires. As severity of the intrinsic intensity of the disease process is defined (i.e., how severe is this). The severity can only be checked directly in the rule before the treatment is started because patients who have responded well to the treatment have few symptoms by definition. The severity of asthma is categorized as intermittent weak persistent Moderate persistent heavy persistent The term status asthmaticus describes a condition with severe, long-lasting, refractory bronchospasm. Control is the degree to minimize the symptoms, impairments and risks from the treatment. Control is the parameter which is evaluated in patients who received treatment. The goal is for all patients is to have asthma regardless of the severity of the disease under control. Control is divided into good controlled Not well controlled Very poorly controlled severity and control are assessed for impairment and the risk of the patient (see Table: Classification of asthma control *, ). Classification of asthma control *, component Good controls controls Not good Very poorly controlled symptoms all age groups except for children 5-11 years: ? 2 days / week Children 5-11 years: ? 2 days / week, but not> once / day All ages except children 5-11 years:> 2 days / week, children 5-11 years:> 2 days / week or more times ? 2 days / week for all ages: during the day Nocturnal awakening Adults and children ? 12 years: ? 2 / month Children 5-11 years: ? 1 / month Children 0-4 years: ? 1 / Month adults and children ? 12 years of age: 1-3 / week children 5-11 years: ? 2 / month children 0-4 years:> 1 / month adults and children ? 12 years: ? 4 / week children 5-11 years: ? 2 / week children 0-4 years:> 1 / week interference with normal activity None Some Extreme restriction restricting use of short-acting ?2-agonist for the control of symptoms (not for the prevention of asthma due to physical exertion) ? 2 days e / week> 2 days / week Several times / day FEV1 or peak flow> 80% predicted / individual maximum 60-80% predicted / Individual maximum value <60% predicted / personal peak FEV1 / FVC (children 5-11 years)> 80% 75-80% <75% exacerbations requiring oral systemic corticosteroids 0-1 / year adults and children ? 5 years: ? 2 / year children 0-4 Year: 2-3 / year adults and children ? 5 years: ? 2 / year Children 0-4 years:> 3 / year Validated questionnaires: Ataq 0 1-2 3-4 ACQ ?0,75 ?1,5 ? / ? ACT ? 2 0 ?15 16-19 Recommended action continuing the current action follow-ups every 1-6 months may back a step, if ? 3 months good control takes place one step further reassessment after 2-6 weeks In severe side effects, other therapeutic options should be considered treatment with topical or systemic corticosteroids for a short time one or two steps further reassessment after 2 weeks in severe side effects, other treatment options should be considered * All ages Grupp s, unless otherwise specified. The degree of control is based on the most severe impairment or risk category. Other factors to consider are the progressive loss of lung function in pulmonary function tests, significant adverse effects and the severity and the time between exacerbations (ie an exacerbation that requires intubation or two hospitalizations within 1 month can be considered a very poor control) , Currently, there is insufficient data to refer frequencies of exacerbations with different levels of asthma control each other. Usually more frequent and intense exacerbations show (z. B. the urgent, unscheduled care, hospitalization or admission to the ICU) to a poorer asthma control. ACQ = questionnaire for the control of asthma; ACT = asthma control test; Ataq = asthma therapy questionnaire on asthma therapy; FEV1 = Forced expiratory volume in 1 s; FVC = forced vital capacity. Adapted from the National Heart, Lung, and Blood Institute: Expert Panel Report 3: Guidelines for the diagnosis and management of asthma-full report 2007. 28 August 2007. Available at http://www.nhlbi.nih.gov/guidelines/ asthma / asthgdln.htm. Impairment related to the frequency and intensity of symptoms and functional limitations of the patient. This is assessed by spirometry, especially forced volume in one second (FEV1) and the ratio of FEV1 to forced vital capacity (FVC), and clinical characteristics such as frequency of occurrence of symptoms frequency of waking during the night frequency of administration of a short-acting ?2-agonists for relief symptoms of asthma How often normal activity interferes risk refers to the likelihood of future exacerbations or decline in lung function and the risk of adverse drug reactions. The risk is assessed by long-term trends in spirometry and the following clinical features: Frequency of the need for oral corticosteroids need of hospitalization Required admission to the ICU need for intubation It is important to note that the category of severity does not predict how serious aggravation may be in a patient. For example, a patient with mild asthma and long periods of time can have a serious life-threatening exacerbation with no or mild symptoms and normal lung function. Symptoms and discomfort patients with mild asthma are typically free of symptoms between exacerbations. Patients with more severe disease and those with exacerbations suffer from shortness of breath, tightness in the chest, audible wheezing and coughing. Cough may be the only symptom in some patients (cough variant asthma). The symptoms may be subject to a circadian rhythm and during sleep, often about 4 am, its most pronounced. Many patients with more severe asthma wake up at night (nocturnal asthma). The symptoms consists in wheezing, pulsus paradoxus (ie, a drop in systolic blood pressure> 10 mmHg during inspiration; Cardiovascular investigation: pulsus paradoxus), tachypnea, tachycardia and recognizable increased work of breathing (use of neck and suprasternalen [additional] muscle groups sitting position , tipped lips, inability to speak). The expiration is a Inspiration / expiration ratios of at least 1: extended frequently. 3 can wheezing during both phases be present or only during expiration, but in patients with severe bronchoconstriction may wheeze also because (n. d. Red .: the often massive hyperinflation and) the significantly restricted ventilation are missing (n. d. Talk .: called . “silent chest”). Patients with severe exacerbation and threatening lung failure often show a mixture of impaired consciousness, cyanosis, paradoxical pulse> 15 mmHg, SaO2 <90%, PaCO2> 45 mmHg and pulmonary emphysema. Rarely, the x-ray shows pneumothorax or pneumomediastinum. Complaints and symptoms disappear between exacerbations, although slight wheezing during forced expiration, at rest or after exercise may be some asymptomatic patients. In patients with long existing untreated asthma, pulmonary emphysema can lead to permanent changes in the chest wall, a so-called. Barrel chest lead. All the symptoms are non-specific, reversible with early treatment and usually caused by one or more triggers. Diagnosis Clinical Evaluation lung function testing Diagnosis is based on history and physical examination findings and is confirmed by lung function tests. They should also try the search for causes and the exclusion of other diseases associated with wheezing. Asthma and COPD can be easily confused occasionally; They cause similar symptoms and similar changes in lung function tests, but differ in important biochemical aspects that are clinically not always visible. Lung function tests is suspected asthma, should be performed to confirm the diagnosis, to assess the severity and Reversibilitätsprüfung of airflow obstruction pulmonary function tests. The results of lung function are assisting dependent, and it is necessary to train the patient from performing. If possible, bronchodilators should be paused before testing: 6 hours at short-acting ?2-agonists such as salbutamol; 8 hours at ipratropium bromide; 12-36 h at theophylline; 24 h at long-acting ?2-agonists such as salmeterol and formoterol, and 48 h at tiotropium bromide. A spirometry (overview of lung function tests) should be performed before and after inhalation of short-acting bronchodilators. Among the signs of lung disease before Spasmolysis include a reduced FEV1 and reduced FEV1 / FVC ratio. The FVC may be reduced also due to pulmonary emphysema, so that measurements of lung volume show an increase of the residual volume and / or the functional residual capacity. An improvement in FEV1 of> 12% or an increase of ? 10% in FEV1 calculated according Spasmolytikagabe demonstrates the reversibility of obstruction, although lack of response should not exclude a therapeutic trial with bronchodilators. The spirometry should be repeated for known asthmatics to monitor the course of disease at least every 1-2 years. The flow volume curves should be checked regularly for the diagnosis of vocal cord dysfunction – a frequent cause of obstruction of the upper airways, asthma may be deceptively similar. A provocation test in which inhaled methacholine (or alternatives such as inhaled histamine, adenosine, bradykinin or a stress test) is used to induce bronchoconstriction in patients with asthma suspicion and normal lung function and normal flow volume curves and in patients with suspected mono symptomatic asthma with cough if no contraindications, indexed. Among the contraindications include FEV1 <1 l or <50%, myocardial infarction or stroke in the current history and severe hypertension (systolic RR> 200 mmHg, diastolic RR> 100 mmHg). A decline in FEV1 of> 20% with a challenge test protocol is relatively specific for the diagnosis of asthma. However, the FEV1 may after administration o. G. drop drugs in other diseases such as COPD. If the FEV1 decline by <20% by the end of the test procedure, the diagnosis of asthma is less wahrscheinlich.Andere function tests in some cases may be even more investigations of benefits: The CO diffusing capacity (DLCO) chest x-ray allergy tests DLCO tests can help to distinguish asthma from COPD. When asthmatics, normal or elevated levels found in COPD usually lower values ??especially. In patients with emphysema. With a chest x-ray recording some of the causes of asthma or other diagnoses such as heart failure or pneumonia can be excluded. When asthmatics of radiographic findings is usually unremarkable, but signs of hyperinflation or segmental atelectasis as an indication of secretion in the bronchi may be present. Infiltrates, esp. If they fluctuate, and occur simultaneously with central bronchiectasis, suggestive of allergic bronchopulmonary aspergillosis (allergic bronchopulmonary aspergillosis (ABPA)), respectively. An allergy test can be performed in children where the history is evidence of allergic causes (especially in allergic rhinitis), as these children can benefit from immunotherapy. In addition, all adults should be tested where an improvement is seen after allergen avoidance and in which a therapeutic trial with anti-IgE (drug therapy) comes into question. By skin prick test and measurement of specific IgE in Radioallergosorbent test (RAST) can be diagnosed (overview of allergic and atopic disease: Specific tests) specific allergic triggers. Increasing the Bluteosinophilen (> 400 cells / mm) and the total IgE (> 150 IU) are an indication, but not proof of the existence of allergic asthma, as they can also occur in other diseases. However eosinophilia is not sensitive. The measurement of eosinophils in the sputum is rarely performed; high eosinophil numbers are an indication of asthma, but neither a sensitive nor a specific criterion. (N. D. Talk .: In secured bronchial asthma, the eosinophil count in sputum However, as is also the determination of NO in exhaled air, good flow parameters of allergic inflammation.) The measurement of peak expiratory flow (PEF) with low-priced handy Peakflow -Metern is recommended for home monitoring of disease severity and treatment. Clinical Calculator: prediction of peak expiratory flow (PEF) diagnosis of exacerbations In asthma patients with an acute exacerbation should be conducted certain tests: pulse oximetry PEF or FEV1 measurement helps the measurement of all three parameters to classify the severity of exacerbations and to document the response to therapy , The PEF values ??are interpreted in terms of the individual maximum value of the patients showing large variations between similarly well-controlled patients. Deviations by 15-20% from this baseline are indicative of a significant exacerbation. If the individual maximum values ??are not known, FEV1 standard value tables allow a rough assessment of lung disease, but no assessment of individual degradation. If no FEV1 measurement can be performed (eg. as in an emergency room) and normal PEF is unknown, könnne PEF standard value tables based on age, height and gender are used. Although PEF standard value tables are less accurate than the comparison to the individual maximum values ??of the patient, they may be used as a basis for the evaluation of therapeutic success. A chest x-ray is not in most exacerbations necessary, but should be made in patients with symptoms and complaints that suggest the suspicion of pneumonia or pneumothorax. BGA measurements should be performed in patients with severe shortness of breath, symptoms or complaints of an impending respiratory arrest. Prognosis For many children disappear asthma again. But however one in four asthmatic child is wheezing into adulthood or has in later years a relapse. Risk factors for persistence and recurrences are female gender, smoking, low of onset, sensitization to house dust mites and pronounced bronchial hyperreactivity. Although a significant number of deaths due to asthma every year, most could be avoided thereof by treatment. The prognosis is good for perception and adherence to treatment. Increased mortality is associated with increased oral Kortikosteroidbedarf before hospitalization, previous hospitalizations for acute exacerbations and lower peak expiratory flows at the start of treatment. In several studies have shown that the use of inhaled corticosteroids, the number of hospitalizations and mortality reduced. With increasing disease duration airways of some patients go through with asthma an irreversible process of change (remodeling) that prevents normalization of lung function. By early aggressive use of anti-inflammatory drugs remodeling could be prevented. Treatment control the trigger Drug therapy monitoring patient education, the treatment of acute exacerbations goal of treatment is to avoid interference and risks, thereby preventing exacerbations and chronic symptoms, incl. Nighttime awakening, Notaufnahme- and hospital stays, minimize, normal lung function and physical maintain load capacity and to avoid unwanted side effects of the therapy. Avoiding triggering factors IWhen some patients can be reduced in hot water timer through the use of synthetic pillow fillings, allergen-tight mattress covers and frequent washing of sheets, pillowcases and duvet covers. Upholstered furniture, stuffed toys, carpets and pets should be removed to reduce dust mites and pet dander. Dehumidifier should be used in basements and other poorly ventilated, damp rooms to reduce mold. The steam cleaning of apartments and houses reduces the exposure to house dust mite allergens. Die Reinigung des Haushalts und Vernichtung von Küchenschaben, um den Kontakt mit diesen zu vermeiden, sind besonders wichtig. Obwohl die Kontrolle der auslösende Faktoren in einer städtischen Umgebungen wesentlich schwieriger ist, bleibt die Bedeutung dieser Maßnahmen weiterhin bestehen. Hocheffiziente Partikelvakuumpumpen und -filter (HEPA) können die Beschwerden lindern, ihre günstigen Auswirkungen auf Lungenfunktion und Medikamentenverbrauch sind jedoch nicht bewiesen worden. Sulfitsensible Patienten sollten Wein vermeiden. Auch unspezifische Auslöser wie Zigarettenrauch, starke Gerüche, reizende Rauchgase, niedrige Temperaturen, hohe Luftfeu