1. Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Email: Qusaibaty@gmail.com Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Email: Qusaibaty@gmail.com Asthma 03

2. 2 Peak Expiratory Flow Rate (PEFR) Peak Flow Peak Flow

3. 3

4. Peak Expiratory Flow Rate(PEFR) Adapted from: Woolcock Institute of Medical Research, 2006.

5. Baseline Predicated PEFR Value Baseline Predicated PEFR Value Personal Best PEFR Value Personal Best PEFR Value 5

6. 6 Redrawn from: Leiner GC, et al, Am Rev Respir Dis 1963; 88:644.

8. Reproduced with permission from: Polger G, Promedhat V. Pulmonary function testing in children: techniques and standards. WB Saunders, Philadelphia 1971. Copyright © 1971 Elsevier Science (USA

9. Baseline Predicated PEFR Value Tall – 80 X 5 = Pred PEFR Example: 150 – 80 x 5 = 350 L/min Nunn AJ, Gregg I. New regression equations for predicting peak expiratory flow in adults. BMJ. 1989 Apr 22;298(6680):1068-70./Radeos MS, Camargo CA. Predicted peak expiratory flow: differences across formulae in the literature. Am J Emerg Med. 2004 Nov;22(7):516-21.

10. Personal Best PEFR Value The patient should then record PEFR measurements The patient should then record PEFR measurements  2 to 4 times daily  For two weeks 10

11. Personal Best PEFR Value The personal best The personal best  is generally the highest PEFR measurement achieved during this post-treatment monitoring period 11

12. The patient's normal PEFR range Defined as 80 and 100 percent of the patient's personal best Defined as 80 and 100 percent of the patient's personal best 12

13. 13 Percentage PEFR Variability Highest – Lowest / Highest x 100

14. Diagnosis of asthma – variable airflow limitation  Excessive diurnal variability From 1-2 weeks’ twice-daily PEFR monitoring From 1-2 weeks’ twice-daily PEFR monitoring

15. 15 Self -Monitoring in asthma

16. 16 Self -Monitoring in asthma 100 % 80 % 50 % All clear Caution Medical Alert

17. Diagnosis of asthma – variable airflow limitation  Significant increase in FEV 1 or PEF after 4 weeks of controller treatment

18. Diagnosis of asthma – variable airflow limitation  If initial testing is negative: Repeat when patient is symptomatic, or after withholding bronchodilators Repeat when patient is symptomatic, or after withholding bronchodilators

19. Time (seconds) Volume Note: Each FEV 1 represents the highest of three reproducible measurements FEV 1 12345 Normal Asthma (after BD) Asthma (before BD) Flow Volume Normal Asthma (after BD) Asthma (before BD) GINA 2015

20. Diagnosis of asthma – physical examination Physical examination in people with asthma Physical examination in people with asthma  Often normal  The most frequent finding is wheezing on auscultation, especially on forced expiration

21. Diagnosis of asthma – physical examination Wheezing is also found in other conditions, for example: Wheezing is also found in other conditions, for example:  Respiratory infections  COPD  Upper airway dysfunction  Endobronchial obstruction  Inhaled foreign body

22. Differential Diagnosis of Wheezing 22

23. Differential Diagnosis Of Wheezing 1.Extrathoracic Airway Obstruction 2.Intrathoracic Airway Obstruction 23 ©2016 UpToDate ®

24. Extrathoracic Airway Obstruction OropharynxLarynx Vocal Cords 24 ©2016 UpToDate ®

28. Intrathoracic Airway Obstruction

29. Tracheal Obstruction Tracheal Obstruction Tracheal Compression Tracheal Compression Lower Airway Obstruction Lower Airway Obstruction Parenchyma Parenchyma Vascular Vascular 29 ©2016 UpToDate ®

30. Tracheal Obstruction Tracheal stenosis Tracheal stenosis Tracheomalacia Tracheomalacia Tracheobronchitis (herpetic) Tracheobronchitis (herpetic) Malignancy Malignancy Benign Tumor Benign Tumor Aspiration Aspiration 30 ©2016 UpToDate ®

32. Lower Airway Obstruction Asthma Asthma COPD COPD Bronchiolitis Bronchiolitis Bronchiectasis Bronchiectasis Carcinoid Tumor Carcinoid Tumor Aspiration Aspiration Malignancy Malignancy 32 ©2016 UpToDate ®

35. Diagnosis of asthma – physical examination Wheezing may be absent during severe asthma exacerbations (‘silent chest’) Wheezing may be absent during severe asthma exacerbations (‘silent chest’)

36. Diagnosis of asthma in adolescents and adults Diagnosis of asthma in adolescents and adults 1.Blood tests 2.Tests for allergy 3.Imaging 36

37. Focused on:  Pulmonary function testing  Chest radiography  Blood tests  Tests for allergy 37 Evaluation

38. Blood Tests

39. No blood tests are available No blood tests are available  Asthma  Asthma Severity39

40. Blood Tests Complete blood count (CBC) + differential white blood cell analysis to screen for eosinophilia Complete blood count (CBC) + differential white blood cell analysis to screen for eosinophiliaor Significant Anemia may be helpful in certain cases Significant Anemia may be helpful in certain cases40

41. Blood Tests - Indications 41

42. Blood Tests - Indications Severe Asthma exacerbation required hospitalisation (Pneumonia - Pneumothorax) Severe Asthma exacerbation required hospitalisation (Pneumonia - Pneumothorax) Nasal polyposis is present (Eosinophilic pneumonia or Churg Strauss syndrome) Nasal polyposis is present (Eosinophilic pneumonia or Churg Strauss syndrome) (Pneumonia) The chest radiograph is abnormal(Pneumonia) A parasitic infection is suspected42

43. 43

44. Eosinophilia Eosinophil percentages: Eosinophil percentages:  >15 percent) or counts >1500 eosinophils/  >15 percent) or counts >1500 eosinophils/ microL) 44

45. Causes of pulmonary Eosinophilia  Allergic asthma  Parasitic infections Strongyloides Strongyloides ( الاسطوانيات ( المعوية 45

46. Causes of pulmonary Eosinophilia  Drug reactions: NSAIDs NSAIDs Ampicillin, Minocycline Ampicillin, Minocycline46

47. Causes of pulmonary Eosinophilia  Eosinophilic pneumonia  Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) 47

48. 48

49. Lifelong non-smoker Lifelong non-smoker Largely irreversible airflow limitation Largely irreversible airflow limitation  Serum alpha-1 antitrypsin   Homozygous Alpha-1 Antitrypsin Deficiency Emphysema Emphysema 49