Download Immunotherapy problem case

‫دکتر افشین شیرکانی‬
‫فوق تخصص آسم و آلرژی و بیماری های نقص ایمنی‬
‫عضو آکادمی آسم و آلرژی و ایمونولوژی آمریکا‬
‫استادیار دانشگاه‬
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1. Wheezing( breathing out) (normal chest exam without
wheezing does not exclude asthma)
2. History of any of the following:
Cough (worse particularly at night)
Recurrent wheeze
Recurrent difficulty breathing
Recurrent chest tightness
3. Symptoms occur or worsen in the presence of:
Exercise
Viral Infection
Inhalant allergens (e.g., animals with fur or hair, house-dust
mites, mold, pollen)
Irritants (tobacco or wood smoke, airborne chemicals)
Changes in weather
Strong emotional expression (laughing or crying hard)
Stress
Menses
4. Symptoms occur or worsen at night, waking the patient
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Symptoms of episodic breathlessness, wheezing, cough,
chest tightness, phlegm production (one or more) PLUS :
1.Increase in FEV1 after a bronchodilator or after a course of
controller therapy ≥12% (and a minimum ≥200 mL)
OR
2.Increase in PEF after a bronchodilator or after a course of
controller therapy of 60 L/min (minimum ≥20%) or an
increase ≥20%, based on multiple daily readings
OR
3.Methacholine PC20 < 4 mg/mL (4-16 mg/mL is
borderline)
OR
4.Decrease in FEV1 after exercise challenge ≥10%-15%
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5% up to 20% of population
About 50%-80% of children who have asthma
developed symptoms before their fifth
birthday
The most common chronic disease in child
Approximately 50% of children under the age
of three have wheezing episodes with viral
respiratory infections,
Both genetic predisposition and
environmental interactions
1. Atopy
2. Early life exposure to pets and farm animals
3. sensitization to Alternaria
4. dust mites
5. Gender and Obesity
6. hygiene hypothesis
7. Viruses and other infections
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Infiltration of the airways with inflammatory
cells is a hallmark of asthma
 Th2 cytokines (IL-4, 5, 13) induce isotype
switching of B lymphocytes to IgE
 Airway Remodeling
1.smooth muscle hypertrophy (AHR)
2.Angiogenesis
3.Mucus gland Hypertrophy ( plugs )
4. Subepithelial fibrosis
5. Increase in thickness of the small airways
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Spirometry :Children older than 5 years of age
CXR : first episode of asthma or with recurrent
episodes of undiagnosed cough or wheeze or Fever
association
FeNo
Skin Prick Test(SPT) or RAST
ALLERGENS
DIAGNOSIS OF ALLERGIC CONDITION 1
SKIN TEST SENSITIVITY•
POSITIVE SKIN TEST
WHEAL & FLARE REACTION
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Curschmann’s spirals: Corkscrew-shaped
twists of condensed mucus
Creola bodies: Clusters of surface epithelial
cells
Charcot-Leyden crystals: Eosinophil cell and
granule membrane lysophospholipase
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C—Cystic fibrosis
R—Respiratory tract infections
A—Aspiration (swallowing dysfunction,
gastroesophageal reflux,tracheoesophageal
fistula, foreign body)
D—Dyskinetic cilia
L—Lung and airway malformations (laryngeal
webs,laryngotracheomalacia, tracheal ,
vascular rings and slings)
E—Edema (heart failure, congenital heart
disease)
1. Allergy:
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Atopic dermatitis
Allergic rhinitis
Elevated total serum IgE levels (first year of life)
Peripheral blood eosinophilia >4% (2–3 yr of age)
Food and inhalant allergen sensitization
2. Gender:
Boys:
Transient wheezing
Persistent allergy-associated asthma
Girls:
Asthma associated with obesity and early-onset puberty
Triad asthma (adulthood)
3. Parental asthma
4. Lower respiratory tract infection
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Respiratory syncytial virus, parainfluenza
Severe bronchiolitis (e.g., requiring hospitalization)
Pneumonia
5. Environmental tobacco smoke exposure (including
prenatal)
QUCK-RELIEF MEDICATIONS
1.Short-acting β2-agonists(SABA)
2.Anticholinergics
3.Systemic corticosteroids
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LONG-TERM CONTROLLERS
1.Corticosteroids—inhaled(ICS) and systemic
2.Long-acting β2-agonists(LABA)
3.Leukotriene receptor antagonists(LTRA)
4.Methylxanthines
4.Cromolyn/nedocromil
5.Anticholinergics
6.Omalizumab
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At least four episodes of wheezing in the past
year that lasted more than one day and
affected sleep, and that had a positive asthma
predictive index
Consider for patients who require
symptomatic treatment more than two days
per week for more than four weeks
Consider in patients requiring oral steroids
twice in six months
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Viral upper respiratory tract (RSV, influenza virus)
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Tobacco smoke, wood smoke
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Dust mites
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Animal dander
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Cockroach allergens
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Indoor mold
1.Status asthmaticus: is an acute exacerbation of
asthma that does not respond adequately to therapy.
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cyanosis, diminished air movement, retractions, agitation,
inability to speak, tripod sitting position, No wheezing,
diaphoresis, and pulsus paradoxus (decrease in blood
pressure of >15 mm Hg with inspiration), Pco2>40mm Hg
Rx:MgSo4,Epinephrin.IM,Atrovent,TerbutalinSQ
,Aminophyllin,Heliox
2.Rhinitis
3.Sinusitis
4.GERD
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1. A history of four or more wheezing episodes,
with at least one diagnosed by a physician
2. In addition, the child must meet at least one of
the following major conditions or at least two of
the following minor criteria