Asthma Diagnosis and Monitoring | Jindal Chest Clinic

Presentation by Dr. S.K Jindal on "Asthma Diagnosis and Monitoring" including breath analysis, causes of wheezing, severity assessment, etc. For more information, please contact us: : 9779030507.

1. Dr. S. K. Jindal
www.jindalchest.com

2. Key Issues
•Underdiagnosis/Misdiagnosisand?Overdiagnosis
•Establishingdiagnosis:criteria
•Severityassessment/Classification
•Monitoring

3. Establishing Diagnosis
A.Clinicalfeatures
B.Demonstrationofairwayobstruction
C.VariabilityandreversibilityofA.O.
D.Excludingothercausesofwheezing/airwayobstruction
E.Establishinghypersensitivity
F.Assessmentofreversibility
G.Demonstrationofinflammation

4. Clinical Features
•Symptoms Episodic
Cough, breathlessness
Wheezing, chest ‘congestion’
‘heaviness’
Expectoration Nil to profuse
Frothy to purulent
•Signs Hyperinflated chest
Rhonchi, crackles
•General systemic

5. Airway Obstruction
•Physicalexamination
Wheezing,prolongedexpiration
•Measuringforcedexpiratorytime
•Chestroentgenography
•PEFmeasurement
•Spirometry:↓FEV
1,FEV
1/VC
•Airwayresistance

6. Establishing variability / reversibility
•Historyofparoxysmalsymptoms,variablephysicalfindings
•Exacerbationsonexerciseandothertriggerexposures
•Bronchoreversibilitytest
>15%increaseinFEV
1&/orFVCafterS(200mg)
•Bronchialhyperresponsiveness
–Airwayinflammation

7. 0
0.2
0.4
0.6
0.8
1
0 0.20.40.60.81
1 - Specificity
Sensitivity Utility of amplitude % mean as a discriminator of asthma
A
B
C
Cut-offs
A = 12.5
B = 16.5
C = 20.0
Aggarwal et al, J Asthma 2002

8. Excluding other causes
of wheezing / A.O.
•Sputumexamination
•Chestroentgenography
PlainCXR
CTScanning
•Bronchoscopicexamination
•Others: Upperairwayexam
Spirometry

9. All that wheezes is
“Not Asthma”
and
All asthma
does not wheeze

11. Establishing hypersensitivity
•Historyofotherallergies:pastorpresent
•Familyhistoryofatopy
•Blood/sputumeosinophilia
•Hypersentivityskintests
•Bronchialhyperresponsiveness
•SerumIgEestimation

12. Demonstration of Inflammation
1.Clinicalfeatures
2.Markersofinflammation
•Direct Bronchialbiopsy
•Indirect BHR
Inducedsputum
Breathanalysis

13. Clinical Uses of Markers
•Differentialdiagnosis
•Diseaseseverity
•Treatmentresponse
•Researchuses
•Studyofkinetics

14. Breath analysis
1.ExhaledNO
2.Volatilegases
CO,Ethane,Pentane
3.Endogenoussubstances
InflammatoryMediators
Cytokines
Oxidants

15. Severity Assessment
•Symptoms:Respirdistress
Workperformance
Mentation
•Physicalexam: Indices
Pulse,R.R.,BP
Breathsounds
Paradox(etc.)
•PEFandFEV
1
•Bloodgasmeasurement

16. Monitoring
•Symptomrelief/recurrence
•Acuteepisodes
•Treatmentresponse
•Drugsideeffects
•Diseasechronicity/irreversibility

17. Diurnal PEF variability
Mathematical expressions
•Amplitudepercentmean
•Standarddeviationpercentmean
•Amplitudepercentmaximum
•Amplitudepercentminimum
•Lowestpercentpersonalbest
•Lowestpercentpredicted
•Maximum/minimumpercent
•Amplitudepercentmesor

18. 1.0
1.5
2.0
2.5
0 4 8 12 16 20 24
Time of day (in hours)
Peak expiratory flow (L/s) 36%
50%
A hypothetical PEF rhythm in asthma
(Jindal et al, J Asthma 2002)

19. 0
20
40
60
80
100
120
140
160
180
0 20 40 60 80 100
VAS (mm)
PEF ( % predicted) 0
20
40
60
80
100
120
140
0 20 40 60 80 100
VAS (mm)
FEV1 (% predicted) Visual Analogue Scale
Gupta et al, IJCDAS 2000
R = –0.5255, p <0.01
R = –0.4609, p <0.01

20. Conclusions
•PEFvariabilityisausefulmarkerofasthmainepidemiologicalstudies
anddaytodaymanagement
•Poorsensitivityinclinicaldiagnosis,populationscreening,assessment
ofseverity