C T Deshmukh
Asthma - Clinical Features
Classical presentation of recurrent prolonged cough, often with breathlessness or wheeze, suggests asthma. Demonstration of a favorable clinical response to bronchodilators and, when measurable, bronchodilation by Pulmonary function test confirms the diagnosis. A positive family history for allergic diseases or asthma, although not essential, tends to support a suspected diagnosis of asthma.
The main symptoms and signs in asthma are cough, wheeze, tachypnea, dyspnea, and prolonged expiration. Other findings include anxiety, use of accessory muscles, monosyllabic speech, diaphoresis, fatigue, pulsus paradoxicus, cyanosis, hyperinflation, tachycardia, abdominal pain and vomiting. The symptoms may come up acutely (exposure to aero-allergen) or insidiously (following viral infections).
Asthma is mainly diagnosed by history and physical examination, but may be difficult in infants and young children. The diagnosis and estimation of asthma severity in smaller children depends on the history and response to therapy as assessed by inconstant third-party observations. In older children direct history and as well as more objective assessment is possible.
Asthma management strategies require identification of the clinical pattern of disease in the patient.

commonly triggered by viral respiratory infections or exposure to an environmental allergen or irritant.
2. Chronic: Patients experience virtually daily symptoms and, in the absence of continuous therapy, do not have extended symptom-free periods.
3. Seasonal allergic: Patients experience virtually daily symptoms during an inhalant allergy season. Allergens and seasonal patterns will vary with the geographic region. Seasonal symptoms may be in reaction to molds, pollens, or a combination of both.

There is potential overlap among these clinical patterns. For example, patients with chronic disease often have intermittent exacerbations from viral respiratory illness and may have seasonal allergic exacerbations. Nonetheless, identification of the clinical pattern contributes to the determination of a therapeutic strategy.
Severity, as assessed by degree of morbidity, is independent of the clinical pattern. Both intermittent and chronic disease may range from relatively benign to life threatening. Severity should be judged by the frequency and intensity of urgent care requirements, missed school or work, and interference with activity or sleep.
The most important cause of death in an asthmatic is failure to identify severe exacerbation of disease. There are various scores to diagnose severity of asthma. Following features are seen in a patient who has Severe acute symptoms:

Sensorium – Irritable or drowsy
Speech – Unable to talk more than a few words at a time.
Posture – Sit up leaning forward with support of back with hands (tripod) or Limp.
Color – Cyanosis, pale, sweating
Use of accessory muscles of respiration
Respiratory rate – Tachypnoea or decreasing respiratory rate.
Pulse – pulsus paradoxux, tachycardia hypotension.
Chest findings – Loud wheeze, absence of wheeze, reduced air entry
O2 Saturation – less than 90 – 92 % in room air
PEFR – less than 30 – 50 % of normal

Wheeze need not be present for diagnosis of asthma. If there is not a firmly established alternative diagnosis asthma should be considered when patients present with following symptoms:

Recurrent/chronic lower respiratory tract wheezing
Recurrent/chronic cough
Repeated diagnosis of bronchitis
Repeated diagnosis of pneumonia not consistent with pyogenic infections

The diagnosis may be confirmed by demonstrating the complete response of symptoms, or spirometric measurement of airway obstruction, to an inhaled ?2 agonist and/or 5 to 10 day course of oral steroids.

Asthma Asthma 12/21/2000
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