MIMICS OF ASTHMA

MIMICS OF ASTHMA

The following disease entities are important differential diagnosis for asthma:

a) Vocal Cord Dysfunction (VCD) which can be differentiated from asthma by its lack of symptomatic response to bronchodilator and the lack of sputum production1. Diagnostic finding is the complete adduction of the vocal cords during inspiration with formation of a small posterior diamond-shaped glottal chink1;

b.)Persistent bronchitis which can be characterized by the presence of a persistent, wet cough present for more than 1 month that resolves with appropriate antibiotic treatment. Diagnosis can be made by doing bronchoscopy and clinical assessment of its response to antibiotic therapy2.;

MIMICS OF ASTHMA c) Foreign body aspiration which should be

suspected in any patient who presents with wheezing of sudden onset even in the absence of a clear history of a choking episode, and in any child with a unilateral wheeze or unequal breath sound. There are occasions wherein it might trigger a generalized irritant response causing diffuse polyphonic wheezes3.;

d.) Bronchiolitis which usually occurs in infants and should be considered in infants who have wheezing for the first time4. This is predominantly caused by Respiratory Syncytial (RSV) and Rhinovirus (RV)5. Most infants will never have a second or third bout of bronchiolitis, so that recurrent wheezing, even if it is associated with upper respiratory symptoms, should raise the suspicion of asthma4. In contrast with asthma, many patients with bronchiolitis do not respond to bronchodilator therapy3.;

MIMICS OF ASTHMA e.) Viral induced wheezing which can present like

asthma due to parainfluenza6, adenovirus6, metapneumovirus and coronavirus6. It is quite difficult to distinguish it from asthma exacerbation since viral infection is a common trigger. The presence of the following categories of symptoms are highly suggestive of a diagnosis of asthma: frequent episodes of wheeze (more than once a month), activity-induced cough or wheeze, nocturnal cough in periods without viral infections, absence of seasonal variation in wheeze and symptoms that persist after age 36.;

f. )Bronchiolitis obliterans [BO] which is a rare form of chronic obstructive lung disease that follows an insult to the lower respiratory tract7 caused by a viral pneumonitis (Adenovirus, RSV, Influenza, and Measles)3 and Mycoplasma pneumoniae8.Serial pulmonary function testing reveals a progressive airway obstruction without a substantial response to bronchodilator3.;

MIMICS OF ASTHMA g.)Congestive heart failure secondary to cardiac

conditions that result in pulmonary artery dilatation and/or left atrial enlargement which can compress large airways and cause wheezing. Left ventricular failure or pulmonary venous outflow obstruction can result in distention of the pulmonary vascular bed, bronchiolar edema and increase airway resistance and wheezing, thus, mimicking asthma3. A high index of suspicion is required to make the diagnosis. Precaution has to be observed with the use of B2 agonist among patients with CHF9. ; and

h.)Gastroesophageal reflux disease [GERD] which can result to chronic microaspiration causing significant mucosal edema and inflammation resulting to chronic cough and wheezing3. Also, neural mediated impulses from the refluxate or the distal esophageal afferent signals can result in local airway reflex responses stimulating mucous secretion, edema and bronchial muscle contraction10. Medical management should be given for the relief of reflux6.

MIMICS OF ASTHMA

There are no available randomized controlled trials comparing and differentiating the response to treatment of the above disease entities from asthma.

References

Ibrahim, Wanis. Paradoxical vocal cord motion disorder: Past, present and future. Postgrad Med J 2007; 83; 164-172.

Donnelly, D. Outcome in children treated with persistent bacterial bronchitis. Thorax 2007; 62: 80-84

Fakhoury,K.MD. Wheezing Illnesses other than asthma in children . UpToDate. October 2008

Silberstein, W. What is asthma. Articles written by Dr. Warren.1997 Singh, AM. Bronchiolitis to Asthma. A review and Call for Studies of Gene-Virus Interactions in Asthma Causations. Am Journal of Resp and Crit Care Med.2007.

175:108 Global Initiative for Asthma. Global Strategy for Asthma Management and

Prevention. Revised 2006. pp 72; 20 Smith,KJ. Insights into post-infectious BO in children. Thorax 2006; 61; 462-463. Chan,PNR. Bronchiolitis Obliterans in children. Clinical profile and diagnosis.

Respirology. 2000; 5:369-375. The Philippine Consensus for the Management of Childhood Asthma. 2002. p67 Jung, AD. Gastroesophageal Reflux in Infants and Children. American Family

Physician. 2001; 64 (11): 1854

SCHOOL ISSUES

SCHOOL ISSUES ON ASTHMA

Children spend most of their day at school, thus, it is very important that not only parents and the patients should understand asthma and its management. It is also imperative that school professionals should also be aware of the prevention of asthma exacerbations in school settings.

At school, some issues on the prevention

of asthma are how to prevent the irritants and allergens present in the school environment and the involvement of children who have asthma in certain activities.

SCHOOL ISSUES ON ASTHMA Common school airway irritants include smoke,

dust, air pollution1 and chalk dust2. In a study done by Abramsom et al, besides dust, house dust mite, domestic cat allergen despite absence of cat in the school and cockroach allergen were noted in the classroom, cafeteria and library3. Other allergens that can be found in school include mold resulting from excess moisture in the building, dander from animals in the classroom, cleaning agents, chemical pollutants from science and art classes, improperly maintained ventilatory system, pollens (trees, grasses and weeds) and respiratory tract infections4. Since these irritants and allergens can trigger asthma exacerbations, it is very important to reduce or if possible avoid exposure to allergens to which the patients is sensitized and exposed5. [Please see related topic on asthma triggers in school____________]

SCHOOL ISSUES ON ASTHMA

Another school issue is the involvement of children in school activities such as exercises during their Physical Education (PE) class. For many children, exercise is a common trigger for their asthma; however, this should not be used as an excuse since exercise is also an important activity of the children. With the proper knowledge of exercise induced asthma and its management, children could still enjoy the school activities without the fear of having acute exacerbations. The NHLBI5 therefore recommends the following strategies on the management of exercise induced asthma:

SCHOOL ISSUES ON ASTHMA The Expert Panel recommends that an important dimension of

adequate asthma control is a patient’s ability to participate in any activity he or she chooses without experiencing asthma symptoms. EIB should not limit either participation or success in vigorous activities. Recommended treatments include: Long-term control therapy, if appropriate. There is evidence

that appropriate long-term control of asthma with anti-inflammatory medication will reduce airway responsiveness, and this is associated with a reduction in the frequency and severity of EIB (Vathenen et al. 1991; Vidal et al. 2001). Frequent, severe EIB may indicate poorly controlled asthma and thus a need to initiate or increase daily long term control therapy.

Pretreatment before exercise which includes inhaled beta2-agonist (SABA or LABA), and LTRAs

A warm up period before exercise may reduce the degree of EIB (de Bisschop et al. 1999)

A mask or scarf over the mouth may attenuate cold-induced

EIB (Beuther and Martin 2006)

SCHOOL ISSUES ON ASTHMA

The Expert Panel recommends that teachers and coaches be notified that a child has EIB, that the child should be able to participate in activities, and that the child may need inhaled medication before activity Individuals involved in competitive athletics need to be aware that their medication use should be disclosed, and they should adhere to standards set by the sports-governing bodies (Anderson et al.2003).

SCHOOL ISSUES ON ASTHMA Management of asthma in school does not only involve

prevention of triggers and medication. The involvement of the school heads, teachers and school physicians, nurses and school based programs play an important role in asthma management. According to Wheeler6, there are five key lessons in order to establish a successful school program in the management of asthma and are as follows: Establish strong links to asthma care clinician. Target students who are the most affected by asthma at school. Choose the right mix of resources/ people to support the

program and to staff it. Use a coordinated multicomponent asthma interventions

addressing health services, patient education, and staff professional development on asthma basics and emergency response procedures. It is also critical to have collaboration of the whole school community which includes the school administrators, faculty and staff, students, parents and local community organizations. And lastly,

Support evaluation of school based programs.

SCHOOL ISSUES ON ASTHMA References

Tinkelmar, D MD: National Jewish Health. February 2006. Copyright 2008.

Bethesda,MD. Physical Activity Issues and Concerns p. 88. NHLBI. Asthma and Physical Activity in School:Making a difference.

Abramsom, S. Allergen in school settings: Result of Environmental Assessment in a 3 city School system. Journal of School Health. 2006;76(6): 246-249.

IAQ. Tools for School. Managing asthma in the school environment. US Environmental Protection Agency. August 2005

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Asthma

Wheeler, L. Managing asthma in School: Lessons learned and recommendations.Journal of School Health. 2006;76 (6): 340-342