Buy the Book
(Samter & Samter, 5th Ed.)

• Allergy
• • Allergic Asthma
  • ABPA
• Infections
• • Bronchiolitis
  • Viral URI's
• Industrial-Occupational
• • Irritants
  • Allergens

• Chemicals or Drugs
• • NSAIDs
  • Sulfiting agents
  • Beta-Adrengeric
    Antagonists
• Exercise
• Vasculitis (Churg & Strauss)
• Idiopathic (Intrinsic)

• 90% of Asthmatics Below 30 y/o + Skin tests
• Asthma onset after age 40, skin tests equal to non-wheezing population, approx. 20%
• 60% IgE >300ng/ml, 40% -WNL
• Aeroallergens and Many foods may provoke asthma in sensitive individuals
• Not all episodes of asthma in sensitive asthmatics are due to allergic triggers.
• Don’t be afraid to refer for allergy evaluation.

• Primary Criteria
• • Asthma
  • Eosinophilia >1000/mm
  • Positive Immediate skin test to Aspergillus antigen
  • IgG antibodies to
    Aspergillus antigen
  • Increased IgE >10,000ng/ml
  • Pulmonary Infiltrates, often transitory
  • Central Saccular bronchiectasis

• Secondary Criteria
• • Aspergillus fumigatus in sputum
  • History of expectorated brown plugs or specks
  • Late phase (or arthus) skin tests to Aspergillus antigen

• Asthma
• Allergic
• ABPA

• Pulmonary embolism
• Cardiac failure
• Foreign Body
• Tumors
• Aspiration
• Carcinoid
• Loeffler's Syndrome
• Tropical Eosinophilia
• Hyperventilation Syndrome
• Sarcoid

• Laryngeal Edema
• Laryngeal or trachael obstruction
• Factitious Wheezing
• Alpha-1-Antitrypsin
• Immotile cilia syndrome
• Kartagener's syndrome
• Overlapping diseases
• • chronic bronchitis and emphysema
  • Cystic fibrosis

• platelet aggregation
• serotonin release
• acute acidosis of airways
• localized wheezing

• Unusual to have diffuse wheezing but can happen secondary to multiple small emboli.
• Suspect when associated with chest pain.
• X-Ray, ECG, Angiogram, Perfusion Scan

• Nocturnal Asthma in adult
  may be bronchial or cardiac.
• Most adult asthmatics
  wheeze at other times then at night.
• Nocturnal Bronchial
  Asthma usually occurs earlier in the night.

• 2 hours for bronchial Vs 4 hours for cardiac after
  supine position is assumed.
• If looks, feels or sounds
  like cardiac dypsnea, probably is.

• Foreign bodies
• Tumors
• 
  
• Edema

• Biogenic Amines
• • They cause wheezing
  • • serotonin
    • bradykinin
    • etc.
    • histamine
• Associated with
• • flushing
  • telangiectasia
  • diarrhea
  • right sided heart failure

• 93% Non-Bronchial Origin
• Bronchial Carcinoids can cause severe asthma

• Generally young women
• Paroxysmal dyspnea occasionally associated with wheezing.
• Inability to take deep breath and complain of chest tightness

• Differentiated By
• • over breathing induced hypocalcemia tetany
  • they have periorbital numbness, induced tetany
  • asthmatics have respiratory alkalosis
• Rebreathing helps this, not asthma

• Croup (children)
• Laryngotracheal Bronchitis
• Tracheostenosis
• Tracheomalacia
• Tracheal polyps, adenomas, malignant tumors
• Involuntary or voluntary closure of larynx

• In each instance, careful ascultation reveals localized rather then diffuse wheezing

• Sinus inverus totalis
• Chronic rhinosinusitis
• Bronchiectasis
• Defect P Immotile cilia (several defects described)

• Chronic cough
• Chronic rhinitis
• Sinusitis with polyps
• Chronic secretory otitis
• Suggested by recurrent upper and lower tract infection
• Infertility

• Sinusitis
• Gastroesophageal Reflux
• Pregnancy
• Influenza, Para-influenza

• Explain to patient:
• • Asthma is a chronic inflammatory process of the airways in their lung. They will have it forever, they will have good days and bad days. That they need to take their medications as directed in order to have less asthma attacks.

• Get PFT's at following up visits and following medication changes.
• Use Anti-inflammatory agent in any person with regular symptoms
• Use enough anti-inflammatory agent to normalize or stabilize FEV
• Have patient use peak flow meter and spacer device.

• Make sure patient uses every inhaler correctly, especially if change in medication has no effect.
• Listen to patients complaints, they may have some other disorder.

• To determine if antigen exposure is causative agent for asthma
• To educate patient on related antigenic triggers and assist primary care in developing treatment plan.
• Allergists are more cost effective then primary care when managing moderate and severe asthmatics.
• Immunotherapy, works when given properly.

• You only lose patients to consultants when you won't send them and the patient was right in seeing one any way.