The asthma is a pulmonary illness with the following characteristics:
Obstruction of the entire or partially reversible airline, spontaneously well or with treatment.
Inflammation bronchial and remodeled (fibrosis) of the architecture of the bronchus, with infiltration of the mucous membrane for eosinófilos and other cells, and a major or minor fibrosis grade subepitelial permanent, still in symptoms absence.
Bronchial hyperreactivity, or developing answer of the airline opposite to different stimuli.
The presence of inflammation of the airline in all the asthmatic subjects indicates that this one constitutes the key fact in the asthmatic patogenia. The inflammation seems to be the primary mechanism that determines the appearance of bronchial hyperreactivity.
The initial desencadenante of the asthma is the liberation for diverse mechanisms (immune or not) of certain substances or mediators (principally histamine and leucotrienos) from mastocitos and other cells, which they provoke straight broncoconstricción and snot hypersecretion, and which also cause emigration and activation of other inflammatory cells (eosinófilos and neutrófilos). These, in turn, across diverse products (citoquinas, basic proteins, etc) provoke alterations in the integrity of the epithelium, in the function mucociliar, in the control neurógeno of the airline and in the reactivity of the bronchial smooth musculature.
The asthma typical studies with crisis cough appellants, generally dry season, thoracic oppression, sibilancias, shortness of breath and free intervals of symptoms. Of atypical form, persistent cough, thoracic oppression can exist exclusively without other symptoms accompanists, or be secret like repetition bronchitis in children. In all the forms the night predominance of the symptoms is typical.
The physical exploration can be normal in intercrisis.
In the crises it can exist taquipnea, printing, exhalation lengthened with roncus and sibilanciasespiratorias spread, or enclosed silence auscultatorio, in case of important obstruction.
Asthma extrinsic (atópico): In which there can be demonstrated a reaction antigen - antibody, in general come up by IgE, like desencadenante of the process. The most frequent antigens as cause of asthma in our environment are the domestic mites; the pólenes of gramíneas, trees and some shrubs; certain fungi spores, and domestic animals epitheliums.
Asthma intrinsic. In the one that is not possible to detect a concrete antigen as it causes precipitante. The asthma intrinsic has also a series of proper characteristics that separate it from the extrinsic one: It usually begins in the adult life, in many cases one associates with nasal polyps, maxillary sinusitis, and/or idiosyncrasy aspirin and other anti-inflammatory notesteroideos (triad A.S.A)., and it presents a chronic course with frequent need for oral steroids for his control. It is exceptional in the infancy.
ACCORDING TO THE CLINICAL EVOLUTION
intermittent asthma or episodic if the illness studies with shortness of breath crisis with asymptomatic intervals.
asthma chronic or persistent if the symptoms are more or less permanent and supported with periodic aggravations.
As for the severity of the process in every patient in particular, light asthma is the one that does not interfere with the daily activities and performs simple pharmacological control. Asthma moderated is that that, sometimes, interferes with the normal activities, and sometimes, it needs more aggressive therapies for his control. Serious asthma (severe) is the one that interferes seriously with the daily activities, it implies an exhaustive control and polytherapy, or studies with episodes that put in danger the life (asthmatic status).
The last international consensuses divide the asthma as his severity in 4 stadiums. The stadium 4 corresponds to serious asthma; the stadium 3 with asthma moderated; the stadium 2, persistent light asthma; and the stadium 1, with intermittent light asthma.
ACCORDING TO THE AGE
Asthma of the nursing one. The majority they are of viral origin, for the same viruses that the bronquiolitis cause.
Asthma of the school age. It affects especially males (of 2:1 to 4:1, according to the age groups), and collaborates with allergy to neumoalergenos in most of the cases.
Asthma of the adolescence. It is characterized by the denial of symptoms and of therapeutic systems, and is the age status with higher mortality.
Asthma of the adult.
CLINICAL CHARACTERISTICS OF THE BRONCHIAL ASTHMA ACCORDING TO THE AGE OF PRESENTATION
ASTHMA OF THE NURSING ONE
Clinical characteristics:
Dry or rough cough and sibilant shortness of breath in episodes.
3 ó more episodes before 2 years of age.
Congenital / hereditary HRB? Acquired?
Factors desencadenantes:
Viral infections (VRS, ADV, VP-1 and 2, RV...)
Passive nicotinism
Increase of the valuation of IgE in the pregnancy
I increase respiratory infections
Annoyance bronchial recipients for smoke Octubrer mucous permeability injured to neumoalergenos
Stimulation S.N.notadrenérgico-not colinérgico (neuropéptidos, etc)
Weather (Fog, Ozone, Cold (unspecific mechanisms)
Neumoalergenos? (Scarce role)
Food allergens?? (Rarely)
Clinical forms:
Night cough / day (exercise, laugh, crying) - "Sibilant happy"
Repetition processes type bronquiolitis viral
ASTHMA OF THE SCHOOL AGE
"Asthma of transition"
Changes in geometry airlines and flexible textile
Masculine predominance (of 2:1 to 4:1, according to the age groups)
Positive cutaneous tests to neumoalergenos (mites,
fundamentally) Aftereffect on the child (changes of character, tendency to excess weight, etc)
ASTHMA OF THE ADOLESCENCE
Denial of symptoms and therapeutic systems
I initiate in poisonous habits and activities of risk
Potentially serious crises: Age group with major mortality.
Peripheral blood and sputum. The eosinofilia is frequent.
Electrocardiogram. It is usually normal, except a tachycardia sinusal before hipoxia moderate or serious.
Radiography of thorax and bosoms paranasales. The thorax RX generally is normal or it shows hyperblowing signs, or of complications (pneumonia, etc). In the asthma chronic the bosoms RX can show signs of rinosinusitis or of polyps.
Respiratory functional tests. (Peak-flow rhythms, espirometría, you curl flow - volume, etc). Indicated for 1) to confirm the diagnosis of asthma (objetivar reversible obstruction); 2) to quantify the grade of obstruction and the answer grade after broncodilatación; 3) chronic pursuit of the evolution of the crises or the asthma.
You try bronchial provocation. Indicated in: asthma atypical, evaluation of the gravity of the asthma, and diagnosis and pursuit of the occupational asthma. The most used methods are the pharmacologists (metahill test, carbacol or histamine), and the exercise test.
You try alergológicas:
You try cutaneous (PC). Realized with the neumoalergenos to which the patient is exhibited. Fundamental for the diagnosis etiológico whenever interrelation exists with the clinic.
Inmunoglubina E entire (IgE).
Specific IgE(CAP-RAST) opposite to certain allergens. Indicated in dermatitisatópica seriously or dermografismo important that make difficult the achievement or interpretation of the PCs, and children younger than 2 years.
Specific bronchial provocations with antigens. When the combined evaluation of case history, PC and CAP-RAST is not conclusive.
A suitable therapy must drive to a correct control of the symptoms, to the prevention of the aggravations and to the securing of a few normal levels of activity.
A) Education of the patient and his family circle.
B) Avoidance of the agents desencadenantes. Control measurements on the exhibition to the causes known as causers of the illness in every patient (mites, pólenes, etc...). It includes measurements as acaricidas, cases of mattresses and pillows and comforters of not permeable fibre to the mites, air filters, dehumidifiers, hoovers with filters HEPA(electroestáticos) etc. Also, it includes to avoid medicines that can worsen the asthma in some patients (aspirin, betabloqueantes, etc).
C) ("Bovine") hyposensitization or immunotherapy: indicated like coadjutant treatment in true asthmas atópicos, when there is not possible the finished avoidance of the only allergen (or a much reduced group of allergens) and we have verified the importance of the same one in the clinic of the patient.
D) Pharmacological therapy. It is adapted to the gravity of the asthma of a rational way and increases gradually according to the needs of the patient.
Corticoids
Inhaled. They constitute at present the therapy of the first line, providing symptomatic benefits, diminishing the HRB and the need for bronchodilators. The budesonida (Pulmicort ®), the beclometasona (Becotide ®, Becloforte ®, Beclo-Asthma ®) and the fluticasona (Flixotide ®, Flusonal ®, Inalacor ®, Trialona ®) is the available medicines of this group. To the conventional doses they tolerate well; the adverse effects are usually: candidiasisorofaríngea, disfonía for atrophy of the laryngeal musculature, cough irritativa, etc. These effects are less frequent with low doses, or using cameras espaciadoras.
Systemic. Prednisona (Dacortin ®), metilprednisolona (Urbason ®, Solu-Moderin ®), deflazacort (Dezacor ®, Zamene ®). They must be used in sharp aggravations, with descending short rules.
Cromonas. The cromoglicato (Unsuch ®, Frenal ®) inhibits the mastocitosdegranulación and is capable of controlling the asthma in some patients. The nedocromilsódico (Ildor ®, Brionil ®, Cetimil ®, Tilad ®) has similar effects.
Beta-2 adrenérgicos. They relax the bronchial smooth muscle. The inhaled route is that of election. Those of short action have an action duration from 4 until 6 hours, being most used in our way: salbutamol (Ventolin ®, Butoasma ®), terbutalina (Terbasmin ®), fenoterol (Berotec ®) and procaterol (Onsukil ®). Also there are medicines beta - agonistas of action prolonged like the salmeterol (Beglan ®, Serevent ®, Inaspir ®, Betamican ®) or the formoterol (Oxis ®, Neblik ®, Foradil ®) with an action duration from 12 until 18 hours. B-2-adrenérgicos oral (Ventolin ®, Terbasmin ®, Respiroma ®, Ventolase ®, Bambec ®, etc) is used like alternative when the inhaled route is not possible; they have more frequent adverse effects and the required doses are higher.
Anticolinérgicos. (Atrovent ®) Bronchodilator less powerful than the beta - 2-adrenérgicos, with a slower beginning of action and with few indications in the chronic treatment of the asthma. It exists also associated with the b-mimetic fenoterol (Combivent ®).
Teofilinas or Xantinas (Theolair ®, Theo-Dur ®, Solufilina ®, Fluidasa ®, etc) Bronchodilators that at present are a therapeutic alternative of third line in the bronchial asthma.
Inhibiting of leucotrienos. Anti-inflammatory specially directed against the synthesis or the action of the leucotrienos (mediators lípidosbroncoconstrictores and proinflamatorios) in the bronchial tree. They exist the montelukast (Singulair ®) and the zafirlukast (Accolate ®). Both are active for oral route, and they take in tablets. Indicated in the asthma light - moderate that he does not answer to other treatments.
Rapid Anamnesis. To establish the time passed from the beginning of the crisis, the medication that usually continues, possible desencadenantes of the current crisis (symptoms of respiratory infection, exhibition to allergens, treatment with some anti-inflammatory notesteroideo, suspension of the medication, etc.).
Physical exploration. The following gravity signs will be valued especially: taquipnea, use of incidental muscles (printing), sudoración, cianosis, lengthening of the exhalation, incapability to adopt the supine decubitus, etc.
Gasometría of arterial blood (balance acid - base). Initially hyperventilation takes place and it diminishes the CO2, what it produces alcalosis respiratory. As the crisis progresses, more CO2 is retained and one is entering respiratory acidosis and hipoxia every time major.
Pulsioximetría: It measures the saturation of O2 of the arterial blood by means of a sensor in the finger. It is correlated very well with the gasometría, and is a much more rapid method, which it does not need neither to puncture the patient nor to wait for results of the laboratory, avoiding, then, many gasometrías.
Measurement of the air flow. It is easy to realize by means of the peak-flow to put, with that there determines the flow peak espiratorio(PEF), which is correlated by the volume espiratorio maximum for second (VEMS or FEV1). The asthma crisis is serious when the PEF is < 30-50% del basal o mejor personal (establecido cuando el asmático está asintomático).
Oxygen. All the patients are administered initially, across mask type Ventimask ® of 28 to 35 %, fitting according to the arterial gasometría and/or the pulsioximetría.
Hydration. In the serious sharp asthma attack there is tendency to the dehydration. The patient must be stimulated so that it consumes a sufficient liquids quantity. During the sharp crisis there usually use wheys IV (glucosado to 5 % or glucosalino) to rhythm of 500 mL/6 hours.
Medication in the sharp asthma crises:
BRONCHODILATORS ADRENÉRGICOS
* Beta-2-adrenérgicos nebulizados. Salbutamol solutions are used to 0,5 % (Ventolín ®), terbutalina to 0,5 % (Terbasmin ®) and hexoprenalina to 0,25 % (Ipradol ®), which can be used to dose of 0,25-0,5 ml of solution dissolved in 3 ml of saline whey, with a maximum of 3 meetings from 5 until 10 minutes of duration every 20-30 minutes.
* Subcutaneous Adrenérgicos. Salbutamol (Ventolín ®; 0,5 mg/ampolla) and hexoprenalina (Ipradol ®; 0,005 mg/ampolla) to initial 1/4 dose ó 1/2 it blisters in every arm, which can recur to 20-30 minutes. Also there is used the proper adrenaline (0,2-0,3 ml of solution to 1/1000), with what a rapid, intense effect is obtained and of short duration (less than one hour). It can be used like medicine of the first election in major and adolescent children, with serious crises.
CORTICOESTEROIDESPARENTERALES
They are indicated if the crisis is serious and does not answer to the initial treatment bronchodilator in one hour. Steroids of short action can be used, like hidrocortisona (Actocortina ®), or of intermediate action like metilprednisolona (Urbasón ®, Solu-Moderin ®). The beginning of the therapeutic effect of the corticoids takes place after several hours. When they want to be suspended, it can be done in a sudden way if his administration has not been supported any more than 3 ó 4 days. If it is not like that, the dose will come down to the half every 24-48 hours up to coming to 20 mg/día and from this dose 5 will diminish mg every 4 days up to suspending them. As soon as beech improvement must pass to the oral administration route.
ANTICOLINÉRGICOS
The solution of bromide of ipratropio (Atrovent ®) nebulizada can provoke an increase of the broncodilatación when beta - 2-adrenérgicos is used in combination with bronchodilators.
METILXANTINASPARENTERALES
They produce relaxation of the bronchial smooth muscle, but his exact action mechanism is not known.
ANTIBIOTICS
They must collaborate if there is observed purulent sputum, fever or pulmonary infiltrators.
Repetition of the evaluation in the Room of Urgencies. After the first hour of treatment the answer to the same one must be valued. According to the answer to the initial treatment the patient can be discharged, continue the treatment or value revenue.
DEFINITION 
DEFINITION
