Dr. Alikhan discusses the diagnosis and management of: 1. Bronchitis 2. Pneumonia

In this continuation of the asthma webinar, Dr. Mobeen presents the stepwise approach to managing asthma in patients presenting in the outpatient.

For your reference, the first part of the webinar is here.

Note: Stepwise management starts at minute 13.

Following topics are covered:

• Diagnosis
  • Pulmonary function tests and the changes
  • Inhaled SABA based testing to confirm asthma.
  • Blood IgE tests
  • Imaging
  • Skin tests
  • Exhaled nitric oxide (NO)
  Stepwise management
  • Difference between relievers/rescue drugs, and controllers
  • Relievers/Rescue drugs/bronchodilators
    • B2 agonists
      • Short-acting (SABA)
      • Long-acting (LABA)
    • Anticholinergics
    • Theophylline
    Controllers
    • Inhaled corticosteroids
    • Systemic corticosteroids
    • Antileukotrines
    • Cromones
    • Anti IgE
  • Thermoplasty
  Management approach in the following stages:
  • Mild
  • Mild Persistent
  • Moderate persistent
  • Severe persistent
  • Very severe persistent

In this part of the clinical approach to asthma we will discuss the background to asthma. That includes:

• Background
  • Asthma vs COPD
    • Reversibility in asthma
    • Difficulty to manage when asthma is chronic
    • Varying airflow obstruction
  •  Need to prevent remodeling of the lung tissue while managing asthma.
  • Higher prevalence of asthma in affluent countries.
  • Peak age for asthma (3 years of age)
  • Gender in childhood is predominantly boys, however, the gender difference goes away in adults.
  • Asthma by itself is not a fatal disease, however, asthma related deaths can occur due to the underlying inflammation and tissue damage.
  • The basic principle of the management is to control the inflammation - not just the symptoms.
  • Why did the mere use of beta agonists actually increased deaths in the asthma patients? (happened in 1960)
  Risk Factors
  • Atopy (Antigen vs. allergen)
  • Infections
  • Diet
  • Air Pollution
  • Occupational exposure
  Triggers
  • Why does laughing and coughing trigger asthma?
  • Role of the mast cells in triggering asthma.
  • Nerve irritation leading to the asthma.
  • Beta blockers (can be fatal.)
  • Exercise. Why does exercise trigger asthma?
  • Cold air, hyperventilation
  • Food
  • Air pollution
  • Occupational factors
  • Hormones (some women before periods can have attacks of asthma.)
  • Gastroeosphageal reflux
  • Stress. Why will stress cause asthma?
  Pathophysiology of asthma
  • Airway inflammation
  • Airway hyper-responsiveness
  • Epithelial shedding due to irritation and inflammation.
    • Loss of epithelium derived nitric oxide.
    • Protection mechanism disappears leading to nerve exposure and nerve irritation.
    • Thickening of the basement membrane leading to irreversibility/difficulty in management. 
    Airway smooth muscle changes
    • Beta receptor decoupling
    • Hyperplasia and hypertrophy of the airway smooth muscles
    Vascular changes
    • Increased blood vessels.
    • More blood flow.
    • Edema
    • Inflammation
    • Swelling
    • Increased mucus secretion
    Mucus hypersecretion
    • Result of chronic irritation and inflammation
  Diagnosis
  • Pulmonary function tests and the changes
  • Inhaled SABA based testing to confirm asthma.
  • Blood IgE tests
  • Imaging
  • Skin tests
  • Exhaled nitric oxide (NO)

In this lecture, Dr. Zaafran continues to explore the world of anti-histamines. In this presentation, he discusses:

-What are decongestants?
-What are the two main types used?
-Are there different administration modalities?
-What are the types of symptoms most often seen in patients requiring - 
 nasal decongestants?
-Discussion of cough physiology
-Different types of cough
- Mechanisms of anti-tussive (cough) medications
-What are the different types of anti-tussives?
-Review of the anti-tussive side effects

Cholinergic type medications are a mainstay in clinical practice today. Dr. Zaafran goes over the

• Basic physiology

• Pharmacology

• Usage of these medications in clinical practice.

All healthcare professionals must master the understanding and management of asthma. This lectures series helps us master asthma, its pathophysiology, diagnosis, and management. In this lecture Dr. Mobeen presents:

Asthma definition.
Asthma and COPD.
Asthma's pathophysiological triad.
Types of asthma including:

• Phasic (Immediate and late).
• Clinical types: Intermittent and status asthmaticus.
• Aetiology: atopic, non-atopic.
• Hygine theory.

Immune system abnormality to give rise to atopy.

Immune system behaviour for cytotoxic and humoral responses.

Airway structures that are affected by asthma:

• Respiratory epithelial cells.
• Mucoa and its glands.
• Smooth muscles of the airways.
• Submcosa, its glands, and nerves.
• Fibroblasts.
• T cells.
• B cells.

Why are eosinophils the dominant players in asthma pathology?
Cytokines and chemokines active in asthma development.

• IL2, IL3, IL4, IL5, IL13

Dr. Zaafran presents asthma, signs, symptoms, and treatment.

Dr. Ahmed Zaafran presents Clinical Hypoxemia and its causes Differential diagnosis Management approach

In this lecture, Dr. Zaafran explores the clinical applications of anti-histamine medications.

What does the common cold look like?
What are the most common etiologies that lead to the common cold?
What the treatment regimens for the common cold?
What are anti-histamines and what are the types of receptors involved?
What body systems are affected by histamines and where are the receptors involved?
What is the Mechanism of Action of anti-histamines?
What are the side effects of anti-histamines?
 

This lecture uses a real case of Pulmonary Embolus to review the clinical presentation of PE and discuss appropriate treatments.

In this lecture, Dr. Ana Crawford presents the definition, etiology, and pathophysiology of pulmonary emboli.

She describes various etiologies of pulmonary emboli while discussing their effects on gas exchange and hemodynamics as well as the ways in which pulmonary emboli can present clinically.

She discusses the pulmonary emboli resulting from:

• Thrombus/blood clot
• Amniotic fluid
• Fat
• Air

She outlines how an embolus will move from the lower systems and end up in the lungs.

Virchow's triad is presented:

• Venous Stasis
• Endothelial Injury
• Hypercoagulable States

She discusses how deep venous thrombi (DVTs) become emboli, lodge in the lungs, and how they can disrupt the pulmonary perfusion and gaseous exchange in the lungs. She discusses how hypoxia is detected in such patients.

She discusses, if the pulmonary emboli increase shunt, or increase the dead space? 

V/Q mismatch, both physiological and pathological, is presented in the light of pulmonary emboli.

She discusses the risk factors for thrombosis:

• Hereditary 
  • Protein C
  • Protein S
  • Antithrombin Deficiency
  • ETc
• Acquired
  • Immobility
  • Recent Surgery
  • Malignance
  • Etc

She then discusses how the fat particles dislodge and result in fat embolism syndrome? And, the situations in which this can happen. 

Definition and presentation of the pulmonary embolism are discussed next. Labs for a massive or high-risk pulmonary embolism are reviewed.

Diagnostic scoring for a pulmonary embolism is discussed. Following scoring methods are presented:

• Wells Score
• Geneva Score
• D-dimer Cutoff

Dr. Zaafran goes into clinical depth regarding respiratory drugs and their application in practice. 
Topics include: 
Usage of bronchodilators
Leukotriene inhibitors 
Mast cell stabilizers
Alpha and beta agonists 
Corticosteroids
Anti-cholinergic agents.

Acid-Base disorders are complicated, but some clinical presentation are common. This lecture discusses three common clinical presentations of Acid-Base disorders and evaluates the arterial blood gases for appropriate compensation.

A normal Acid-Base status is essential for the proper functioning of all physiologic processes, and our bodies work hard to maintain pH homeostasis. This lecture gives a basic review of acids, bases, pH, and how our bodies compensate for acid-base disorders

ARDS results from lung injury resulting in significant hypoxemia and respiratory distress. This translates into significant morbidity and mortality for patients and is managed primarily in the Intensive Care Unit. This lecture is divided into two modules covering the epidemiology, pathophysiology, and timeline, as well as the clinical presentation and definition of ARDS.

Dr. Zaafran goes into clinical depth regarding respiratory drugs and their application in practice. 
Topics include: 

• Usage of bronchodilators
• Leukotriene inhibitors
• Mast cell stabilizers 
• Alpha and beta agonists 
• Cortoicosteroids 
• Anti-cholinergic agents

In this lecture Dr. Mobeen discusses the severeity assessment of asthma, management approach according to the severeity, and drugs with their dose adjustment in a 6 step approach.

Initial visit workup:

• Diagnosis (separate lecture)
• Severity assessment
• Medication.
  • Inhaled Corticosteroids (ICS)
  • Short acting beta agonists (SABA)
  • Long acting beta agonists (LABA)
  • Leukotrine Receptor Antagonists (LTRA)
  • Cromolyn
  • Theophyline
  • Oral Corticosteroids
• Plan of treatment.
• Follow up

Follow up visit:

• Assess control
• Review medication compliance
• Review side-effects
• Decide medication modification if needed.
• Update the plan if necessary.
• Plan follow up.

Dr. Mobeen discusses the following classifications of Asthma.
National Asthma Education and Prevention Program (NAEPP), Veteran’s Administration/Department of Defense (DoD). This classification is based on the severity assessment and guides the management approach.
2016 Global Initiative for Asthma (GINA). This classification is retrospective and establishes a category based on the management regime that worked for the patient

Mir Alikhan, MD presents pulmonary function tests. Topics discussed are: Spirogram - volumes and capacities. Flow-volume loops Components of PFTs Pattern recognition Accessory PFTs

Chest X-Ray is a routine clinical investigation. It is important for healthcare professionals to be comfortable approaching and interpreting it. In this webinar, Dr. Alikhan shares his excellent method to identify key elements that are frequently encountered on the chest x-ray.

View Notes

Dr. Alikhan discusses the diagnosis and management of: 1. Bronchitis 2. Pneumonia

This is a comprehensive insight into the conditions that affect and interact with the pulmonary vasculature. The lecture will focus on the areas of pulmonary edema, pulmonary embolism, and pulmonary hypertension.

Mir Alikhan MD, Pulmonologist discusses upper respiratory tract infections.