Transcript The Co-Morbid Asthma Condition Often Not Considered2.pps

Disclosure
• I have no conflict of interest to disclose
concerning the information provided in this
lecture
The Co-Morbid Asthma Condition
Often Not Considered
Phillip E. Korenblat MD
Professor Clinical Medicine
Washington University School of Medicine
St. Louis, MO
Co-morbid Asthma Conditions
• RHINITIS/Sinusitis
• Allergic
Bronchopulmonary
Aspergillosis (ABPA)
• Obesity
• Obstructive Sleep
Apnea (OSA)
• Depression
• Bronchiectasis
• Gastroesophageal
Reflux (GERD)
• Dysfunctional
Breathing
• Paradoxical Closure of
Vocal Cords
• Cystic Fibrosis
• COPD with Asthma
• Continued Smoking
Tale of Two Patients
• 70 yr old male w/ hx
childhood asthma. Sx
returned as adult, + skin
test, FEV1 reversibility,
sx severe & could not
practice as a trial lawyer.
State of art care w/ well
controlled asthma for
years. Recent sx of cough
and inability to mobilize
secretions. Repeat
requirement for oral
steroids required for
symptom relief.
• 48 yr old female asthma dx
as having asthma after
pulmonary infection 6 yrs
ago. Sx of expiratory
dyspnea and cough w/an
inability to mobilize
secretions. Rx w/LTRA,
LABA/ICS plus repeated
oral steroid use.
• Airway variability over
time without FEV1 12% &
200cc reversibility post
bronchodilator; neg. skin
tests.
Tracheobronchomalacia Presenting as
Either a Co-Morbidity or Masquerader of Asthma
Phillip E. Korenblat ,Andrew Bierhals, Robert Senior
• Poorly controlled asthma, despite multiple medications,
including combination therapies remains a serious
problem
• Asthma diagnosis and management can be confounded
by other diagnoses or co-morbidities, one of which is
tracheobronchomalacia (TBM)
• Asthma diagnosis can incorrectly be assigned when a
masquerader is present and diagnostic characteristics of
asthma are not applied, such as appropriate airway
reversibility, although this may be variable
• Severity level assessment can be erroneous if co-morbid
condition not detected when present
Assigning Severity
• Severity level assessment can be erroneous if
co-morbid condition not detected when present
• Severity has taken “2nd seat” to control of
asthma
• However, severity assessment does include
consideration of response to therapy
• An unrecognized comorbidity may be the
primary reason or complicating factor for poor
asthma control
Tracheobronchialmalacia
• TBM is defined as a structure of the tracheal &
bronchial cartilage which results in any degree of
collapse of the lateral cartilaginous walls
concurrently producing a lengthening of the
posterior smooth muscle membrane of the airway
which bridges the C shaped ends of the cartilage
Tracheobroncholmalacia
• The incursion of the pars membrane into the airway of the
trachea can compromise the air flow from partial airway
occlusion and when it occupies ≥50% of the airway it meets the
consensus definition of tracheal malacia
• Recent data by Boiselle et al would challenge the above since
they have shown 75% of normal males exceed 50% incursion
into the tracheal airway with sustained forceful exhalation
• Closure of the main steam bronchi may be present without
tracheal malacia
Differential Diagnosis and Considerations
Pediatric Tracheomalacia
• Congenital
– Ehlers-Danlos Syndrome
– Trisomy 21 Syndrome
– Mounier-Kuhn syndrome
(congenital
tracheobronchomegally)
– DiGeorges Syndrome
– Larsen Syndrome
– William-Campbell Syndrome
• Preterm newborn Chronic
Lung
• Secondary
– Pectus excuvatum/mass
causing mechanical
compression
– TE fistula
– Vascular mal-formations
– Sequela of intubation
– Radiation therapy
– Any process causing chronic
irritation/inflammation
Adapted from Doshi J. Krawlec ME. JACI 2007;120:1276-8
Considerations in Adult
Tracheomalacia
• Primary (Congenital)
–
–
–
–
–
Polychondritis
Ehlers Danlos Syndrome
Trisomy 21 Syndrome
TE fistula
Tracheomegally
(Mournier-Kuhn
Syndrome)
• 75%diagnosed after age 28
– Vascular Rings
– Double Aortic Arch
• Secondary (Acquired)
–
–
–
–
–
–
–
COPD
Post Traumatic
Radiation therapy
External Compression
Chronic Infection
Chronic Inflammation
Amyloidosis
Diagnosis of TBM
• Traditionally diagnosed by bronchoscopy and
not unusual to see dynamic collapse<50%
• 3 sets of images
– Inspiration
– Forced Expiration
– Sustained Expiration
• Low radiation dose
– 1 to 2 mSv (typical chest CT 5 to 7 mSv)
• 3D reconstructions to evaluate distribution
– Virtual bronchoscopy
• Evaluate lung parenchyma
1
2
3
4
5
4
5
6
A
Inspiration
B End Expiration
Figure 1. Inspiration and Expiration Views of Tracheobronchomalacia
Measurements of the trachea (Case 10, age 74) were made in both inspiration and end
expiration at the thoracic inlet (1), mid trachea (2), at the carina (3), right main stem
bronchus (4), bronchus intermedius (5) and left main stem bronchus (6). Image B.
depicts collapse of the trachea and bronchi, retraction of the trachea and air trapping
(Red arrow). There is no evidence of emphysema.
• Exaggerated movement of the membranous portion of trachea
• Lateral displacement of cartilaginous rings
• Great than 50 % loss of cross-sectional area
Criteria for Patient Selection to Have 3D
Chest CT
•
•
•
•
Cough which may resemble a seal bark
Inability to mobilize secretions
Expiratory dyspnea with or without wheezing
Prolonged or frequent systemic corticosteroid
use
• Prolonged (beyond expected asthma
exacerbation recovery) or repetitive hospital
stays
Patient Selection
• Pulmonary Function findings that may be
present
– Decrease in mid flows (MMEF 25-75%)
– Post bronchodilator reversibility reaching or
not reaching 12% and 200cc improvement
(i.e. variability without reversibility)
– “Birds Beak” or “Double Notch” at peak of
full expiration
Phenotypic Determinates of Uncontrolled
Asthma
• Uncontrolled asthma more frequent in:
– ICS users (27.6%,35%,37.4% well controlled, partly
controlled & uncontrolled vs non-ICS users
(60%,23.9%,16.1%)
– In ICS users chronic cough or phlegm and female sex
most common
– In non-ICS users elevated IgE and sensitization to
mold were associated w/ asthma control
– Smoking & rhinitis not associated w/ control
Siroux V et al.JACI Oct.2009; 124;(4) 681-687
Current Clinical Trial
• 59 subjects with physician diagnosed or treated as
difficul- to-control asthma
• 12 with asthma no TBM (asthma control group)
– 6 male 6 females
mean age 66.2
• 27 without 12% & 200cc reversibility with TBM
– 9 males 18 females mean age 58.2
• 20 with 12% & 200cc reversibility and TBM or BM
– 8 males 12 females
mean age 52.9
CONTROL
TBM with Asthma
TBM without Asthma
Cough100
100%
100%
100%
Wheeze
100%
95%
90%
Mucus
66.6%
95%
92.5%
Dyspnea
95%
90%
81%
Current smoker
0
0
0
Months prior smoker
3/12 17pk/yrs
6/20 134.5 pk/yrs
11/27 242 pk/yrs
Rhinosinusitis
66.7%
85%
77.7%
GERD
58%
40%
55.5%
Average Months
Symptoms prior Dx
23.8
78.2
81.8
Intubation /surg
66.6%
80%
77.7%
58%
50%
55.5%
Months ICS (Average) 2,079 (173)
2,776 (138.8)
2,449 (90.7)
Months oral steroid
707.8 (35.4)
406 (15)
Previous chest CT
615 (51)
Tracheal Collapsibility in Healthy Volunteers During
Forced Expiration : Assessment with Multidetector CT
• Data from Boiselle et al (Radiology 2009; 252(1):255262) has demonstrated in 25 healthy volunteers (25 men
and 26 women) mean age 50 yrs had mean % expiratory
reduction in tracheal lumen cross sectional area of
54.34% in upper trachea and 56.14% in the lower
trachea
• Forty (78%) exceeded current diagnostic criterion for
tracheomalacia
• We have demonstrated trachea collapsibility of ≥ 70% is
associated with higher level of malacia in smaller airways
Symptoms
May Be
Persistent or Intermittent
COUGH (“SEAL BARK”)
INABILITY TO MOBILIZE SECRETIONS
BRONCHOSPASM
SYSTEMIC STEROIDS
PROLONGED/FREQUENT HOSPITAL STAYS
PULMONARY FUNCTION
12% & 200cc
FEV1 Reversibility
& Airway Variability
May or may not have
“Bird’s Beak”
12% & 200cc Improvement In FEV1
Post Bronchodilator
Symptoms greater than PFTs reveal
Decreased MMEF25-75%
Minimal
Reversibility
But
Airway Variability
FEV1 REVERSABILITY
12% & 200 cc
Post Dilator
MITAGATE ETIOLOGY &
EXACERBATING
FACTORS
TBM DIAGNOSED
GO TO MANAGEMENT
PROVIDE STATE OF
ART ASTHMA
MANAGEMENT
DYNAMIC 3D
INSPIRATORY
EXPIRATORY CHEST CT
CONTINUED
SYMPTOMS
Treatment When a TBM Co-morbidity
of Asthma
• Evaluate the etiology of their asthma
IgE
non-IgE
Infectious Other
• Determine causative factors for continued
symptoms
• Mitigate exacerbating factors and comorbidities, especially GE reflux
• Institute state of the art asthma management
AIRWAY
VARIABILITY
WITHOUT FEV1
Reversability12%
& 200cc Post
Bronchodilator
DYNAMIC
3D CHEST CT
TBM
DIAGNOSED Go
To
Management
Treatment When a Masquerader of
Asthma
• Only when appropriate include measures usually
employed with asthma (some may have a degree of
reversibility)
• Recognize that corticosteroids may have adverse
effect due to drying and increase mucus viscosity
• Management measures common to TBM regardless
if co-morbidity or the primary diagnosis:
adequate hydration, mucus clearing flutter valve,
chest percussion device, bronchoscopy, temporary
stent, tracheoplasty
Enter the Surgeon
INTERVENTION
•
•
•
•
•
CASE #1 FECV1 REVERSABILITY
DYNAMIC 3D CT DIAGNOSED
TBM
LABA/ICS
ADEQUATE HYDRATION
DAILY PERCUSSION VEST
ORAL CORTICOSTEROIDS
HALTED
CASE #2 FEV1 VARIABILITY
• DYNAMIC CT DIAGNOSED
TBM
• PRESERVED LUNG FUNCTION
(without FEV1 12%/200cc
reversibility)
• DAILY SYMPTOMS
• SURGICAL REPAIR OF
TRACHEA & MAINSTEAM
BRONCHI
• NO FURTHER THERAPY
REQUIRED
Conclusion
• TBM is not rare. It should be considered in asthma-like situations
that have atypical features, especially the need for repeated use of
systemic corticosteroids to help with airway mucus clearance
• Normal or near-normal spirometry does not exclude the diagnosis
of TBM
• TBM may be a significant co-morbid condition with asthma or the
primary diagnosis of symptoms which may be (a masquerader)
confused with asthma
• Trachea collapsibility of ≥ 70% is associated with higher level of
malacia in smaller airways
• 3D chest CT is a precise means of imaging the airways for TBM.
However, the current criteria for diagnosis of tracheomalacia of
50% airway collapse will need to be revisited given data from
Boiselle and Limanovich group
Conclusion
• TBM is not rare. It should be considered in asthma-like situations that have
atypical features, especially the need for repeated use of systemic
corticosteroids to help with airway mucus clearance
• Normal or near-normal spirometry does not exclude the diagnosis of TBM
• TBM may be a significant co-morbid condition with asthma or the primary
diagnosis of symptoms which may be (a masquerader) confused with
asthma
• Trachea collapsibility of ≥ 70% is associated with higher level of malacia in
smaller airways
• 3D chest CT is a precise means of imaging the airways for TBM. However,
the current criteria for diagnosis of tracheomalacia of 50% airway collapse
will need to be revisited given data from Boiselle and Limanovich group
References
• References
• Lee K, Sun M, Ernst A, et.al. Comparison of Dynamic Expiratory CT
With Bronchoscopy for Diagnostic Airway Malacia. Chest 131,
2007.
• Hunter HH, Stanford W, Grillo HC, Wiler JM. Collapse of the
Trachea Presenting as Worsening Asthma. Chest 1993;104:633-35
• Boiselle PM, O’Donnell CR, Baniker AA. et.al. Tracheal
Collapsibility in Healthy Volunteers during Forced Expiration:
Assesment with Multidetector CT. Radiology 2009; 252(1):255-262
• Litmanovich D, O’Donnell, Baniker AA. et.al.Bronchial
Collapsability in Healthy Volunteers during Forced Expiration:
Assesment with Multidetector CT. Radioligy 2010;257(2):560-567
• Doshi J. Krawlec ME. JACI 2007;120:1276-8