ASTHMA D r. S. R . B E N A T A R * , M .B . C h.B ., F .F .A . (S.A.) P H Y S I O T H E R A P Y JUNE 19, , A s m a w o rd g e d e fin ie e r a s o m k e e rb a r e lu g w eg o b stru k sie . P re sip ite re n d e fa k to r e w o r d g e n o e m en die v o o r k o m s by k in d e rs en v o lw a sse n es b e sk ry f. D ie p a tr o n e en e v a lu e r in g v a n asm a, a s o o k die b e h a n d e lin g in a k u te - en tu sse n -fa se s w o r d be sp re ek . D ie belo n g v a n fis io - terapie in a sm a w o r d g e n o em . T h e w o r d “ a s th m a ” is d e riv e d f r o m th e G r e e k w o rd f o r s h o r t- d r a w n b re a th o r p a n tin g . T h e c o n d itio n has b e e n r e fe r r e d to in th e a n c ie n t w ritin g s o f th e H e b re w s, G re e k s a n d E g y p tia n s , b u t th e first c lin ic a l d e s c rip tio n o f a n a s th m a tic p a ro x y s m w as m a d e b y A re ta e u s th e C a p p a d o c ia n in th e se c o n d c e n tu ry A .D . A lth o u g h A re ta e u s , T h o m a s W illis (1678), S ir J o h n F lo y e r (1698) C u lle n (1784) a n d L a e n n e c (1819) a ll re c o g n ise d it as a d is tin c t c lin ic a l e n tity , th e te rm a s th m a h a s u n ­ f o r tu n a te ly b een in d is c rim in a te ly a ss o c ia te d w ith m a n y cau ses o f d y sp n o e a th ro u g h th e y e a rs. G r e a t a d v a n c e s h a v e b e e n m a d e o v e r th e last 2 0 y e a rs in o u r u n d e r ­ sta n d in g o f m a n y a sp e c ts o f a s th m a b u t d e sp ite th is w e a re s till ig n o ra n t o f th e b a sic cause. In d e e d th e o n ly s a tis f a c to r y d e fin itio n o f a s th m a a t p re s e n t is “r e v e rs ib le a irw a y s o b s t r u c ti o n ” a n d th is d e fin itio n is n o t w ith o u t its lim ita tio n s . T h e b a s is o f re v e rs ib le a i r ­ w a y s o b s tr u c tio n is a h y p e r-re a c tiv e b ro n c h ia l tree w h ic h re s p o n d s in itia lly b y b ro n c h o -c o n s tric tio n b u t la te r w ith c o m p lic a tin g m u co sal o e d e m a , se c re tio n s a n d in fla m m a to ry c hanges. T h e te n d e n c y to h y p e r-re a c tiv e b ro n c h i is p r o b a b ly in h e rite d a n d a s th m a m a y h a v e its o n se t a t a n y age a n d m a y a lso re m it a t a n y age. T h e m e c h a n is m s u n d e rly in g th is “sw itc h in g o n a n d o ff” o f a s th m a a r e u n k n o w n . A s th m a is n o t a n “ a ll o r n o th in g ” p h e n o m e n o n a n d th e re is a ra n g e o f b ro n c h ia l re a c tiv ity w ith in th e p o p u la tio n , w ith n o rm a l p e o p le a t o n e end o f th e s p e c tru m a n d se v e re a s th m a tic s a t th e o th e r. T h e d e g re e o f b ro n c h ia l h y p e r-re a c tiv ity m a y a lso flu c tu a te in a n in d iv id u a l o v e r a p e r io d o f tim e a n d th e p re sen c e o f c lin ic a l a s th m a re q u ire s a c o m b in a tio n o f h y p e r-re a c tiv e b ro n c h i a n d so m e trig g e rin g fa c to r. F a c to r s w h ic h m a y p r e c ip ita te a tta c k s o f a s th m a in su s c e p tib le in d iv id u a ls in c lu d e p h y sic al a g e n ts (cold a ir, e x erc ise, la u g h in g ), a lle rg e n s (fo re ig n . p r o te in , o rg a n ic d u sts, fu n g i) in fe c tio n s (v ira l a n d b a c te ria l), p h y sic a l ir r ita n ts (in o rg a n ic d u sts, s u lp h u r d io x id e ) a n d p sy c h o ­ g e n ic fa c to rs . T h e im p o rta n c e o f e ac h o f th e s e fa c to rs v a rie s in d iffe re n t in d iv id u a ls a n d p e rh a p s e v en in the sa m e in d iv id u a l a t d iffe re n t stages o f life. I t is n o w w id e ly a c c e p te d th a t p sy c h o g e n ic fa c to rs, h o w e v e r, p lay v e ry m u c h less o f a r o le th a n b e lie v e d in th e past. C H I L D H O O D A S T H M A T h e in c id e n c e o f a s th m a in c h ild h o o d is v e ry v a r ia b le in d iffe re n t c o m m u n itie s b u t is a p p ro x im a te ly 5 % . It is th e m o s t c o m m o n c h ro n ic d ise a s e o f c h ild h o o d . B oys a re a ffe c te d tw ic e as c o m m o n ly as girls. T h e o n se t o f a s th m a in c h ild h o o d o c c u rs u n d e r th e age o f 5 y e a rs in 80% o f cases, a n d a tro u b le s o m e c o u g h ( p a rtic u la r ly a t n ig h t) is a c o m m o n m o d e o f p re s e n ta tio n . M o s t (75% ) affe c te d c h ild re n h a v e o n ly m ild s y m p to m s a n d w ill u su a lly “ g ro w o u t ” o f t h e ir a s th m a in th e ir e a r ly tee n s, a lth o u g h re la p s e s m a y o c c u r in la t e r life in som e. * S e n io r S p e c ia lis t, R e s p ir a to r y C lin ic ;Q ro o te S c h u u r H o s p ita l & D e p a r tm e n t o f M e d ic in e U n iv e r s ity o f C a p e T o w n S y m p to m a tic tre a tm e n t w ith a b r o n c h o d ila to r m av k a ll th a t is re q u ir e d to c o n tro l th e s e m ild ly affect j c h ild re n . C h ild re n w ith m o re se v e re a s th m a have g re a t te n d e n c y to a ss o c ia te d flex u ra l eczem a a h a lth o u g h th e la tte r o fte n ten d s to d is a p p e a r in tk teens, th e a s th m a is less lik e ly to r e m it th a n in mildl a ffe c te d c h ild re n . “ R o u n d -th e -c lo c k ” r e g u la r theran w ith b r o n c h o d ila to r s p lus s o d iu m c ro m o g ly c a te and/n c o rtic o s te ro id s is o fte n n e e d e d to c o n tro l a sth m a in th e s e c h ild re n . O f c o u rse , in a ll c h ild re n , re m o v a l of a g g ra v a tin g e n v iro n m e n ta l fa c to rs is e sse n tia l. T h e de­ v e lo p m e n t o f s o d iu m c ro m o g ly c a te a n d in h a le d steroid p r e p a r a tio n s (B e c lo m e th a s o n e ) h a s m a d e a verv v a lu a b le c o n tr ib u t io n to th e m a n a g e m e n t o f a sth m a in c h ild re n as th e y h a v e re d u c e d th e n e e d fo r systemic s te ro id s w ith all th e ir a tte n d a n t side-effects. g B e ca u se c h ild re n o fte n g ro w o u t o f th e ir a sth m f a n d b e c a u se e x erc ise is such a c o m m o n p re c ip ita tin g fa c to r in c h ild re n , m a n y a re u n d e r tr e a te d a n d deprived o f n o rm a l c h ild h o o d a c tiv itie s. P s y c h o g e n ic fa c to rs have in th e p a st a lso b een o v e re m p h a s iz e d . T h e la tte r should n e v e r be in v o k e d w ith o u t so m e m e a s u re o f re sp irato ry f u n c tio n h a v in g b een m a d e , as q u ite se v e re airw ays o b s tr u c tio n m a y go u n re c o g n is e d c lin ic a lly . A p p ro ­ p r ia te tre a tm e n t o f th e a s th m a tic c h ild w ill u su a lly allow h im to le a d a n o rm a l life . C o n tro l o f sy m p to m s and re v e rsa l o f a irw a y s o b s tr u c tio n w ill o fte n lea d to d is a p p e a r a n c e o f “ p sy c h o lo g ic al p r o b le m s ”. A D U L T A S T H M A A s th m a w ith o n se t in a d u lt life m a y a lso pass th rough p h a se s o f v a ry in g s e v e rity b u t th e te n d e n c y to p ro ­ lo n g e d re m is s io n is less th a n in c h ild h o o d . P re se n ta tio n is u su a lly w ith a c u te e p is o d e s o f w h e e z in g a n d dys­ p n o e a in th e y o u n g a d u lt. I n la te a d u lt life p re se n ta tio n m a y b e less d istin c tiv e , w ith c h ro n ic c o u g h a n d sputum p ro d u c tio n d o m in a tin g . I t is im p o r ta n t to re c o g n ise that a c h ro n ic c o u g h in th e a b se n c e o f m a r k e d w heezing m a y be d u e to a s th m a , o th e rw is e th e d ia g n o s is m a y be m is se d a n d th e p a tie n t in a d e q u a te ly tre a te d . F a c to rs p r e c ip ita tin g a tta c k s a re m u c h th e sa m e as in ch ild ­ h o o d a lth o u g h e x e rc is e p lay s a less p r o m in e n t role. T V - im p o rta n c e o f e n v iro n m e n ta l a n d in d u s tria l a g en ts i in c re a s in g ly b e in g re c o g n ise d a n d b ro n c h ia l challengfc- s tu d ie s h a v e sh e d m u c h lig h t o n d iffe re n t p a tte rn s of re sp o n se to such a gents. T h e list o f in d u s tria l p ro d u c ts (w h ic h m a y p la y a d o m in a n t ro le in u p to 2 % o f ad u lt a s th m a tic s ) c o n tin u e s to grow . I t in c lu d e s c o m p le x salts o f p la tin u m , sa lts o f c h ro m e a n d n ic k e l, a n tib io tic s, e n zy m es, d e te rg e n ts, to lu e n e d i-is o c y a n a te , g ra in dust, flo w e r a n d v e g e ta b le d usts. T h e i m p o rta n c e o f re co g n is­ in g th e s e e x te rn a l a g e n ts is th a t p re v e n tio n o f exposure to th e m is a m o re effe c tiv e m e a n s o f th e r a p y than sy m p to m a tic u se o f d ru g s. H o w e v e r, in th e large m a jo r ity o f a sth m a tic s, in d iv id u a l e n v iro n m e n ta l agents a r e o n ly o c c a s io n a lly re c o g n is e d a n d b ro n c h o d ila to rs, c ro m o g ly c a te a n d c o rtic o s te ro id s re m a in th e m ain sta y o f th e ra p y . P A T T E R N S O F A S T H M A T h e c o m m o n ly o b s e rv e d p a tte rn o f a s th m a is the o c c a s io n a l a tta c k o f v a ry in g se v e rity , in re la tio n to c lim a tic c h a n g e s o r k n o w n p r e c ip ita tin g a g en ts, w ith in te rv e n in g a s y m p to m a tic p e rio d s a n d a te n d e n c y to be slig h tly w o rs e in th e m o rn in g s . T h e r e a re h o w e v er, a R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) m ore u n u s u a l p a tte rn s w h ic h h a v e b e en re ce n tly fe'v fibed. T h e “ m o rn in g d ip p e r ” c h a ra c te ris tic a lly has desC a jrw ays o b s tr u c tio n in th e e a rly h o u rs o f th e seVrning w ith re tu r n to a lm o s t c o m p le te n o r m a lity la te r 5n°th e day. P a tie n ts w h o sh o w th e g re a te s t d e g re e o f 'n h d iu rn a l v a r ia ti o n m a y be a t p a r ti c u la r risk o f Sl'dden d e a th . E x te n s iv e stu d ie s h a v e fa ile d to id e n tify Sh exact m e c h a n is m s in v o lv e d , b u t re c e n t b ro n c h ia l hallenge stu d ie s h a v e sh o w n t h a t r e c u r r e n t e p is o d e s o f c rning a s th m a (fo r u p to a w e ek ) m a y fo llo w a single " I n o s u r e to som e a lle rg e n s. “ B r ittle ” a s th m a is c h a ra c - 6 Jjsed by in tra c ta b le p e rs is te n t a s th m a w h ic h flu ctu ate s te nsid e rab ly d u rin g th e c o u rs e o f d a y s a n d w e ek s b u t Cever reverses c o m p le te ly d u rin g th is p e rio d . R e sp o n se f0 b ro n c h o d ila to rs seem s to be s h o rt-liv e d a n d th ese t i e n t s th e r e f o r e te n d to o v e ru se th e ir in h a le rs . T h e y o ften a cc u se d o f b e in g e m o tio n a l a s th m a tic s . R e c o g ­ n i t i o n o f th e s e v e rity o f t h e ir a irw a y s o b s tru c tio n a n d intensification o f th e r a p y w ith so d iu m c ro m o g ly c a te o r c o r t i c o s t e r o i d s w ill im p ro v e m a n y o f th ese p a tie n ts . Once th e ir b a se -lin e p u lm o n a r y fu n c tio n h a s b e en im - / . 0 v e d , re g u la r “ ro u n d -th e -c lo c k ” tre a tm e n t w ill o fte n chieve c o n tro l w h e re th is w a s n o t p re v io u s ly p ossible. The “ irre v e rs ib le ” a s th m a tic is a p a tie n t w h o re sp o n d s poorly to all tre a tm e n t in c lu d in g c o rtic o s te ro id s a n d fnay re m a in in a p h a se o f p e rsistin g se v e re a irw a y s obstruction f o r p ro lo n g e d p e rio d s b e fo re g ra d u a lly i m p r o v i n g . R e v e rs a l o f a irw a y s o b s tru c tio n i s n e v e r complete in th ese p a tie n ts w h o , ev en a t th e ir best, w ill have som e d e g re e o f irre v e rs ib le o b s tru c tio n . a s s e s s m e n t o f a s t h m a T he c o m p le te a sse ss m e n t o f a n a s th m a tic p a tie n t requires a fu ll a n d c a re fu l h is to ry o f th e o n s e t a n d pattern o f a s th m a o v e r th e p a ti e n t ’s life, w ith p a r tic u la r attention to p r e c ip ita tin g fa c to rs, a fu ll c lin ic a l e x a m in a ­ tion, chest r a d io g r a p h , sk in p ric k -te s ts to a v a rie ty o f comm on a lle rg e n s, so m e m e a s u re m e n t o f th e d e g re e o f airways o b s tru c tio n , a n d a n e o s in o p h il c o u n t in th e p e ripheral b lo o d . I n a sse ssin g th e p a tie n t w ith a n e x acerbation o f sy m p to m s , th e c lin ic a l c la ssific a tio n o f S h erw ood-Jones is u s e fu l (T a b le I ) a n d sh o u ld be ____________________ T A B L E I _______________________ G ra d in g o f S e v e rity o f A s th m a (S h e rw o o d Jo n e s) Grade l a D iffic u lty w ith jo b o r h o u se w o rk , sleep o c c a sio n a lly d istu rb e d , lb G r e a t d iffic u lty w ith jo b o r h o u se w o rk , sleep fre q u e n tly d istu rb e d . 2a P a tie n t o n ly a b le to get o u t o f b e d o r c h a ir w ith m o d e ra te d iffic u lty . M in im a l re lie f fro m in h a le r. S leep d istu rb e d . 2b C o n fin e d to c h a ir o r bed a n d o n ly a b le to get u p w ith g re a t difficulty. N o sleep. P u lse > 1 2 0 /m in u te. 3 C o m p le te ly u n a b le to m ove. N o sleep. N o re lief f r o m in h a le r. P u lse > 1 2 0 /m inute. 4 C o m p le te e x h a u s tio n . NB A d m it to h o s p ita l w h e n p a tie n t re a c h e s 2a. su p p le m e n ted b y th r e e specific o b s e rv a tio n s : (a) p ulse rate, (b) p u lsu s p a ra d o x u s , (c) m e a s u re m e n t o f p e ak e x p ira to ry flow ra te o r F E V 1 /F V C , in a d d itio n to lo o king f o r th e w e llk n o w n c lin ic a l f e a tu re s o f se v e re a sthm a, such a s in a b ility to c o m p le te a se n te n c e w ith o u t taking a b re a th , u se o f a c c e s so ry m u sc le s, a n d in te r ­ costal re ce ssio n . T a c h y c a r d ia a lm o s t a lw a y s im p lie s severe a s th m a a n d th is m a y ta k e se v e ra l d a y s to r e tu r n jUNIE I 978 5 to c o m p le te n o r m a lity a f te r a n a c u te se v e re a tta c k . P u lsu s p a r a d o x u s is th e p re se n c e o f a fa ll in sy sto lic b lo o d p re s s u re d u rin g in s p ira tio n , a n d a lth o u g h u p to 1 0 m m m e rc u ry fa ll m a y o c c u r in n o rm a l p e o p le , a f a ll o f m o r e th a n 1 0 m m m e r c u r y in d ic a te s se v e re a irw a y s o b s tru c tio n . A lth o u g h s im p le to e lic it, it is a p h y sic a l sign n e g le c te d b y m a n y a n d n e e d s to be a d v e rtis e d m o re w id e ly so th a t i t b e co m es a r o u tin e p a r t o f a sse ssin g a s th m a tic p a tie n ts . M e a s u re m e n t o f p e a k e x p ir a to r y flow r a te o r F E V 1 /F V C s h o u ld a lso be u se d ro u tin e ly . T h e s e tests can b e d o n e w ith ro b u s t e a s ily p o r ta b le , re la tiv e ly c h e a p in s tru m e n ts a n d b e c a u se th e y a d d so m u c h o b je c tiv e in f o r m a tio n to th e c lin ic a l a sse ssm e n t o f a sth m a , th e i r u se sh o u ld be ro u tin e , n o t o n ly in c lin ic s a n d h o s p ita ls b u t a lso in d o m ic ilia ry p ra c tic e . T h e use o f th e p e ak flow m e te r is re c o m m e n d e d in a sse ssin g th e v e ry se v e re a s th m a a tta c k a s o n ly a s h o rt s h a rp fo rc e d e x p ir a tio n (a fte r a fu ll in s p ir a tio n ) is n e e d e d to re c o rd p e a k flow ra te . T h is is e a s ie r f o r th e p a tie n t to do a n d in d u ce s less b ro n c h o - sp a sm th a n th e p ro lo n g e d fo rc e d e x p ir a tio n re q u ir e d to re c o rd F E V 1 /F V C . W h e n th e p a tie n t is a little b e tte r th e p e ak flow m e te r can still b e u se d , b u t th e F E V 1 / F V C re c o r d e d o n a V ita lo g r a p h p ro v id e s m o re in ­ fo r m a tio n . T h e u se o f such m e a s u re m e n ts e n h a n c e s o u r a b ility to u se b r o n c h o d ila to rs a n d c o rtic o s te ro id s r a tio n a lly . T R E A T M E N T O F A S T H M A A cu te A ttack T h e c h ild w ith a c u te severe a s th m a w h o has n o t re s p o n d e d to h is u s u a l b r o n c h o d il a to r a e ro s o l o r sy ru p is p r o b a b ly b e st tre a te d w ith s u b c u ta n e o u s a d re n a lin e . T h is seem s to b e th e d ru g o f c h o ic e d e s p ite th e d e ­ v e lo p m e n t o f n e w e r a n d m o re specific a g en ts. E x p e rie n c e w ith th e s e n e w e r d ru g s w ill c la rify th e ir r o le in a c u te c h ild h o o d a sth m a . I n tra v e n o u s a m in o p h y llin e c a n b e u se d b u t b e c a u se o f th e n a rro w th e r a p e u tic ra n g e o f b lo o d levels a n d p o s s ib le u n p le a s a n t side-effects, th is s h o u ld b e u se d w ith c a u tio n a n d p r e fe r a b ly w ith m o n ito r in g o f b lo o d levels. W e t a e ro s o lis e d se lec tiv e b e ta - 2 a d r e n e rg ic s tim u la n t d ru g s (e.g. s a lb u ta m o l, h e x a p re n a lin e , fe n o te ro l, c a rb u te ro l) s h o u ld a lso be used. F a i lu r e to sh o w a d e q u a te re s p o n s e to su c h tr e a t­ m e n t is a n in d ic a tio n f o r th e a d m in is tr a tio n o f sy ste m ic ste ro id s . A e ro s o lis e d s te ro id s h a v e no p la c e in a c u te se v e re a sth m a . I n a d u lts th e in itia l th e ra p y o f c h o ic e is in tra v e n o u s a m in o p h y llin e , 5 m g /k g as a lo a d in g d o se o v e r 20 m in u te s a n d th e n 0,5 m g /k g p e r h o u r as a c o n tin u o u s in fu s io n . A n a lte rn a tiv e is i.v. sa lb u ta m o l 100 m ic r o ­ g ra m s fo llo w e d b y 5 m ic ro g ra m s /m in u te . W e t a e ro so l i n h a la tio n s o f a se le c tiv e b e ta - 2 s tim u la n t u s in g a sim p le n e b u liz e r is v e ry e ffective a n d th e r e is n o a d d itio n a l b e n efit d e riv e d f r o m u s in g a n e x p e n s iv e p o s itiv e p re s ­ s u re a p p a r a tu s (e.g. B ird v e n tila to r) to d e liv e r th e w et a e ro so l. A g a in , as in th e c h ild , c o rtic o s te ro id s s h o u ld be g iv en if th e re is n o t a r a p id re s p o n s e to th e a b o v e tre a tm e n t. J u d ic io u s u s e o f o x y g e n a n d fluids m u s t b e in c lu d e d in m a n a g e m e n t a n d th e v a lu e o f p e rs o n a l c o m fo rt a n d r e a s s u ra n c e p ro v id e d b y th e d o c to r, n u rse , o r p h y s io th e ra p is t m u s t n e v e r b e fo rg o tte n . S e d a tio n is a b s o lu te ly c o n tra -in d ic a te d e x c e p t u n d e r v e ry sp e c ia l c irc u m s ta n c e s w h e re p u lm o n a ry f u n c tio n is b e in g c a r e ­ fu lly m o n ito r e d a n d w h e re re s u s c ita tio n can be c a rrie d o u t e x p e rtly . M o re p a tie n ts w ith se v e re a s th m a a re h a rm e d b y se d a tio n th a n h e lp e d . T h e a g ita tio n a n d d istre s s o f a p a tie n t w ith se v e re a s th m a is d u e to se v e re a irw a y s o b s tr u c tio n a n d h y p o x ia . T h e u se o f se d a tio n is in a p p r o p r ia t e in th is s e ttin g a n d is o n ly r e s o r te d to by th o s e w h o lac k u n d e r s ta n d in g o f sev ere F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 a s th m a a n d w h o h a v e f a ile d to assess th e s e v e rity o f a s th m a a d e q u a te ly . O n ly a sm a ll p e rc e n ta g e o f p a tie n ts p re s e n tin g w ith a c u te se v e re a s th m a w ill f a il to re s p o n d to a ll th e m e a s u re s o u tlin e d a b o v e a n d th e s e p a tie n ts m a y n e e d i n tu b a tio n a n d v e n tila tio n as a life -sa v in g p ro c e d u re . A lth o u g h p a tie n ts w ith se v e re a tta c k s o f a s th m a m a y b e s y m p to m a tic a lly b e tte r w ith in m in u te s a n d h o u r s o f in s titu tin g a p p r o p r ia te tre a tm e n t, it o fte n ta k e s m a n y d a y s o f tre a tm e n t to a c h ie v e c o m p le te r e v e rs ib ility o f a irw a y s o b s tru c tio n . T w ic e d a ily m o n ito r in g o f p e a k flow r a te o r F E V 1 /F V C , a n d p u ls e r a te d u rin g th e re c o v e ry p e r io d w ill b e th e m o s t a c c u ra te m e a n s o f a sse ssin g p ro g ress. In terval T herapy T h e o b je c t o f in te rv a l th e ra p y o f a sth m a is to k e ep th e p a tie n t a s y m p to m a tic a n d to k e e p p u lm o n a ry fu n c tio n as close to n o r m a l as p o ssib le . T h is s h o u ld b e a c h ie v e d w ith th e lea st a m o u n t o f d ru g s p o ssib le . I n so m e p a tie n ts re g u la r u se o f a d ry a e ro s o l w ill b e a ll th a t is re q u ir e d , w h e re a s o th e r s m a y n e e d m o re in te n s iv e “ ro u n d -th e -c lo c k ” d ru g th e r a p y in c lu d in g in h a le d a n d o r a l c o rtic o s te ro id s . A s a s th m a is a flu c tu a tin g c o n d itio n , th e ra p y n e e d s c o n tin u a l a d ju s t­ m e n t to c o p e w ith e x a c e rb a tio n s a n d re m iss io n s . T h e u se o f a d ia r y c a rd k e p t b y a n in te llig e n t p a tie n t, c o m b in e d w ith s e ria l m e a su re s o f p e a k flow r a te o r F E V 1 /F V C , e n a b le u s to fo llo w th e p a tt e r n o f a sth m a in a n y in d iv id u a l p a tie n t a n d to re g u la te h is th e ra p y a c c o rd in g ly . P r e c ip ita tin g fa c to rs m u s t b e a v o id e d w h e re v e r p o ss ib le . I t m u s t b e e m p h a s iz e d th a t such o p tim u m in te rv a l th e r a p y re q u ire s fu ll p a tie n t co­ o p e r a tio n a n d th is can o n ly b e a c h ie v e d if th e p a tie n t is e d u c a te d a b o u t h is dise ase, a n d is w illin g to c o o p e ra te . D e s e n s itiz a tio n to a lle rg e n s p la y s a little r o le in th e o v e ra ll m a n a g e m e n t o f m o s t a s th m a tic s b u t m a y be im p o r ta n t in a fe w c a re fu lly se le c te d p a tie n ts w ith specific a lle rg ie s. P H Y S IO T H E R A P Y W h a t is th e r o le o f th e p h y s io th e r a p is t in a s th m a ? S h e is, in m y v iew , a v ita l p e rs o n in th e tre a tm e n t o f th e a s th m a tic p a tie n t. N o t o n ly s h o u ld sh e d e liv e r w et a e ro s o liz e d b r o n c h o d ila to r s , a n d h e lp th e p a tie n t c o u g h a n d c le a r se c re tio n s , b u t she s h o u ld h a v e a ni to in h e lp in g to e d u c a te p a tie n ts a b o u t t h e i r disease th e u se o f th e ir v a r io u s d ru g s, p a r tic u la r ly b r o n r ^ d ila to rs . H e r ro le in c o m fo rtin g a n d re a ss u rin g h p a tie n t w ith se v e re a s th m a in th e h o s p ita l se ttin g m n o t b e u n d e re s tim a te d a n d sh e c a n m a k e a re a l c o m ' 1 b u t io n in th is a re a . I t is n o w w e llk n o w n th a t v igorori' chest p h y s io th e r a p y is d a n g e ro u s d u rin g severe a sth rrf a n d is se ld o m re q u ir e d b e tw e e n a tta c k s. G e n tle ne c u ssio n a n d tip p in g m a y b e o f so m e v a lu e in p a tie n t' w ith e x cessive se c re tio n s a sso c ia te d w ith com plicatin b ro n c h ie c ta s is . B re a th in g e x erc ises in th em se lv es a re of lim ite d v a lu e b u t p r o v id e a b a sis f o r inter-reaction b e tw e e n p a tie n t a n d t h e r a p is t w h ic h le a d s to increased p a tie n t confidence. T h e p h y s io th e r a p is t sh o u ld bp f a m il ia r w ith th e W r ig h t ’s P e a k F lo w M e te r a n d the V ita lo g r a p h a n d sh e s h o u ld u s e th e s e ro u tin e ly to assess th e re s u lts o f th e b r o n c h o d il a to r th e ra p y she is a d m in is te r in g to h e r p a tie n t. D E A T H F R O M A S T H M A A lth o u g h d e a th f r o m a s th m a w as th o u g h t to be u n ­ c o m m o n a t th e t u r n o f th e c e n tu ry it is n o w widelv a c c e p te d th a t n o t o n ly d o e s d e a th o c c u r f r o m asthm a b u t t h a t in m a n y cases th is m a y b e p re v e n ta b le . One o f th e s tr ik in g fe a tu r e s w h ic h h a s b e e n em phasized r e c e n tly is h o w i n a d e q u a te th e a sse ss m e n t a n d tre a t­ m e n t o f a s th m a h a s b e e n in m a n y p a tie n ts d ying of a sth m a . Im p ro v e m e n t i n a sse ss m e n t a n d tre a tm e n t of p a tie n ts w ith a c u te a s th m a a n d im p ro v e m e n t in in te r­ v a l m a n a g e m e n t o f th e m a n y a s th m a tic s in o u r pop u ­ la tio n w ill r e q u ir e e d u c a tio n o f d o c to rs , p h y sio ­ th e ra p is ts a n d p a tie n ts a b o u t th e d ise a s e , a n d the p ro v is io n o f a d e q u a te sta ff a n d fa c ilitie s . C O N C L U S IO N S A s th m a is a c o m m o n d is o rd e r. I t p ro d u c e s a g reat d e a l o f su ffe rin g a n d a n o t in c o n s id e ra b le m o rta lity . O u r u n d e rs ta n d in g o f th e c o n d itio n h a s advanced g re a tly in th e la s t d e ca d e, a n d th e b e n e fit o f our. im ­ p ro v e d k n o w le d g e n o w n e e d s to b e tra n s la te d into p a tie n t c a re , n o t o n ly in sp e c ia lis e d u n its , b u t th ro u g h ­ o u t a ll h e a lth c a re services. JUNE 1978P H Y S I O T H E R A P Y PHYSIOTHERAPY IN OBSTRUCTIVE AIRWAYS DISEASE M IS S D . G A S K E L L , M .C .S .P . T h e p h y s io th e r a p y te c h n iq u e s u se d in th e tre a tm e n t o f a s th m a , c h ro n ic b r o n c h itis a n d e m p h y s e m a a r e v e ry s im ila r, b u t th e i r a p p lic a tio n in th e tre a tm e n t o f th ese d ise ases is to ta lly d iffe re n t. F o r th is r e a s o n t h e d ise ases w ill b e d e a lt w ith se p a ra te ly . A sthm a P h y s io th e r a p y m a y b e o rd e re d f o r a s th m a p a tie n ts w h o se c o n d itio n w ill v a r y f r o m th e p e rs o n in s ta tu s a s th m a tic u s to so m e o n e c o m p le te ly fr e e o f a s th m a a t th e tim e o f tre a tm e n t. T h e ty p e o f p a tie n t se e n b y p h y s io th e ra p is ts in o u t ­ p a tie n t d e p a rtm e n ts w ill v a ry f r o m a y o u n g c h ild to th e o ld e r in d iv id u a l w ith m o re c h ro n ic d isease. I t sh o u ld n o t b e n e c e s s a ry f o r o u tp a tie n ts to a tte n d f o r lo n g p e rio d s o f tre a tm e n t, sin c e th e r o le o f th e p h y s io th e r a ­ p is t is to e d u c a te th e p a tie n t a n d h is re la tiv e s in how to c o p e w ith h is c o n d itio n a t h o m e . I t m a y b e necessary to tr e a t th e p a ti e n t s u b s e q u e n tly f o r lim ite d p e rio d s o f tim e d u r in g a c u te e x a c e rb a tio n s , b u t if th e p a tie n t has b e e n c o rre c tly tr a in e d b y th e p h y s io th e r a p is t, h e should b e a b le to c o p e o n h is o w n f o r m o s t o f th e tim e. T h e a im s o f tre a tm e n t a re to a c h ie v e b ro n c h o d ila ta - tio n , to re m o v e a n y s e c re tio n s p re s e n t a n d t o te a c h the p a tie n t h o w to c o n tro l h is b r e a th in g in v a rio u s re ­ la x e d p o sitio n s . C h ild re n m a y r e q u ir e p o s tu re exercises. I t is h e lp f u l to assess p a tie n ts b e fo re a n d a fte r p h y s io th e ra p y b y m e a n s o f a p e a k flow m e te r o r a V ita lo g ra p h y . M a n y o u tp a tie n ts w ill get a m e a s u r a b le re s p o n s e to a b r o n c h o d ila to r g iv e n b y m e a n s o f a p re s s u ris e d a e ro so l, p ro v id in g th e y a re u s in g th e device c o rre c tly . P a tie n ts w h o d o n o t get a g o o d , re sp o n se are fre q u e n tly u sin g th e d e v ic e in c o rre c tly a n d it is im por- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )