By T. Pranck. Missouri Southern State College. 2018.
Alternatively cheap theo-24 cr 400 mg, a single dose of triamcinolone diacetate 40 mg intramuscularly also has been reported to be as effective as prednisone 40 mg/day for 5 days after treatment in the emergency room for asthma ( 71) purchase 400mg theo-24 cr fast delivery. Patients in this group require ongoing treatment either in the emergency room or general medical ward cheap 400mg theo-24 cr. Physicians should err on the side of admission when there is a harmful home environment and when directly observed therapy is needed in noncompliant patients. This practice improves oxygen delivery to peripheral tissues such as respiratory muscles, reverses hypoxic pulmonary vasoconstriction, and may result in bronchodilation. Oxygen also protects against the decrease in Pa O2 resulting from b agonist induced pulmonary vasodilation and increased blood flow to low V/Q units ( 72,73). They should be given until there is either a clinical response or side effects limit further administration. In general, patients can be classified as albuterol responders (approximately two thirds of patients) or albuterol nonresponders (who may have a greater component of inflammation and airway architectural distortion). In the study by Rodrigo and Rodrigo, 67% of patients improved significantly and could be discharged from the emergency room after 2. Half of the responders met discharge criteria after receiving only 12 puffs of albuterol. Similarly, Strauss and co-workers found that two thirds of patients with acute asthma could be discharged after three 2. Dose-response relationship to 4 puffs albuterol (400 g) every 10 minutes in 116 acute asthmatics. Sixty-seven percent of patients obtained discharge criteria after administration of 2. Therapeutic response patterns to high and cumulative doses of salbutamol in acute severe asthma. Peak expiratory flow rates improved in a dose-response fashion as the cumulative quantity of albuterol increased. Overall, the 5-mg regimen increased peak flows more rapidly and to a greater extent than the standard 2. There was also a trend toward fewer hospitalizations in the high-dose group (25 of 80 patients, 31%) than in the lower dose group (37 of 80 patients, 46%) ( p = 0. There is no difference between continuous and repeated dose administration In general, albuterol should be used in a continuous or repetitive manner (both work equally well) ( 78) until there is a convincing clinical response or side effects limit further drug administration ( Table 28. Tremor and tachycardia are common, but significant cardiovascular morbidity is not ( 83). Drugs used in the initial treatment of acute asthma Albuterol is preferred over metaproterenol because its greater b 2 selectivity is associated with fewer side effects, and it has a longer duration of action ( 84,85). Some clinicians prefer metaproterenol or isoetharine for initial therapy because of their faster onset of action, despite the tendency of these drugs to increase side effects (86). Levalbuterol, the R-isomer of racemic albuterol, has been reported to have a slighter better safety profile than racemic albuterol. Salmeterol maintenance therapy results in fewer exacerbations and exacerbations of lesser severity ( 89). After several hours of inhaled b agonist (without a convincing response) subcutaneous epinephrine may be helpful (97). Known ischemic heart disease and age greater than 40 years are relative contraindications to parenteral therapy ( 98). Older patients without a history of recent myocardial infarction or angina tolerate subcutaneous epinephrine reasonably well. Intravenous b agonists are not recommended, with the possible exception of patients in cardiac arrest. Several studies have demonstrated that inhaled drug results in greater improvement in airflow and less toxicity compared with intravenous administration ( 99,100,101 and 102). Systemically administered corticosteroids are the most effective treatment of this inflammation, justifying their use in most cases. Corticosteroids should be given quickly in the emergency room to all but the mildest cases because antiinflammatory effects do not occur for hours. This delay explains the results of several studies demonstrating that corticosteroid use in the emergency room does not improve lung function over the first few hours and does not decrease hospitalization rates ( 103,104 and 105). In the meta-analysis by Rowe and colleagues, ( 108) doses lower than 30 mg of prednisone every six hours were less effective, but higher doses were no more effective. In another metaanalysis by Reid and colleagues, no therapeutic differences were identified among different doses of corticosteroids (60 80 mg/day of methylprednisolone vs. Emerman and Cydulka compared 500- and 100-mg doses of methylprednisolone in the emergency room, finding no benefit to higher dose therapy (115). Haskell and co-workers reported that patients receiving 125 mg intravenous methylprednisolone every 6 hours improved more rapidly than patients receiving 40 mg, although there was no difference in peak improvement (116). In this study, both 125- and 40-mg doses of methylprednisolone were superior to 15 mg every 6 hours in terms of the rate and absolute level of improvement. Bowler and colleagues found no difference between hydrocortisone 50 mg intravenously four times daily for 2 days, followed by low-dose oral prednisone and 200 or 500 mg of hydrocortisone, followed by higher doses of prednisone ( 117). For adults, we recommend 40 to 60 mg of methylprednisolone (or its equivalent) every 6 hours by vein during initial management. Oral drug is as effective ( 118) but should be avoided in patients with gastrointestinal upset or in patients at risk for intubation. Recent trials have demonstrated the benefit of inhaled corticosteroids in acute asthma. In children discharged from the emergency room, a short-term dose schedule of inhaled budesonide, starting at high dose and then tapered over 1 week, was reported to be as effective as a tapering course of oral prednisolone ( 119). Rodrigo and Rodrigo conducted a randomized, double-blind trial of the addition of flunisolide 1 mg versus placebo with 400 g salbutamol every 10 minutes for 3 hours in 94 emergency room patients (120). McFadden has suggested that this early benefit may stem from high-dose inhaled steroid-induced vasoconstriction, decreasing airway wall edema, vascular congestion, and plasma exudation (121). Overall, these data suggest that there is little benefit to the addition of inhaled steroids to high-dose b-adrenergic agonists and systemic corticosteroids in the management of acute asthma. Still, consideration should be given to the use of high-dose inhaled corticosteroids in refractory patients. Karpel and colleagues studied 384 patients randomized to receive nebulized albuterol 2. Additionally, there were no significant differences in the number of patients requiring additional emergency room or hospital treatment. Garrett and colleagues randomized 338 asthmatics to a single dose of nebulized ipratropium bromide 0. Results of a recent metaanalysis and a pooled analysis of three studies also demonstrate a modest benefit for combination therapy. The direction of all three outcome measures favored combination therapy, but differences did not reach statistical significance. In children, Ducharme and Davis did not demonstrate benefit from combination therapy in their study of nearly 300 asthmatics with mild to moderate acute asthma ( 137). Other small studies examining the addition of ipratropium bromide to b-adrenergic agonists in acute asthma have yielded mixed results ( 138,139). The above studies demonstrating modest (or no) benefit to combination therapy generally used small doses of ipratropium bromide.
Cyanosis is not present in very anaemic patients nocleidomastoid in the lower third theo-24 cr 400mg mastercard. Cyanosis is divided from the carotid pulse by its double waveform best theo-24 cr 400 mg, it is non- into two categories: palpable order 400 mg theo-24 cr free shipping, it is occluded by pressure and pressure on the r Peripheral cyanosis, which is seen in the ngertips and liver causes a rise in the level of the pulsation (hepato- peripheries. The jugular waveform and pressure give it is due to poor perfusion, as the sluggish circulation information about the pressures within the right atrium leads to increased desaturation of haemoglobin. This as there are no valves separating the atrium and the in- may be as a result of normal vasoconstriction in the ternal jugular vein (see Fig. Slow rising The slow rising pulse is seen in aortic stenosis due to obstruction of outflow. Collapsing The collapsing pulse of aortic regurgitation is characterised by a large upstroke followed by a rapid fall in pressure. This is best appreciated with the arm held up above the head and the pulse felt with the flat of the fingers. Alternans Pulsus alternans describes a pulse with alternating strong and weak beats. Bisferiens This is the waveform that reults from mixed aortic stenosis and regurgitation. The percussive wave P T (P) is due to ventricular systole, the tidal wave (T) is due to vascular recoil causing a palpable double pulse i. Paradoxus This is an accentuation of the normal situation with an excessive and palpable fall of the pulse Inspiration pressure during inspiration. Once the atrium is filled with blood it contracts to give the a wave a The a wave is lost in atrial fibrillation. The a wave is increased in pulmonary stenosis, pulmonary hypertension and tricuspid stenosis (as a consequence of right atrial or right ventricular hypertrophy). The atrium relaxes to give the x descent; however, the start of a ventricular contraction causes ballooning of the tricuspid valve as c it closes, resulting in the c wave. The further x descent is due to descent of the closed valve towards the cardiac apex. This may occur in right-sided heart Timing to systole or diastole is achieved by palpation failure, congestive cardiac failure and pulmonary em- of the carotid pulse whilst auscultating. Murmurs are further described according to their Precordial heaves, thrills and pulsation relationship to the cardiac cycle. Thisoccursinmitralregurgitation, ventricular hypertrophy when the impulse is at the tricuspid regurgitation and with a ventricular septal same time as the apex beat and carotid pulsation. It is heard r A thrill is a palpable murmur and is due to turbulent with aortic stenosis, pulmonary stenosis and with an blood ow. For example, a diastolic thrill at r A late systolic murmur is heard in mitral valve pro- the apex is suggestive of severe mitral stenosis (aortic lapse. This is most tercostal space) and the relationship to the chest (mid- helpful when the ow of blood is considered according clavicular line, anterior axillary line, etc). The normal to the lesion, for example aortic stenosis radiates to the position is the fourth or fth intercostal space in the neck, mitral regurgitation radiates to the axilla. Investigations and procedures Heart murmurs Coronary angioplasty Heart murmurs are the result of turbulent blood ow. Coronary angioplasty is a technique used to dilate stenosed coronary arteries in patients with ischaemic heart disease. These slowly disease or triple vessel disease to be treated by bypass release a drug (e. In addition, patients with concomitant condi- Coronary artery bypass surgery tions precluding bypass surgery, e. It has Early angiography and angioplasty is now being in- also been shown to improve outcome in patients with creasingly used immediately following a myocardial triple vessel disease or left main stem coronary artery infarction, in order to reduce the risk of further infarc- disease. A small whilst maintaining an adequate circulation to the rest balloon is passed up the aorta via peripheral arterial ac- of the body cardiopulmonary bypass is most commonly cess under radiographic guidance. A cannula is placed in the right atrium in order fected coronary artery, the balloon is inated to dilate to divert blood away from the heart. The blood is then the stenosis, compressing the atheromatous plaque and oxygenated by one of two methods: stretching the layers of the vessel wall to the sides. A stent r Bubble oxygenators work by bubbling 95% oxygen is often used to reduce recurrence. If the myocardium is to be opened, cross-clamping the Complications aorta gives a bloodless eld; the heart is protected from The main immediate complication of balloon angio- ischaemia by cooling to between 20 and 30C. Systemic plasty is intimal/medial dissection leading to abrupt ves- cooling also lowers metabolic requirements of other or- sel occlusion. Beatingheartbypassgraftingisnow has been largely resolved with the routine implantation possible using a mechanical device to stabilise the target of a stent. There is a risk of complications, including surface area of the heart, but access to the posterior sur- emergency coronary artery bypass surgery, myocardial face of the heart can be difcult. More commonly, local The internal mammary artery is the graft of choice haematoma at the site of arterial puncture may occur. The coronary arteries are opened distal to the obstruction and the grafts are placed. If the saphenous Prognosis vein is used, its proximal end is sewn to the ascend- Depending on the anatomy of the lesion, signicant ing aorta. Valvular regurgitation when due to dilation of the valve Complications ring may be treated by sewing a rigid or semi-rigid Aspirin is usually continued for the procedure, but other ring around the valve annulus to maintain size (annulo- antiplatelet drugs such as clopidogrel are stopped up to plasty). During the procedure patients are due to infective endocarditis or chordal rupture, part of heparinised to prevent thrombosis. Antibiotic cover is the leaet may be resected or even repaired with a piece provided using a broad spectrum antibiotic to prevent of pericardium to restore valve competence. Operative mortality depends on many fac- Valve replacement: Using cardiopulmonary bypass the tors including age and concomitant disease, it usually diseased valve is excised and a replacement is sutured varies from 1 to 5%. Current designs all have Approximately 90% of patients have no angina postop- some form of tilting disc such as the single disc Bjork eratively, with almost all patients experiencing a signi- Shiley valve or the double disc St Jude valve. Over time symptoms may gradually durable, but require lifelong anticoagulation therapy return due to progression of atheroma in the arteries or to prevent thrombosis of the valve and risk of em- occlusion of vein grafts. Outcome is improved by risk factor modi- r Biological valves may be xenografts (from animals) cation(stoppingsmoking,loweringhighbloodpressure, or homografts (cadaveric). They are treated with glutaraldehyde to possible if medication is insufcient to control symp- prevent rejection and are used to replace aortic or mi- toms; however, repeat surgery has a higher mortality. They do not require anticoagulation unless Angioplastyusingstentimplantationissuitableforgrafts the patient is in atrial brillation but have a durabil- or native vessels. Valve failure may result from leaet shrinkage or weakening of the valve com- petence causing regurgitation, or calcication causing Valve surgery valve stenosis. Valvesurgery is used to treat stenosed or regurgitant Valve replacements are prone to infective endocarditis, valves, which cause compromise of cardiac function. The aortic valve is not usually amenable to conservative Valve replacement provides marked symptomatic re- surgery and usually requires replacement if signicantly lief and improvement in survival. A stenosed mitral valve may be treated by fol- is approximately 2%, but this is increased in patients lowing procedures: with ischaemic heart disease (when it is usually com- r Percutaneous mitral balloon valvuloplasty in which a bined with coronary artery bypass grafting), lung dis- balloon is used to separate the mitral valve leaets.
Intrinsic causes include multiple scle- rosis and acute transverse myelitis buy theo-24 cr 400mg without a prescription, both of which may result in paraplegia and pain discount 400mg theo-24 cr free shipping. In certain developing countries discount theo-24 cr 400mg mastercard, for example in sub-Saharan Africa, intrinsic damage may be attributable to neurotoxins as in the case of incorrectly prepared cassava, which leads to tropical spastic neurological disorders: a public health approach 129 paresis. Other causes include compressive lesions, for example tumours and infections, especially tuberculosis and brucellosis. Pain indirectly caused by diseases or abnormalities of the nervous system Pain arises as a result of several distinct abnormalities of the musculoskeletal system, secondary to neurological disorders. These can be grouped into the following categories: musculoskeletal pain resulting from spasticity of muscles; musculoskeletal pain caused by muscle rigidity; joint deformities and other abnormalities secondary to altered musculoskeletal function and their effects on peripheral nerves. Pain caused by spasticity Pain caused by spasticity is characterized by phasic increases in muscle tone with an easy pre- disposition to contractures and disuse atrophy if unrelieved or improperly managed. In developed countries, the main causes of painful spasticity are strokes, demyelinating diseases such as multiple sclerosis, and spinal cord injuries. Strokes and spinal cord disease are also major causes of spasticity in developing countries, for example stroke is the most common cause of neurological admissions in Nigeria. Pain caused by muscle rigidity Pain can be one of the rst manifestations of rigidity and is typically seen in Parkinson s disease, dystonia and tetanus. Apart from muscle pain in the early stages of Parkinson s disease, it may also occur after a long period of treatment and the use of high doses of L-Dopa causing painful dystonia and freezing episodes. Tetanus infection, common in developing countries, is characterized by intense and painful muscle spasms and the development of generalized muscle rigidity, which is extremely painful. During intense spasm, fractures of spinal vertebrae may occur, adding further pain. Pain caused by joint deformities A range of neurological disorders give rise to abnormal stresses on joints and, at times, cause deformity, subluxation or even dislocation. For example frozen shoulder or pericapsulitis occurs in 5 8% of stroke patients. Disuse results in the atrophy of muscles around joints and various abnormalities giving rise to pain, the source of which are the tissues lining the joint. In addition, deformities may result in damage to nerves in close proximity resulting in neuropathic pain of the evoked or spontaneous type. The literature does not give data for the prevalence and incidence of the pain associated with the disorders mentioned. The symptoms exceed both in magnitude and duration those which might be expected clinically given the nature of the causative event. Other features of the syndrome include local oedema or swelling of tissues, abnormalities of local blood ow, sweating (autonomic changes) and local trophic changes. They are a cause of signicant psychological and psychiatric disturbance, and treatment is a major problem. They have been the subject of considerable research and been carefully classied by the International Headache Society. Epidemiological studies have focused primarily on migraine and tension-type headaches (primary headache disorders). Pain is a subjective experience but physiological changes that accompany it may be measured: they include changes in heart rate, muscle tension, skin conductivity and electrical and metabolic activity in the brain. These measures are most consistent in acute rather than chronic pain and they are used primarily in laboratory studies. The use of words as descriptors of pain have permitted the development of graded descriptions of pain severity. Such measures are often repeated at intervals to gain information about the levels of pain throughout the day, after a given procedure or as a consequence of treatment. More sophisticated verbal measures use groups of words to describe the three dimensions of pain, namely its sensory component, the mood-related dimension and its evaluative aspect. This technique was devised by Melzack and others and is best seen in the Short-Form McGill Pain Questionnaire (5). Often because of age, not having English as a rst language or as a result of some form of mental impairment, the scale cannot be used. In its place it is possible to use a faces scale in which recognizable facial images representing a range of pain experiences from no pain to very severe pain are readily understood. In the case of patients with pain generated as a result of a lesion within the nervous system (neuropathic pain) specic measures have been devised to distinguish between that type of pain and pain arising outside the nervous system (6). In the assessment of a patient with neuropathic pain, the evalua- tion of sensory function is crucial and can be carried out at the bedside with simple equipment. Another technique used in clinical assessment includes pain drawings, which allow the patient to mark the location of pain and its qualities using a code on a diagram of the body. A pain diary is used by patients to record levels of pain throughout the day, using a visual analogue scale. This reveals the pattern of pain severity in relation to drug therapy and activity levels. Finally, pain behaviour is neurological disorders: a public health approach 131 often used to aid diagnosis. It is especially useful for determining the extent to which psychological factors inuence pain. Pain assessment should take account of the patient s sex and ethnic and cultural background, all of which tend to inuence the clinical presentation. The study revealed that persistent pain was associated with depression, which affected the quality of life and reduced the level of daily activity of the sufferers (7). It was concluded that the essential need to work and to earn income might be a reason why many people in developing countries tolerate pain rather than reporting to doctors or hospitals. Therefore, lack of an adequate social and health-care support network, cost implications and job security must inuence the extent to which people living in developing countries and suffer pain fail to seek help. A detailed study of the prevalence, severity, treatment and social impact of chronic pain in 15 European countries was carried out recently (8). Of the respondents, 25% had head or neck pains (migraine headaches, 4%; nerve injury from whiplash injuries, 4%). Although back pain may have a neuro- logical cause, the likelihood was that in the great majority pain was the result of musculoskeletal disorders or back strain. The authors concluded that one in ve Europeans suffer from chronic pain which is of moderate severity in two thirds and severe in the remainder. The study also reveals that, in the opinion of 40% of the respondents, their pain had not been treated satisfactorily and 20% reported that they were depressed. In economic terms, 61% were less able or unable to work outside their homes, 19% had lost their jobs because of pain and another 13% had changed their jobs for the same reason. A large-scale survey in Australia (9) of just over 17 000 adults with pain daily for at least three months (chronic pain) yielded a prevalence rate of 18. It is therefore evident from the three surveys that a prevalence rate for chronic pain of 18 20% is to be expected in adult populations selected at random from developed countries. Unfortunately, these gures do not give any detail about pain arising from the nervous system, except for the information about head and neck pain in the European survey.
Ascoreof2ormorecorefeaturessuggestaseverepneu- Aetiology monia with indication for initial combined antibiotic M proven 400 mg theo-24 cr. It is spread by coughing up of live bacilli after invasion of the disease into a main bronchus (open tu- berculosis) cheap theo-24 cr 400mg with amex, which are then inhaled order 400 mg theo-24 cr fast delivery. Approximately 7000 new cases a year in the United r Theemergenceofmultipledrugresistanceduetonon- Kingdom and rising throughout Europe and the United States. It may occur at any time from weeks just below the pleura in the apex of the upper lobe or up to years after the original infection. It matory process forms the Ghon focus usually just differs from primary infection in its immunopathol- beneath the pleura. The lymph nodes are rarely involved, and there is lymph nodes at the lung hilum, and excite an immune reactivation of the immune response in the tissues. This pattern forms the primary r Inthelung,thebacteriahaveapreferencefortheapices complex with infection at the periphery of the lung (higher pO2), and form an apical lung lesion known and enlarged peribronchial lymph nodes. It begins as a small caseating r The outcome of the primary infection depends on the tuberculous granuloma, histologically similar to the balance between the virulence of the organism and Ghon focus, with destruction of lung tissue and cavi- the strength of the host response (see Table 3. T cells are re-induced by the secondary infec- the host can mount an active cell mediated immune tion, with activation of macrophages, and exactly as response the infection may be completely cleared. Collagen is healing of the apical region with collagen de- is deposited around these, often becoming calcied. This is called a progres- tissue, thinning of the collagen wall and increasing sive primary infection. Coughing disperses these bacilli into the at- Poor immune system eg Good immune response, e. This disease is sometimes Use of appropriate antibiotics called galloping consumption. By that time there may be no evidence of tu- comesinfectedbymiliarydisseminationwithmultiple berculosis elsewhere. The hypersensitivity reaction may produce patient mounts a good immune response, organisms atransient pleural effusion or erythema nodosum. Microscopy Formal culture of material is the only way of accu- The characteristic lesion, the tubercle (granuloma) con- rately determining virulence and antibiotic sensitivity sists of a central area of caseous tissue necrosis within and should be attempted in every case, results may which are viable mycobacteria. It relies on the hypersensitivity reaction, usually heals spontaneously but occasionally may per- and is rarely helpful in the diagnosis of tuberculosis: sist giving rise to bronchiectasis particularly of the i The Tine test and Heaf test are for screening: 4/6 middle lobe (Brock s Syndrome). If the spots are conuent, logicalfractures,particularlyofthespinetogetherwith the test is positive, indicating exposure. The reaction is read at Investigations 48 72 hours and is said to be positive if the indura- r An abnormal chest X-ray is often found incidentally tion is 10 mm or more in diameter, negative if less in the absence of symptoms, but it is very rare for a than 5 mm. The X-ray shows puried protein derivative this can indicate active patchy or nodular shadowing in the upper zone with infection requiring treatment. In an immunocom- brosis and loss of volume; calcication and cavita- promised host (such as chronic renal failure, lym- tion may also be present. Human immunity depends largely on the haemag- niazid, ethambutol and pyrazinamide, and a further glutinin (H) antigen and the neuraminidase (N) antigen 4months of rifampicin and isoniazid alone. Major shifts in these antigenic re- taken 30 minutes before breakfast to aid absorption. Thesecancauseapandemic,whereasantigenicdrift organism is sensitive for a full 6 months to avoid de- causes the milder annual epidemics. Other upper and lower respiratory symptoms to6weeks after birth (without prior skin testing) in ar- may develop. Individuals are infective for 1 day prior to eas with a high incidence of tuberculosis. Less commonly, secondary Five per cent of patients do not respond to therapy, only Staph. Inuenza A causes worldwide annual epidemics and is Retrospective diagnosis can be made by a rise in spe- infamous for the much rarer pandemics, the most seri- ciccomplement-xingantibodyorhaemagglutininan- ous of which occurred in 1918 when 40 million people tibody measured 2 weeks apart, but this is usually un- died worldwide. Spread is by respiratory r Bed rest, antipyretics such as paracetamol for symp- droplets. Clinical features They are particularly indicated in the elderly, those Patients present with worsening features of pneumonia, with underlying respiratory disease such as chronic usually with a swinging pyrexia, and can be severely ill. Some are manufactured in strates one or more round opacities often with a uid chickembryosandtheseshouldnotbegiventoanyone level. Echocardiogram should be considered to look for infec- These predications depend on global surveillance or- tive endocarditis. This surveillance depends on viruses being cultured Complication and therefore on nose/throat swabs being taken and Breach of the pleura results in an empyema. Management Lung abscess Posturaldrainage,physiotherapyandaprolongedcourse of appropriate antibiotics to cover both aerobic and Denition anaerobic organisms will resolve most smaller ab- Localisedinfectionanddestructionoflungtissueleading scesses. Largerabscessesmayrequirerepeatedaspiration, to acollection of pus within the lung. Organismswhichcausecav- Denition itation and hence lung abscess include Staphylococcus Thereareessentiallythreepatternsof lungdiseasecaused and Klebsiella. Pathophysiology Aetiology The abscess may form during the course of an acute It is a lamentous fungus, the spores (5 mindiame- pneumonia, or chronically in partially treated pneu- ter) are ubiquitously present in the atmosphere. This results from Aspergillus growing within an area of previously damaged lung such as an old tuberculous Allergic bronchopulmonary aspergillosis cavity (sometimes called a mycetoma). Seen on X-ray as a round lesion with an air halo above i Initially it causes bronchospasm which commonly it. In immunosuppressed individuals with a low granulo- iii Chronic infection and inammation leads to irre- cyte count, the organism may proliferate causing a severe versible dilatation of the bronchi (classically proximal pneumonia, causing necrosis and infarction of the lung. The organisms are present as masses of hyphae invad- iv If left untreated progressive pulmonary brosis may ing lung tissue and often involving vessel walls. Investigation Theperipheralbloodeosinophilcountisraised,andspu- Management tum may show eosinophilia and mycelia. Eosinophilic Invasive aspergillosis is treated with intravenous am- pneumonia causes transient lung shadows on chest X- photericin B (often requiring liposomal preparations ray. Itraconazole and voriconazole have been used more re- Lung function testing conrms reversible obstruction in cently but current studies comparing efcacy with am- all cases, and may show reduced lung volumes in cases photericin B have yet to prove denitive. Management Obstructive lung disorders Generally it is not possible to eradicate the fungus. Itra- conazole has been shown to modify the immunologic Asthma activation and improves clinical outcome, at least over the period of 16 weeks. Oral corticosteroids are used to Denition suppress inammation until clinically and radiograph- A disease with airways obstruction (which is reversible ically returned to normal. Maintenance steroid therapy spontaneously or with treatment), airway inammation may be required subsequently. The asthmatic compo- and increased airway responsiveness to a number of nent is treated as per asthma guidelines. With time this repeated stimula- Can present at any age, predominantly in children. They secrete mediators of acute and 2 Intrinsic asthma tends to present later in life.
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