Vocal cord dysfunction in a child

Vocal cord dysfunction (VCD) involves paradoxical adduction of the vocal cord during the respiratory cycle. This usually occurs during inspiration, but can also be seen in expiration. Vocal cord appositioning produces airflow obstruction sufficient to cause wheezing, shortness of breath, chest tightness, and coughing. These symptoms often imitate the respiratory alterations of asthma, thus leading to inappropriate treatment; intubation or tracheotomy may prove necessary. An 11-year-old girl was admitted with intractable dyspnea. She had been diagnosed with atopic asthma, although she failed to respond to an increase in antiasthma medication, including high-dose oral steroids. Flow-volume loops were abnormal, with evidence of variable extrathoracic airway obstruction, manifested as a flat inspiratory loop. No structural abnormalities were seen with either computed tomography (CT) or magnetic resonance imaging (MRI). Fibroscopy revealed paradoxical adduction of the vocal cords during the respiratory cycle, no obstructive disorder being observed. After the diagnosis of VCD, the clinical manifestations resolved with psychiatric treatment. Adduction was not demonstrable at repeat fibroscopy after treatment. VCD may simulate bronchial asthma; it may also be associated with that disorder, thus masking the diagnosis. It should be suspected in patients with recurrent wheezing who fail to respond to usual asthma treatment. An early diagnosis avoids unnecessary aggressive management. Treatment should consist of respiratory and phonatory exercises; psychotherapy may be useful.     

Plasma immunoreactive leukotriene C4 levels in patients with Kawasaki disease

The incidence of wheezing in Kawasaki disease (KD) has been investigated retrospectively. We measured plasma immunoreactive-leukotriene C4 (i-LTC4) levels of patients with KD. Wheezing was observed in 32 (12.5%) of the 256 patients with KD. Patients who had a prior history of bronchial asthma wheezed more frequently than other patients. During the acute stage of KD, plasma i-LTC4 levels both of wheezing and nonwheezing were significantly higher than those of healthy children. During the convalescent stage, plasma i-LTC4 levels of wheezing cases were higher than those of nonwheezing cases. We speculate that LTC4 contributes to the appearance of inflammatory symptoms during the acute stage of KD. During the convalescent stage when patients were taking aspirin, the presence of wheezing was associated with increased plasma levels of i-LTC4. More attention should be paid to the appearance of wheezing during the course of KD, especially in those cases in which the patient has a prior history of bronchial asthma.     

Clinical evaluation of eosinophils in the sputum.

The sputum differential eosinophil/neutrophil count was done in 384 patients using Leishman staining. The patients were distributed in four groups: bronchial asthma (197 patients); chronic bronchitis with wheezing (45 patients); chronic bronchitis and/or emphysema without wheezing (73 patients); other pulmonary diseases (64 patients). Eosinophils were present in patients from all groups but more frequently (P less than 0.001) in asthma: 142 (72%) of 197 patients. In bronchial asthma and chronic bronchitis with wheezing the percentages of eosinophils were more frequently (P less than 0.001) above 80%: 57% and 58% of the patients respectively. The other two groups had more cases with 19% or less eosinophils. There is no percentage level specific for asthma but levels above 80% of eosinophils are strongly suggestive of asthma or of chronic bronchitis with wheezing.     

Prevalence of asthmatic phenotypes and bronchial hyperresponsiveness in Turkish schoolchildren: an International Study of Asthma and Allergies in Childhood (ISAAC) phase 2 study.

BACKGROUND: Numerous epidemiologic studies have revealed that bronchial asthma affects populations without regard to frontiers. However, standardized methodological approaches are necessary to compare these populations. OBJECTIVE: To investigate objective markers of childhood asthma on an epidemiologic basis and to include Turkish children in international comparisons. METHODS: Parental questionnaires were collected and skin prick tests performed on fourth grade primary schoolchildren, aged 8 to 11 years, residing in Ankara, Turkey. Pulmonary function tests and bronchial challenge with hypertonic saline (HS) were conducted in children selected from this cohort with a stratified random sampling according to the presence of current wheezing. RESULTS: A total of 3,041 questionnaires were included in the evaluation. Skin prick tests were performed on 2,774 children (97.1%). A total of 347 children from this cohort underwent pulmonary function and bronchial challenge tests. In 18 (5.1%) of the 347 children, bronchial challenge tests could not be successfully completed. The prevalence values were 11.5% for current wheezing, 6.9% for physician-diagnosed asthma, and 7.7% for physician-diagnosed recurrent bronchitis. Population-based weighted prevalence of bronchial hyperresponsiveness (BHR) was 21.8%. Frequency of responses to HS was 38.6% among physician-diagnosed asthma cases and 30.5% among patients with current wheezing. Skin test positivity was present in 38.7% of the children with a diagnosis of asthma or asthmatic bronchitis, 35.0% of current asthmatic patients, and 19.2% of patients with current wheezing. CONCLUSIONS: Objective markers, in addition to the questionnaire-based prevalence figures, need to be used in epidemiologic surveys for asthma, especially in countries with inadequate health care facilities or problems with interpretation of the wheeze concept.     

Chronic cough, sinusitis, and hyperreactive airways in children: an often overlooked association

Ten patients, aged 7 to 16 years, were prospectively evaluated for chronic cough of more than 4 months duration. All patients denied wheezing, but in addition to cough complained of chronic obstructive nasal symptoms. Sinus roentgenograms were consistent with sinusitis in 7/10 patients. Methacholine bronchial provocation was positive in 6/9 patients. The patients were recalled for a 2-year follow-up evaluation. Of seven follow-up patients, bronchial asthma had developed in three, two patients had chronic cough and exercise-induced bronchospasm, and two patients had chronic cough without wheezing. Methacholine bronchial provocation was positive in 6/6 patients. Sinus roentgenograms were compatible with sinusitis in 4/7 patients. Chronic cough in some children may be a complaint of diffuse hyperreactive airways complicated by sinusitis. In some of the children the clinical course evolved into a diffuse respiratory tract disorder including chronic obstructive eosinophilic rhinitis, recurrent or chronic sinusitis and bronchial asthma. An IgE-mediated mechanism usually could not be shown in the pathogenesis.     

Asthma and Allergy in Finnish Conscripts

We studied the occurrence of asthma, bronchial wheezing, allergic rhinitis and atopic dermatitis in 295 young men aged 18–19 years. The relationship of these symptoms to the immediate skin test reactivity was also determined. Symptoms indicating past or current allergy' and bronchial wheezing were observed in 36%. The cumulative prevalence of asthma was 2.7% bronchial wheezing 9% in addition, allergic rhinitis including allergic conjunctivitis; 20% and atopic dermatitis (including allergic urticaria) 20%. Positive immediate skin prick test reactions were observed in 50% of the population. Allergic rhinitis was most clearly connected with a positive skin test. This study shows that the respiratory disorders, generally considered to be allergic in origin, and atopic dermatitis are more common in Finland than has been assumed. The results are however, in accordance with the observations made in other industrialized countries.
Susceptibility to asthmatic reactions and allergic symptoms should be taken into account, more so than at present, when judging the capability of a young man to manage compulsory military service.     

Maximal expiratory flow-volume patterns in airway allergy

We considered upper and lower airway allergies as different phases of airway allergy and MEFV patterns to vary according to the intensity of airway obstruction in maximal expiratory flow-volume and volume-time tests on fourteen patients with nasal allergy, two with allergic bronchitis, two with bronchial asthma, and sixteen nonsmoking healthy subjects. In nasal allergy, flow changes during high lung volumes were different from those in allergic bronchitis and bronchial asthma, and MEFV patterns in nasal allergy were more widely varied than those in allergic bronchitis and bronchial asthma. We classified MEFV patterns into five ones.     

支气管哮喘与Th1/Th2/Th17的相关性分析

支气管哮喘是一种涉及多种临床症状,例如咳嗽、气喘、呼吸困难等常见的呼吸系统疾病,其发病率之高严重威胁着人类的健康.哮喘的发病与遗传和环境都有着密切的联系,因其发病机制十分复杂至今尚未明了.众多的细胞及其细胞因子均参与了哮喘的发病过程,其中辅助性T细胞(Thelper,Th)及其亚群(Th1、Th2和Th17)已被证实与支气管哮喘的发生有着十分密切的关系.     

The efficacy of intravenous theophylline injection for treatment of acute exacerbations of bronchial asthma]

The efficacy of the intravenous injection of aminophylline for treatment of acute exacerbations of bronchial asthma has been recognized since 60 years ago by many reports. It has been published on the "Asthma Prevention and Management Guidelines 1998, Japan" as one of important treatment for acute exacerbations of bronchial asthma. An intravenously Administered Theophylline (IAT) was newly developed in Japan in 2000. Different from aminophylline, the theophylline is not combined with ethylenediamine. We investigated efficacy and safety of IAT. In the present study, subjects were 16 asthmatic patients with mild acute exacerbations of bronchial asthma. They were administered IAT (200 mg theophylline with 200 ml saline) intravenously for two hours. After administration of the IAT, PEF and FEV1 were increased significantly. And severity of asthma, Borg scale, wheezing and breath sound were improved significantly. It should be emphasized that none of the patients treated in this study had any adverse symptom. The present study suggested that IAT is useful for patients with acute exacerbations of bronchial asthma.     

Atopic march: link to upper airways

PURPOSE OF REVIEW: This review examines the role of the upper airways in the atopic march. Evidence examining the theory that allergic rhinitis precedes asthma will be discussed. In addition, the role of allergic rhinitis as an end point in the atopic march will be reviewed. RECENT FINDINGS: Ciprandi and colleagues found that nasal symptoms, airflow and markers of inflammation (eosinophils, cytokine levels) directly correlated with lower airway markers. This confirms previous studies finding that many patients with allergic rhinitis have lower airway hyperreactivity or bronchial hyperresponsiveness and the link between upper and lower airways. Leynaert and colleagues questioned over 90 000 individuals and found that patients with rhinitis have increased risk for asthma and lower airway reactivity compared with patients without rhinitis. In the German Multicenter Atopy Study, a longitudinal study of 1300 children, patients with atopic dermatitis were found to have increased risk for asthma at 7 years of age. Patients with atopic dermatitis and no wheezing in the first 3 years, however, did not have an increased risk for developing current wheezing or bronchial hyperresponsiveness at 7 years of age. It was proposed that atopic dermatitis and asthma are linked, but atopic dermatitis does not precede asthma. SUMMARY: Allergic rhinitis is a risk factor for asthma and can precede asthma in the atopic march.     

Sinus computed tomography scan and markers of inflammation in vocal cord dysfunction and asthma.

BACKGROUND: The inappropriate closure of the vocal cords is characteristic of vocal cord dysfunction (VCD). These patients present with wheezing and frequently receive a misdiagnosis of asthma. OBJECTIVE: To demonstrate the ability of computed tomography (CT) scored for the presence and extent of sinus disease and markers of inflammation to distinguish patients with VCD from patients with asthma. METHODS: Comparisons of 13 patients with VCD were made to 77 patients presenting to the emergency room with acute asthma, 31 non-acute asthmatic patients, and 65 nonasthmatic controls. Evaluation consisted of exhaled nitric oxide gas (eNO), circulating eosinophils, and total serum immunoglobulin (Ig)E, as well as the sinus CT scan. RESULTS: Extensive sinus CT changes were present in 23 of 74 acute asthmatic patients, 5 of 29 non-acute asthmatic patients, and 2 of 59 nonasthmatic controls. In addition, absolute eosinophil counts, eNO, and total IgE were significantly elevated among the asthmatic patients. Sinus symptoms reported by questionnaire did not predict sinus CT findings. Among the patients with VCD, none had extensive sinus disease. They also had normal eNO, low IgE, and normal eosinophil count. Five of the patients presenting to the emergency room who were identified as acute asthmatic were identified with VCD by laryngoscopy and were all characterized by the absence of significant inflammation on their sinus CT scan, low IgE, and normal eosinophil count. CONCLUSIONS: Among patients presenting with intermittent or reversible airway obstruction, patients with VCD can be distinguished from asthma by minimum or absence of inflammation in their sinuses as shown by CT scan. Clinical symptom scores are not predictive of presence or extent of sinus disease in most cases.     

Cough variant asthma is associated with a higher wheezing threshold than classic asthma

Cough variant asthma is an occult form of asthma in which the only sign or symptom is chronic cough. It is a common problem amongst all ages that frequently goes unrecognized, leading to under diagnosis and under treatment. To characterize the pathophysiological abnormalities in these patients, we performed bronchial provocation tests with methacholine using the stepwise doubling concentration technique, and measured the concentration of methacholine and the severity of airway obstruction when wheezing was first detected. Airway hyper responsiveness, defined as PC20 in the cough variant asthma group was not significantly different from that of classic asthma. There was a good correlation between the PCW (the concentration of methacholine causing wheezing) and the PC20 with the PCW values higher than PC20 values in both groups. However, in the cough variant asthma group, the PCW: PC20 ratio was greater than that of the classic asthma group. Furthermore, the mean % fall in FEV₁ at which wheezing was first detected in the former group was significantly larger than that of the latter group. The results indicated that the mechanism for the manifestation of cough without wheeze in the cough variant asthma may be a higher wheezing threshold, i.e. wheezing becomes audible at the greater degree of airway obstruction than classic asthma. They suggested that patients with cough variant asthma may represent a subset of asthmatic subjects whose airways are less able to produce a wheeze.     

Vocal cord dysfunction treated with long-term tracheostomy: 2 case studies.

BACKGROUND: Vocal cord dysfunction (VCD) is an increasingly recognized condition that affects the upper airway, which can be difficult to discriminate from asthma. Speech therapy and psychological cognitive therapy are the mainstays of treatment, but other modalities have been used when response is unsatisfactory. OBJECTIVE: To present 2 case studies in which VCD has been treated with long-term tracheostomy. METHODS: In the first patient, VCD was diagnosed by nasoendoscopic demonstration of paradoxical movement of the vocal cords. The patient was transferred to a regional unit, where nasoendoscopy was performed, which revealed immobile and adducted vocal cords. The decision to perform emergency surgical tracheostomy was made. In the second patient, a possible additional diagnosis of VCD was suggested during a hospital stay, and nasoendoscopy was performed. RESULTS: Both patients report considerable subjective benefits. Objective improvement was seen in only one patient. CONCLUSIONS: Tracheostomy is an invasive procedure that carries risk of potential morbidity and should only be considered as a final option in carefully selected cases.     

Paradoxical vocal cord adduction mimicking as acute asthma in a pediatric patient

We report an adolescent girl with paradoxical vocal cord adduction who presented with acute onset of hyperventilation, wheezing and stridor that did not respond to bronchodilator and anti-inflammation therapy. The paradoxical vocal cord motion was confirmed by flexible fiberoptic bronchoscopic examination. We found the stridor was induced by hyperventilation, and was caused by paradoxical vocal cord movement. The abnormal cord motion may be psychogenic and could be misdiagnosed as asthma. It is important to investigate the underlying background and social history and to avoid unnecessary use of beta-agonists, steroids, and even endotracheal intubation or tracheostomy.     

The Bronchial Challenge Test: A New Direction in Asthmatic Management

Bronchial asthma can be diagnosed when a patient develops the clinical manifestations of bronchial reactivity: wheezing, cough, tachypnea, and dyspnea. Occasionally, despite immunotherapy, bronchodilator therapy, and avoidance of the provocative factors, some asthmatic patients do not respond to treatment. Bronchial inhalation challenge, a method to test airway reactivity after inhalation of a nonspecific drug, can be used to plan and assess different modes of treatment, as well as screen for bronchial hyperreactivity in an occupational setting.     

Prevalence of wheeze, bronchial hyper-responsiveness and asthma in the elderly Chinese

BACKGROUND: Asthma is a common health problem affecting patients of all ages. Because of the ease of sampling, epidemiological studies have concentrated mainly on the paediatric and general population. OBJECTIVE: This study aimed to determine the prevalence of wheeze, bronchial hyper-responsiveness and asthma amongst our elderly population and deduce any clinical and laboratory risk factors that might identify elderly asthmatics at an earlier stage. METHODS: Two thousand and thirty-two elderly Chinese aged > or = 70 years, randomly selected from a registered list of all recipients of Old Age and Disability Allowances in Hong Kong, were administered a questionnaire on lung health. Two hundred and fifty subjects were invited to attend our laboratory for skin tests and pulmonary function tests and 179 agreed. Of these, 173 (96.6%) and 176 (98.3%) had eosinophil count and serum IgE levels measured, respectively. Two definitions of asthma were used: (1) bronchial hyper-responsiveness (BHR) plus current wheeze, and (2) history of wheezing without previous diagnostic labels of emphysema or chronic bronchitis. RESULTS: Fifteen patients (out of 179: 8.4%) reported wheezing over the past 1 year. Fifty-one patients (28.5%) demonstrated BHR on spirometry or histamine challenge tests. Seven patients had both symptoms of wheezing and evidence of BHR. The prevalence of asthma using this definition is therefore 3.9% (95% CI 1.6-7.9%). Nine patients had symptoms of wheezing without previous diagnostic labels of chronic bronchitis or emphysema and, using this definition, the prevalence is 5.0% (95% CI 2.3-9.3%). Using multiple logistic regression studies, sex, social class, age, smoking habits, serum IgE levels and eosinophil counts did not predict a diagnosis of asthma using either definition. We found no association between a positive skin test and any respiratory symptoms or illnesses including asthma. CONCLUSION: Wheeze, bronchial hyper-responsiveness and asthma are prevalent amongst our elderly population. However, there were no identifiable demographic and laboratory risk factors in this study that may help us predict a diagnosis of asthma.     

Measurement of serum eosinophil cationic protein levels in wheezing infants]

Many infants have episode of wheezing. Some infants will outgrow the condition in early childhood, but some of them will become asthmatic. However, it is difficult to predict whether the wheezing infant is subsequently likely to experience bronchial asthma. To determine whether eosinophil inflammation is present in wheezing infants and can predict the development of asthma, serum eosinophil cationic protein (ECP) levels were measured in 33 infants who could not be diagnosed typical asthma, and 11 controls. Serum ECP levels were higher in the infants who had asthma within 3 months follow-up period. In addition, all 17 infants with serum ECP levels above 20 ng/ml developed asthma within 3 months. The data suggested that serum ECP measurements appear to be useful for identifying infants with wheezing at high risk for infantile asthma.     

Bronchial asthma due to inhaled wood dust: Tanganyika aningré

Three cases of bronchial asthma due to wood dust from Tanganyika anigré are reported. All patients were woodworkers and had symptoms of dyspnoea, cough and wheezing, and sometimes itchiness and rhinorrhoea, after exposure to Tanganyika aningré. The intradermal skin tests were positive for untigenic extract of Tanganyika aningré. In two patients the bronchial provocation test with the wood dust and with the soluble extract inhaled by aerosol was positive showing an immediate reaction; in the same patients bronchial hyperreactivity was also found. Atopy was present in one subject. No precipitins or specific IgE were found in patient sera by the immunodiffusion technique or by RAST.     

Airway responses to antigen challenge in allergic rhinitis and allergic asthma

The density dependence of the maximum expiratory flow-volume curve, functional residual capacity (FRC), and specific airway conductance (SGaw) were determined before and during bronchial provocation with ragweed extract in 27 subjects with ragweed hypersensitivity and a history of either bronchial asthma (16 subjects) or allergic rhinitis (11 subjects). Mean baseline SGaw was significantly lower while mean volume of isoflow (Visov) and FrC were significantly higher in subjects with bronchial asthma. During antigen challenge, 10 of 16 subjects with bronchial asthma (63%) and five of 11 subjects with allergic rhinitis (45%) showed a greater than 35% decrease in SGaw ("reactors"): mean relative decreases in SGaw from baseline were 46% and 53%, respectively. The remaining subjects showed a less than 35% decrease in SGaw ("nonreactors") with mean relative decreases of 9% (allergic asthma) and 6% (allergic rhinitis). Mean Visov increased in all subjects with bronchial asthma and in eight of 11 subjects with allergic rhinitis. A significant increase in FRC (6%) was seen only in the "reactors" with bronchial asthma. Following antigen challenge, the beta adrenergic agonist, isoetharine, increased SGaw and decreased Visov. We conclude that in asymptomatic subjects with ragweed hypersensitivity, (1) central and peripheral airway function is more abnormal in subjects with bronchial asthma than in subjects with allergic rhinitis, (2) subjects of both groups show quantitatively and qualitatively comparable airway responses during antigen challenge with a decrease in SGaw or an increase in Visov, possibly representing increase in central and/or peripheral airflow resistance, respectively, (3) Visov may be a more sensitive indicator of airway response to antigen challenge than SGaw, and (4) the bronchodilator effects of a beta adrenergic agonist on antigen-induced bronchospasm are similar in both groups.     

儿童血清特异性IgE水平与哮喘临床及气道反应性之间的关系

目的:为了探讨儿童血清特异性免疫球蛋白(SIgE)同哮喘临床(喘息、咳嗽)及气道反应性(BHR)的关系方法:对4000例学龄儿童(10—11岁)作哮喘调查,并随机抽查了其中64例有哮喘症状者(Ⅰ组)和60例无症状者(Ⅱ组)用荧光酶联免疫法测定其血清SIgE,和采用乙酰甲胆碱激发试验测定BHR结果:SIgE的阳性率在Ⅰ组58例(90.6%),在Ⅱ组17例(28.3%).而其中气道高反应(BHR)58例中SIgE的阳性56例(96.6%),正常BHR66例SIgE的阳性19例(28.8%).Ⅰ组中且具备BHR者,SIgE的阳性率呈现100%.3者分别作卡方检验p<0.001.说明儿童血清SIgE与哮喘临床症状及气道反应性有显著相关.结论:Ⅰ.吸入性变应原与儿童哮喘及气道高反应性具有密切相关.2.SIgE检测可作为哮喘诊断的重要参考指标,尤适用于不能完成气道激发试验的幼儿.