Bronchial asthma / Pulmonary oedema
(cardiac asthma)
  1. Usually long duration of recurrent episodes of cough, wheeze and breathlessness
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  1. Relatively short duration, recurrent episodes are not as common as in asthma

  1. History to suggest hyperirritable airways present
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  1. No such history except when both diseases co-exist

  1. Acute breathlessness is often precipitated by respiratory infection, exposure to cold, dust, pollen, emotional upset, or exertion
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  1. Can be precipitated by emotional upset or exertion. Often preceding chest pain (IHD-LVF) and palpitation present (e.g. IHD-LVF and MS with pulmonary oedema)

  1. Past history of bronchial asthma
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  1. Past history of angina, infarction, hypertension, rheumatic heart disease, other cardiac problems

  1. Blood pressure: Usually normal (but reactive hypertension can OCcur. Can be differentiated by absence of end organ damage and return to normal BP when asthma is controlled)
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  1. High BP or hypotension favours diagnosis of pulmonary oedema

  1. Usually tachycardia only. No arrhythmia
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  1. Arrhythmias like AF, ventricular ectopics, complete heart block, and ventricular tachycardia favours pulmonary oedema

  1. Normal JVP
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  1. Elevated JVP if present favours diagnosis

  1. No cardiomegaly, heart sounds normal. Sometimes difficult to make out heart Sounds due to the rhonchi
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  1. Cardiomegaly, presence of S3 or murmurs and muffled heart sounds favour pulmonary oedema

  1. Rhonchi only or Rhonchi more than crepitations. Rhonchi are uniformly heard all over the chest
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  1. Crepitation more than rhonchi. Crepitations more at the base (Ronchi alone can occur sometimes in early pulmonary oedema)

  1. . ECG - Normal, unless there is coexisting IHD
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  1. ECG - Evidence of IHD, LVH or left atrial enlargement favour cardiac asthma

Note: In patients with acute breathlessness, when there is difficulty in differentiating between bronchial asthma and acute pulmonary oedema III when both co-exist the following guidelines will help. This problem is vory common in elderly individuals with acute breathlessness. Late onset asthma is common in the elderly and lacks typical features like atopic tendency

GIVE drugs useful in both, e.g.: Aminophyllin and Oxygen

Use drugs, which are indicated in one condition but not contraindicated in the other like - isosorbide dinitrate, frusemide, steroid, digoxin and dextrose when indicated

AVOID drugs contraindicated in pulmonary oedema and Bronchial asthma (e.g.: avoid Adrenaline, Salbutamol, Terbutaline, and Normal saline which are contraindicated in pulmonary oedema and .avoid Morphine which is contraindicated in asthma)