CASE DISCUSSIONRIVERA, JOANNA GRACE

ASMPH BATCH 2013

At the end of this case presentation, we should be able to do the following: Discuss the case of bronchial asthma Understand the pathophysiology of

bronchial asthma Know the basic management and

prevention of bronchial asthma

OBJECTIVES

EPYN Female 3 years old Filipino Roman Catholic Mandaluyong City Informant: Father Reliability: 80%

GENERAL INFORMATION

CHIEF COMPLAINT

Difficulty of Breathing(two days duration)

Two days PTA

HISTORY OF PRESENT ILLNESS

• Nonproductive cough• Difficulty of breathing• (-) colds and fever• Nebulized with

salbutamol with improvement of DOB

Few hours PTA

HISTORY OF PRESENT ILLNESS

DAY OF ADMISSION

• Worsening of cough and DOB

• Unrelieved by salbutamol nebulization

• No other associated symptoms

REVIEW OF SYSTEMS

• General: (-) changes in weight, (-) sweats, (-) weakness, (-) fatigue

• Skin: (-) itchiness, (-) color changes, (-) pigmentation, (-) rashes, (-) photosensitivity, changes in hairs and nails

• Eye: (-) blurring of vision, (-) redness, (-) itchiness, (-) pain, (-) increased lacrimation

REVIEW OF SYSTEMS

• Ear: (-) deafness, tinnitus, discharge• Nose: (-) epistaxis, (-) nasal discharge, obstruction,

(-) postnasal drip• Mouth and throat: (-) bleeding gums, sores,

fissures, tongue abnormalities, dental caries, (-)sore throat, lump sensation• Pulmonary: (-) hemoptysis

Review of Systems

• Cardiac: (-) easy fatigability, orthopnea, nocturnal dyspnea, syncope, edema

• GI: (-) retching, hematemesis, melena, hematochezia, dysphagia, belching, indigestion, food intolerance, flatulence, (-)abdominal pain, (-) diarrhea, (-) vomiting, constipation, anal lesion

Review of Systems

• GU: (-) urinary frequency, urgency, hesitancy, nocturia

• Musculoskeletal: (-) joint stiffness, pain, swelling, cramps, muscle pain, weakness, wasting

• Endocrine: (-) heat-cold intolerance, polyuria, polydipsia

Review of Systems

• Hematopoietic: (-) abnormal bleeding, (-) bruising• Neurologic: (-) headache, seizure, mental status

changes, head trauma

PAST MEDICAL HISTORY

• Asthma – Nov 2010• Reliever medications: Salbutamol

and Prednisone• Last attack: January 2012 • Denies nocturnal awakenings• (+) occasional shortness of breath

after heavy exercises or activities• Allergic to Peanuts• No known allergies to medications

BIRTH AND MATERNAL HISTORY

Born full term via CS to a 38 year old G2P2 in Makati Medical Center attended by an Ob-Gyne

BW: 3 kg Cord-coil

IMMUNIZATION HISTORY

BCG (1 dose) DPT/IPV (3 doses) Hepa B (3 doses) Measles (1) Rotavirus (2)

NUTRITIONAL HISTORY

• Breastfed until 2 months• Formula fed with Nestogen (3

ounces/bottle)• Weaning age: 6 months (Cerelac); 9

months (rice)

NUTRITIONAL HISTORY

• 24 hour food recall• Breakfast: ½ cup of rice +

tocino/hotdog/sausage/bacon/egg• Lunch: ½ cup of rice + sausage/fried

chicken• Snacks: 1 pack of biscuit• Dinner: ½ cup of rice +

tocino/sausage/chicken• Loves eating chocolates, candies and junk

foods

Developmental HistoryGROSS MOTOR

6 months: sits with support10 months: stands with support1o months: walks with support15 months: walks well alone2 years: runs well, can climb up and down stairs, jumps3 : throws balls, downstairs on one foot per step, hops on one foot

FINE MOTOR9 months: holds bottle1 year and 3 months: can drink from cup2 years old: can imitate a circle; 3 years old: imitates cross

LANGUAGE9 months: can speak mama and papa1 and ½ year: can indicate needs; can speak three-word sentences2 years old: can point to parts of the body and can follow directions; names on pictures3 years old: tells little stories about experiences, gives full name and sex; recognizes 3 or more colors, counts to ten

SOCIAL2 years: can remove garment; toilet trained; uses spoon3 years: dry by night; play interactive games; dresses with supervision; tells tail tales

FAMILY HISTORY

• Asthma (Maternal grandmother and cousins)• Hypertension and Diabetes (paternal)• (-) Allergies

GENOGRAM

40 41

18 3

Casino dealer Call center agent

PERSONAL-SOCIAL HISTORY

Lives in a two bedroom condominium with 6 household members

With good ventilation Water source: Mineral water Garbage collected twice a week House is not near factories or highway No pets at home Parents and sibling are smokers

Physical Examination

PHYSICAL EXAMINATION

GENERAL APPEARANCEAlert, quiet, weak-looking, in respiratory distress

VITAL SIGNSBP: 100/70 RR: 40 O2 Sat (room air): 89% HR: 110 Temp: 37º C

ANTHROPOMETRICS:Height: 106 cm (2 to 3) Weight: 22.6kg (3) BMI: 20.11 (3)

PHYSICAL EXAMINATION

SKINwarm skin, good skin color and turgor

HEENTno lesions or matting of the eyelids, no eye discharge, no swellling, anicteric sclerae, pink palpebral conjunctiva, No tragal tenderness, no ear discharge, intact TM

PHYSICAL EXAMINATION

HEENTNo alar flaring, nasal septum midline, with minimal nasal dischargedry lips, moist tongue, no circumoral cyanosis, no buccal mucosal lesions, no TPCno masses in the neck, (-) CLAD, flat neck veins

PHYSICAL EXAMINATION

RESPIRATORYcan talk in sentences, (+) subcostal retractions, symmetric chest expansion, wheezes on both lung fields, no crackles or rhonchi

HEARTadynamic precordium, no thrills, heaves or lifts, PMI at 5th ICS, MCL, normal rate, regular rhythm, distinct S1 and S2 sounds, no murmurs

PHYSICAL EXAMINATION

ABDOMENFlabby abdomen, normoactive bowel sounds, soft, no organomegaly, no tenderness

EXTREMITIESfull and equal pulses, no edema, no cyanosis, no atrophy/hypertrophy, no deformities

NEUROLOGIC EXAMINATIONIntact cranial nerves, no sensory and motor deficits, normoreflexive, (-) Babinski, (-) clonus

SALIENT FEATURES

SUBJECTIVE OBJECTIVE

3/F Asthmatic Difficulty of breathing Cough Audible wheeze Relieved by

Salbutamol nebulization initially unresponsive

Respiratory distress Tachypnea Desaturation

(87%) Retractions

Wheeze Normal cardiac

findings

PRIMARY WORKING IMPRESSION

BRONCHIAL ASTHMA IN ACUTE

EXACERBATION

Differential Diagnosis

• Bronchiolitis• Pneumonia• Upper Respiratory Tract Infection

Course in the wards

O2 supplementation via face mask at 6 LPM

Salbutamol 1 nebule x 3 doses 20 minute interval

On admission: Salbutamol 1 nebule every 6 hours Salbutamol + Ipatropium (Combivent) 1

nebule every 6 hours Prednisone 20 mg/5 ml 3 ml every 12

hours

Emergency Treatment

Day 1Subjective Objective

(+) cough(+) audible wheeze(-) difficulty of breathing(-) fever(+) Good activity and good

appetite

• awake, alert, cooperative, not in respiratory distress

• Normal vital signs• (-) alar flaring, (-)

cyanosis of buccal mucosa

• (-) retractions, symmetric chest expansion, (+) wheeze

• Normal rate, regular rhythm, (-) murmurs

• full and equal pulses, (-) cyanosis

Day 1Assessment Plan

Bronchial Asthma in Acute Exacerbation, resolving

• Revise nebulization toSalbutamol + Ipatropium every 8 hoursSalbutamol every 8 hours

• Shift to IV Hydrocortisone 100 mg/IV every 6 hours

Day 2Subjective Objective

(+) occassional cough(-) audible wheeze(-) difficulty of breathing(-) fever(+) Good activity and good

appetite

• awake, alert, cooperative, not in respiratory distress

• Normal vital signs• (-) alar flaring, (-)

cyanosis of buccal mucosa

• (-) retractions, symmetric chest expansion, clear breath sounds

• Normal rate, regular rhythm, (-) murmurs

• full and equal pulses, (-) cyanosis

Day 1Assessment Plan

Bronchial Asthma in Acute Exacerbation, resolving

• Revise nebulization toSalbutamol every 6 hours

• Start Prednisone 10 mg/5 mL, 7.5 mL twice a day

• May go home

DISCUSSION

Bronchial Asthma

• Chronic inflammatory condition of the lung airways resulting in episodic airflow obstructiono Airway hyperresponsiveness

Excessive Contraction of the

smooth muscleUncoupling

Thickening of the airway wall

Sensitized sensory nerves

INFLAMMATORY CELLS

Mast cellsEosinophils

T-lymphocytesDendritic CellsMacrophagesNeutrophils

INFLAMMATORY CELLS

Airway epithelial cells

Airway smooth muscle cells

Endothelial cellsFibroblasts

MyofibroblastsAirway nerves

INFLAMMATORY MEDIATORS

ChemokinesCysteinyl

LeukotrienesCytokinesHistamine

Nitric oxideProstaglandin D2

Smooth muscle contraction

EdemaAirway

thickeningMucus

hypersecretion

BLOOD VESSEL WALL

PROLIFERATION

SMOOTH MUSCLE INCREASE

MUCUS HYPERSECRETIO

N

Clinical Signs and Symptoms

WheezingCough

BreathlessnessNocturnal symptoms/awakenings

Diagnostic Examinations

SPIROMETRY Airflow Limitation

Low FEV1 (relative to percentage of predictive norms)

FEV1 /FVC ratio <0.80 Bronchodilator response

Improvement in FEV1 ≥12% and ≥200 mL Exercise challenge

W0rsening in FEV1 ≥15% Peak Expiratory flow monitoring

Day to day and/or AM-to-PM variation ≥20%

Therapeutic Trial Short-acting bronchodilators and

inhaled glucocorticosteroids (at least 8-12 weeks)

Test for Atopy Immediate hypersensitivity Skin testing Antigen-specific IgE antibody

Chest Radiograph Hyperinflation and peribronchial

thickening

Diagnostic Examinations

1. Regular Assessment and monitoring2. Patient Education3. Control of Factors Contributing to Asthma

Severity4. Principles of Asthma Pharmacotherapy

Treatment and Management

Regular Assessment and Monitoring

Component 1

Levels of Asthma Control for Children

CHARACTERISTICCONTROLLED

(All of the following)

PARTLY CONTROLLED(Any measure present in any

week)

UNCONTROLLED(3 or more of

features of partly controlled asthma

in any week)

Daytime symptoms None More than twice/week

More than twice/week

Limitation of activities None Any Any

Nocturnal symptoms/awakenings

None Any Any

Need for reliever/rescue

treatment≤2 days/week >2 days/week >2 days/week

Patient Education

Component 2

Control of Factors Contributing to Asthma Severity

Component 3

Eliminating and reducing problematic environmental exposures Annual influenza vaccination

Treat co-morbid conditions Gastroesophageal Reflux Rhinitis Sinusitis

Principles of Asthma Pharmacotherapy

Component 4

CONTROLLER OPTIONSContinue as needed rapid-acting beta-2

agonists

Low-dose inhaled glucocorticosteroids

Double low-dose inhaled

glucocorticosteroidsLeukotriene modifier Low-dose inhaled

glucocorticosteroid plus leukotriene

modifier

Asthma educationEnvironmental control

As needed rapid-acting beta-2 agonists

Controlled on as needed rapid-acting

beta-2 agonists

Partly controlled on as needed rapid-acting

beta-2 agonists

Uncontrolled or early partly controlled on

low-dose inhaled glucocorticosteoid

Reliever Medications

Short-acting inhaled beta-agonists Bronchodilation through inducing airway

smooth muscle relaxation reduced vascular permeability and airways edema and improvement of mucociliary clearance

Levobuterol: less tachycardia and tremor Anticholinergic

Ipatropium bromide: prevent cholinergic nerve-induced bronchoconstriction and mucus secretion

Inhaled glucocorticosteroids Leukotriene modifiers Theophylline Long-acting beta-2 agonists Cromolyn and nedocromil sodium

Controller Medications

Leukotriene Modifier Cysteinyl-leukotrienes: potent

bronchoconstrictors cause microvascular leakage, and increase

eosinophilic inflammation Antileukotrienes (montelukast and zafirlukast)

block cys-LT1-receptors and provide modest clinical benefit in asthma

Controller medications

Theophylline a phosphodiesterase inhibitor can reduce asthma symptoms and the need

for rescue SABA use narrow therapeutic window

headaches, vomiting, cardiac arrhythmias, seizures, and death.

Controller medications

Long-acting beta-2 agonists Salmeterol: maximal bronchodilation about 1 hr

after administration Formoterol: onset of action within 5–10 min. for individuals who require frequent SABA use

during the day to prevent exercise-induced bronchospasm

an “add-on” agent in patients who are suboptimally controlled on ICS therapy alone

Controller medications

Cromolyn and Nedocromil sodium non-corticosteroid anti-inflammatory agents that

can inhibit allergen-induced asthmatic responses and reduce exercise-induced bronchospasm.

inhibit exercise-induced bronchospasm, they can be used in place of SABAs, especially in children who develop unwanted adverse effects with β-agonist therapy (tremor and elevated heart rate).

Controller medications

Management of Acute Asthma Exacerbation

An increase in wheeze and shortness of breath

An increase in coughing (especially nocturnal cough)

Lethargy or reduced exercise tolerance Impairment of daily activities, including

feeding A poor response to reliever medications

Symptoms

Inhaled glucocorticosteroids Most effective anti-inflammatory agent

Reduce number of inflammatory cells and their activation in the airways

Switch off the transcription of multiple activated genes that encode inflammatory proteins

Effective in preventing asthma symptoms but also prevent severe exacerbations

Adverse effects: oral candidiasis and dysphonia

Controller medications

SYMPTOMS MILD SEVERE

Altered consciousness

No Agitated, confused or

drowsy

Oximetry on presentation (SaO2)

≥94% <90%

Talks in Sentences Words

Pulse rate <100 bpm >200 bpm (o-3 years)

>180 bpm (4-5 years)

Central cyanosis Absent Likely to be present

Wheeze intensity Variable May be quiet

Management2 puffs of salbutamol

(given 20-minute interval for an hour)

Recurrence within 2-3 hoursNo recurrence within 1 to 2

hours

2-3 puffs hourly (max: 10 puffs/day)

+ oral glucocorticosteroid

No further treatment

Repeat 2 puffs after 3-4hours

Prednisone 1-2 mg/kg/day(max: 20 mg in children <2

30 mg in children 3-5Hospital

Management

Treat hypoxemia Oxygen supplementation via a 24%

facemask (4LPM) Bronchodilator Therapy

Two puffs of salbutamol (100 µg per puff) or equivalent

Dose of 2.5 mg salbutamol solution (air-driven nebulization or pressurized MDI)

Every 20 minutes for 1 hour

Management

Bronchodilator Therapy Inhaled Ipatropium: no significant response

within the first hour Systemic corticosteroids (oral or IV)

Oral: 1-2 mg/kg daily for up to 5 days IV: 1 mg/kg every 6 hours on day 1; every

12 hours on day 2, then daily

Management

When to discharge: Sustained improvement in symptoms Normal physical findings PEF >70% of predicted or personal best Oxygen saturation (room air): >92%

Home medications: Inhaled beta-agonist: every 3-4 hour Oral corticosterioid (3-4 hours)

Within 1 week and another within 1-2 months

Recurrent coughing and wheezing occurs in 35% of preschool age children

1/3: persistent asthma into later childhood 2/3 improve on their own through their

teenage years

Prognosis and Follow-up

Moderate to severe asthma and with lower lung function measures: persistent asthma as adults

Milder asthma and normal lung function: periodically asthmatic (disease free for months to years)

Prognosis and Follow-up