Asthma

ASTHMA

Dorian Matzen, PGY-2Family Medicine

May 21st, 2015

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Case 1 – Acute Shortness of breath

C/C SOBAn 8 Y/O male presents to ER for acute respiratory distress. Mother is present, states that he had been having increased dyspnea over the past 24 hours, was breathing fast after coming home from school. Has been using his inhaler frequently. He didn’t eat much dinner last night or breakfast this morning has been coughing non-stop and has vomited x2, normal emesis. No recent sick contacts, it is springtime in Elmira and it has been warm weather and there has been a significant pollen count over the past several days. No fever reported, grossly audible wheezing and apparent respiratory distress with tachypnea and increased WOB.

Very High High Extreme Low

PMHx: Asthma

HoMeds: Albuterol MDI, Advair diskus 100/50mcg

All: NKDA

PSHx: None

SocHx: Lives with single parent and 7 siblings

FamHx: Father - childhood asthma

Vaccinations are up to date


PE:VS: T-99.7F, HR-190, RR-66, BP-126/75, 86% O2 sat initially, now 91% on Simple mask with continuous albuterol via large volume nebulizer, wt: 62lbsGen: WDWN 8 Y/O male in severe distress 2/2 asthma exacerbationHEENT: NCAT, EOMI, PERRLA @5mm, oral mucosa slightly dry, no thrushNeck: +suprasternal retractions, No tracheal deviation, no thyromegaly, no anterior/posterior cervical, submandibular or supraclavicular lymphadenopathyChest: +intercostal retraction, notable increased WOB of muscles of respiration, +expiratory wheezing, prolonged expiratory phase.Abd: Soft, NTND, hypoactive bowel sounds, no guarding, no reboundGU: Grossly normal male, circumcised, Tanner stage I, both testes descendedMSK: Good UE and LE tone, able to move all extremitiesSkin: No rashes or bruising noted on trunk or extremitiesNeuro: A&O x3 (person, place, date), +2/4 patellar and brachioradialis reflexes b/lLymph: no anterior/posterior cervical lymphadenopathy, no axillary lymphadenopathyExtremities: no clubbing, no cyanosis, no nail stipplingOsteopathic: Posterior paraspinal muscular tension in T1-T5 +ropey texture bilaterally, Left ribs 4-7 stuck in inhalation.


Labs:

CMP:

CBC:

ABG: 7.33pH, 71PaO2, 21HCO3, 34PaCO2, BE: -4 Blood culture x2 pendingViral Panel pendingUA: essentially negative

97137 101 22 4.2 36 0.7 8.8

13.77.7 332 43.4???

An 8 Y/O male presents to ER for acute SOB, ongoing for the past 24hrs, likely asthma exacerbation given past medical history of Asthma. Pt. responding with limited improvement to nebulized medications, continued dyspnea with persistently increased work of breathing.

Assessment:

Plan:

#1) Asthma Exacerbation – Acute- Albuterol and Ipratropium (Duonebs) q4hr- Methylprednisolone IVP 30mg IVP BID (1-2mg/kg/day)- Initial Spirometry and serial PEFs to monitor resolution- Asthma control assessment, Asthma Action Plan

THE 4 STAGES OF BLOOD GAS PROGRESSION IN PERSONS WITH STATUS ASTHMATICUS ARE AS FOLLOWS:

STAGE 1 - CHARACTERIZED BY HYPERVENTILATION WITH A NORMAL PARTIAL PRESSURE OF OXYGEN (PO 2) STAGE 2 - CHARACTERIZED BY HYPERVENTILATION ACCOMPANIED BY HYPOXEMIA (IE, A LOW PARTIAL PRESSURE OF CARBON DIOXIDE [PCO 2] AND LOW PO 2) STAGE 3 - CHARACTERIZED BY THE PRESENCE OF A FALSE-NORMAL PCO 2; VENTILATION HAS DECREASED FROM THE HYPERVENTILATION PRESENT IN THE SECOND STAGE; THIS IS AN EXTREMELY SERIOUS SIGN OF RESPIRATORY MUSCLE FATIGUE THAT SIGNALS THE NEED FOR MORE INTENSIVE MEDICAL CARE, SUCH AS ADMISSION TO AN ICU AND, PROBABLY, INTUBATION WITH MECHANICAL VENTILATION. STAGE 4 - CHARACTERIZED BY A LOW PO 2 AND A HIGH PCO 2, WHICH OCCURS WITH RESPIRATORY MUSCLE INSUFFICIENCY; THIS IS AN EVEN MORE SERIOUS SIGN THAT MANDATES INTUBATION AND VENTILATORY SUPPORT.

Status Asthmaticus workup, Medscapehttp://emedicine.medscape.com/article/2129484-workup#aw2aab6b5b4

Recommended doses of medications to treat children with an asthma exacerbation

Albuterol (Salbutamol) 0.15mg/kg per dose, 2.5mg min., 5.0mg max every 20 to 30 minutes for 3 dosesContinuous is 0.5mg/kg (max 20mg/hr) by LVN

5 - 10kg --- 7.5mg/hr 10-20kg --- 11.25mg/hr >20kg --- 15mg/hr

MDI w/spacer 1/3 – 1/4 puff per kg or 4-8 puffs q20-30min for x3 doses, then every 1-4hrs as needed. Add a mask for children less than 4 Y/O.

Levalbuterol – 1/2 the recommended dose for racemic albuterol

The SABAs – Short Acting Beta-2 Agonists


Ipratropium (Atrovent) <20kg – 250 mcg/dose, q20 min for x3 doses nebulizer solution ≥20kg – 500 mcg/dose multidose inhaler 18mcg/puff

4-8 puffs q20min PRN for 3hrs


Systemic glucocorticoids:Prednisone or Prednisolone – 1 to 2 mg/kg PO (max 60mg/day), then 0.5 to

1mg/kg twice daily for subsequent doses, typically 3-10 day course.

Methylprednisolone - 1 to 2mg/kg (max 125mg/day) IV

Dexamethasone - 0.6mg/kg (max 16mg/day) PO, IM or IV


Systemic beta-2 agonistsEpinephrine - 0.01mg/kg IM or SQ (Max 0.4mg/dose)

may be repeated x3 q10-20min- OR -

Terbutaline - 0.01mg/kg SQ or IM (Max 0.25mg/dose)may be repeated x3 q20min, then q2-6hrs PRN

Other TreatmentMagnesium Sulfate – 25 to 75 mg/kg IV (Max 2g)

infuse over 20 minutes a metastudy showed an ARR of 0.26 the endpoint being hospitalization.

4

When I was up in Rochester…

Spirometry/Peak Flows

POISEUILLE'S LAW

Even though asthma is a prevalent disease, annual per capita mortality from asthma is relatively low worldwide, ranging from 1.51 per million population in the United Kingdom to 13.66 in the United States, 25.56 in Japan, 31.6 in Germany, and 86.92 in South Korea

Asthma epidemiology

Case 2 – The clinic visit

HPI: A 24 Y/O male presents to clinic acutely complaining of cough, wheezing, runny nose and dyspnea. He states that his hearing has been “like he is under water” since this morning. He reports that has been using his albuterol inhaler more frequently over the past 3 days, up to every 2-4 hours on average. He was only recently diagnosed with Asthma 3 months ago and was started on an Albuterol MDI inhaler, which he reports was controlling his asthma well and had been only using his inhaler 1-2 times/day. The patient states that he has stopped running his daily 3-5 miles and is concerned about staying on track for his 10k run in June.


PMHx: Asthma

Meds: Albuterol MDI

All: ASA

PSHx: Adenoid/Tonsillectomy

FamHx: Father – DM II, HTN, Emphysema; Mother – HLD, Asthma-COPD

SocHx: Social alcohol, 1-2 drinks/week, Non-smoker, never smoked, no illicit drugs, works as a new car salesman

Vaccinations: Completed childhood and pre-college vaccinations.


VS: T-98.8F, HR-88, RR-20, BP-118/74, 95% O2 sat on R/A, Wt. 174lbs, Ht-5’10”Gen: 24 Y/O WDWN male in NADHEENT: NCAT, PERRLA @5mm, oral mucosa moist, some serous fluid noted behind tympanums without any injection or erythema, no tonsilar exudate, no posterior oropharyngeal cobblestoning, some noted erythema and mild edema of the nares bilaterally, some clear drainage noted as well.Neck: no thyromegaly, trachea midlineCV: S1S2 noted, RRR, = radial pulses bilaterallyPulm: Lungs have notable diffuse expiratory wheezing, expiratory phase not notably prolonged, no rhonchi or rales notedAbd: Soft, NTND, normoactive bowel soundsSkin: no rashes or bruises notedExtremities: no clubbing or cyanosis notedNeuro: CN II-XII grossly intact, Pt. A&O to person, place, datePsych: alert and appropriate to questions, no blunted affectLymph: some + shotty posterior cervical lymphadenopathy, no anterior cervical, submandibular or supraclavicular lymphadenopathy.Osteopathic: Some noted upper cervical paraspinal muscular tension


Assessment: 24 Y/O male presents to clinic with moderate persistent asthma with 3 day history of URI symptoms provoking an asthma exacerbation, frequent daily MDI SABA use and increased fatigue.

Plan: 1) Asthma exacerbation – Acute; Advair MDI Fluticasone &

Salmeterol) 45/21mcg, 2 inhalations BID, In-office nebulizer treatment with albuterol-ipratropium, in-office spirometry (if available), PEF evaluation prior to and after nebulizer treatment, Consider Allergy referral for skin allergen testing if no improvement, F/U in 2 weeks for resolution of URI, adherence to new therapy.2) URI – Likely viral, will given sinus toileting regimen of Ocean nasal spray 4x daily, Flonase (Fluticasone) 2 sprays per nostril qd, benedryl 25mg PO qhs

Goals of Asthma Management1) Routine monitoring, ie clinic visits2) Patient education3) Controlling environmental risk factors that increase severity4) Pharmacologic therapy

Goals of Asthma Treatment1) Reduce Impairment

-Freedom from frequent or troublesome symptoms-Minimize need for SABAs to ≤2 days/week-Minimize night-time dyspnea awakenings to <2 nights/month-Optimize lung function-Maintenance of normal activites: school, work, athletics-Satisfaction with asthma care by Pt. and her family

2) Reduce Risk-Prevent recurrent hospitalizations and ER visits/hospitalization-Prevent reduced lung growth in children and loss of function in adults-Optimize pharmacotherapy with minimal/no side effects

Assessment of Impairment-Nighttime awakenings-Frequency of SABA MDI usage-Unscheduled care for asthma, Urgent care or ER visits-Participation in life activities: work, school, athletics-Peak expiratory flow measurements, monitoring and reduction in best PEF-Side effects of medications

Assessment of Risk-Monitoring adherence with inhaled glucocorticoids-Taking any oral glucocorticoids in the past year-Hospitalized in the last year? How many times?-Currently smoking?-Worsening of asthma symptoms with ASA or NSAIDS?

The STEPS approach to Asthma Control

The Methylated Xanthines

The Purine Salvage Pathway

Question 2

A 24 year-old woman with persistent asthma, which is well controlled on low-dose fluticasone and albuterol as needed, became pregnant 2 months ago and asks for advice about asthma therapy during her pregnancy. Before she started fluticasone therapy, she had frequent asthma symptoms and occasional exacerbations requiring emergency department treatment. Since she became pregnant, her asthma has remained under good control. The physical examination is un remarkable and spirometry is normal.

Which of the following is the most appropriate management for this patient?

A)Continue the current regimen

B)Stop Fluticasone; add theophylline

C)Stop Fluticasone; add salmeterol

D)Stop Fluticasone; add inhaled cromolyn

An overview of asthma management; UpToDate; Christopher Fanta MD, Robert Wood MDhttp://www.uptodate.com/contents/an-overview-of-asthma-management?source=search_result&search=Asthma&selectedTitle=1%7E150 Treatment of acute exacerbations of asthma in adults; UpToDate; Christopher Fanta MD, Bruce Bochner MD, Roberst Hockberger MD FACEPhttp://www.uptodate.com/contents/treatment-of-acute-exacerbations-of-asthma-in-adults?source=search_result&search=asthma&selectedTitle=3%7E150 Diagnosis of asthma in adolescents and adults; UpToDate; Christopher Fanta MD, Peter Barnes DM DSc, Bruce Bochner MDhttp://www.uptodate.com/contents/diagnosis-of-asthma-in-adolescents-and-adults?source=search_result&search=asthma&selectedTitle=4%7E150 Acute asthma exacerbations in children: Home/office management and severity assessment; UpToDate Gergory Sawicki MD MPH, Kenan Haver MD, Robert Wood MD, Gregory Redding MDhttp://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-home-office-management-and-severity-assessment?source=search_result&search=asthma&selectedTitle=5%7E150 Asthma in children younger than 12 years: Initiating therapy and monitoring control; UpToDate; Gregory Sawicki MD MPH, Kenan Haver MD, Robert Wood MD, Gregory Redding MDhttp://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-initiating-therapy-and-monitoring-control?source=search_result&search=asthma&selectedTitle=7%7E150

Asthma in children younger than 12 years: Initial evaluation and diagnosis; UpToDate; Gregory Sawicki MD MPH, Kenan Haver MD, Robert Wood MD, Gregory Redding MDhttp://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?source=search_result&search=asthma&selectedTitle=8%7E150 Acute asthma exacerbations in children: Emergency department management http://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-emergency-department-management?source=search_result&search=Asthma&selectedTitle=9%7E150 Wheezing phenotypes and prediction of asthma in young children; UpToDate; Theresa Guilbert MD, Robert Lemanske Jr MD, Gregory Redding MDhttp://www.uptodate.com/contents/wheezing-phenotypes-and-prediction-of-asthma-in-young-children?source=search_result&search=asthma&selectedTitle=10%7E150

Healio.comhttp://www.healio.com/pediatrics/curbside-consultation/%7B3e7ee620-1201-4d45-b60b-9034ee0355f3%7D/what-other-tests-will-my Status Asthmaticus workup, Medscapehttp://emedicine.medscape.com/article/2129484-workup#aw2aab6b5b4

Medical Physiology And Pathophysiology, Essentials and clinical problemshttp://www.zuniv.net/physiology/book/chapter13.html Beta-adrenergic receptor agonists and cyclic nucleotide phosphodiesterase inhibitors: shifting the focus from inotropy to cyclic adenosine monophosphatehttp://content.onlinejacc.org/article.aspx?articleid=1125893 Magnesium for treatment of asthma in children; Can Fam Physician. 2009 Sep; 55(9): 887–889.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/ Identifying patients at risk for fatal asthma; UpToDate: Mark Madison, MD, Richard Irwin MDhttp://www.uptodate.com/contents/identifying-patients-at-risk-for-fatal-asthma?source=search_result&search=Asthma&selectedTitle=12%7E150

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