Pathology Conference on Asthma

FIRST CLINCOPATHOLOGICAL

CONFERENCE17th Batch

February 26, 2016

Elishbah Naveed Abila Shakoor Ammmara Mahroof Awab Hassan Ali Raza Bahroz Khan

PRESENTERS

Case Presentation

“Parween Bibi”, a 35 year old married female, from Garhi Habibullah, came to King

Abdllah Teaching Hospital, Mansehra on 22 feb,2016 at 10:00 a.m in OPD. She

presented with complaints of fever for 2 days ,cough for 1 day, breathlessness

for 2 hours. She was conscious and well oriented. Overall health state was

weak

HISTORY

Parveen Bibi

Name: Parveen Bibi Sex: Female Age: 35 Years Marital Status: Married Children: 3 (2 sons, 1 daughter) Occupation: Housewife Address: Garhi Habibullah, Mansehra Date of Arrival: 22 Feb 2016 Time of Arrival: 10am Mode of Admission: OPD

History of Patient

Fever (last 2 days) Cough(1 day)Breathlessness(2 hours)

Chief Complaints

Our patient was alright 2 days back, then she developed fever which was gradual on onset, low grade (99 F documented). Fever was intermittent with diurnal variations.

Fever was associated with cough, palpitations and breathlessness.

Upon arrival to hospital patient had an episode of vomiting. There was no history of unconsciousness.

Fever was relieved by taking anti-pyretics (Parectomol).

History of Present Illness

Patient developed a cough one day back which was gradual in onset, patient had several episodic attacks of cough which lasted for 15 minutes.

Cough was productive, sputum was white in color, scanty.

Cough aggravates upon lying down and is relieved on sitting position.

Associated with chest discomfort and fever.


Patient developed breathlessness for the last 2 hours which was gradual in onset.

Breathlessness was also present at rest and aggravated upon exertion.

It was associated with: Cough Fever Palpitations


Systemic Inquiry:

1. General A. Reduced AppetiteB. Disturbed SleepC. Weakness & Lethargy


Respiratory System Inquiry:1. Cough 2. Respiratory wheeze


Alimentary System:◦ No remarkable findings

Urinary System:◦ No significant history

ON SYSTEMIC INQUIRY THERE WERE NO OTHER REMARKABLE FINDINGS


Past Medical History:◦ Patient has been asthmatic for last 15 years◦ No other major illnesses reported

Past Surgical History◦ No significant past surgical history

History of Past Illness

Positive for Asthma.

Patient’s mother has asthma.

Patient’s daughter has asthma as well

Family History

No history of smoking tobacco

Leading a healthy & active lifestyle

With regular bowel habits

Personal History

Her SES was satisfactory

She lives in her own house of 4 rooms with her 6 family members

Socioeconomic History

Patient was prescribed the following drug regimen for her asthma:◦ Salbo inhaler (Salbutamol)◦ Tab Montiget (Montelukast)◦ Tab Profylline (Doxofylline)

Patient’s compliance to drug was poor.

Drug and Treatment History

According to patient she is not allergic to any specific allergen but exposure to cold weather worsens her condition.

Allergic History

Bronchial Asthma

Emphysema

COPD

Bronchiectasis

History based Diffrential Diagnosis

Patients general appearance◦Pale and anxious

General Physical Examination

Vitals-

◦B.P: 110/90 mm/Hg ◦Pulse: 86 bpm◦Temperature: 99 F◦Respiration: 26 breaths per minute


No clubbing

No peripheral / central cyanosis

Eyes: Anemia not indicated

Jaundice was not present


Dental hygiene good

No abnormality seen on thyroid examination

Lymph nodes not palpable

Pedal and sacral edema absent

No other significant findings


1. CVS Systemic Examinationa. Inspection:

• No Chest deformity• No sternotomy or any other surgical scar

b. Palpation: Apex beat: Normal

c. Auscultation:S1 + S2 + 0

• No added sounds• No murmurs

Systemic Examination

b. Respiration:Inspection

Chest Wall Movement: RegularRespiratory Rate: Increased (26 breath/min)No external deformityNo scars

Palpation:Position of Trachea: No tracheal shift

Local Tenderness: Not present


Percussion: Percussion note: Resonant

Auscultation:Vesicular breathing with prolonged

expirationOccassional respiratory wheeze

Few Ronchi


c. GIT: INSPECTION:

Shape, contour, movement were normalUmbilicus central and invertedScars, striae and prominent veins absent

PALPATION: Abdomen is soft and non tender

There is no palpable mass Liver not palpable

• Spleen not palpable• Ascites not present


c. GIT: AUSCULTATION:

Bowel Sounds were presentPALPATION:

Abdomen is soft and non tenderThere is no palpable mass

Liver not palpable• Spleen not palpable• Ascites not present PERCUSSION: No significant findings.


c. CNS: Patient was conscious, oriented well with space, time and place.


1. Following investigations were performed1. Chest X-Ray (PA view)2. Complete Blood Picture3. Urine RE

2. Specialized investigations like spirometry and PFT were not done due to non availability in the hospital.

Investigations

Findings:

There were no significant findings on X-Ray Exam

Chest X Ray

Complete Blood Picture

Complete Blood Picture Findings:

Mild Leucocytosis

CHRONIC ASTHMA EXACERBATED BY MILD RESPIRATORY INFECTION AND NON COMPLIANCE TO DRUGS

Investigations based diagnosis

Upon her arrival to the hospital the patient’s acute symptoms were relieved by:

O2 inhalation @ 2 lit/min Nebulization with Ventoline(Salbutamol)

every 4 hourly for 10 mins. Nebulization with Atem(Ipratropium

bromide) x B.D Nebulization with Clenid (corticosteroid) x

B.D

Management

After the relief of her acute symptoms, patient was advised to continue this drug regimen:◦ Tab Paracetamol- 1Tab x SOS◦ Tab Moxiget (Moxifloxacin) 400mg x O.D◦ Tab Myteka (Montelukast) 10 mg 1 x at night◦ Tab Delracortil (Prednislone) 5mg 3+0+3

For the 1st 3 days then 2+0+2 for 2 days then 1+0+1 for 1 day (as we have to taper off steroid slowly) Tab Hydraline 1 tsp x TDS

Management

Patient was discharged after 4 days and was asked to come for a follow up after 2 weeks.

Management

Asthma is clinically defined as:

“A chronic inflammatory reversible disorder with air way hyper reactivity and variable air obstructions”

Definition

Epidemiology of Asthma

Asthma is a global health problem Worldwide more than 350 million people are

suffering from asthma. Approximately 250,000 people die from

asthma each year

Epidemiology

Asthma is more common in women than men.

In contrast young boys are affected more than young girls.

Hygiene hypotheses is implicated in the increasing incidence of asthma

Epidemiology

This hypothesis has been proposed by scientists to explain the rise in incidence of asthma.

The hypothesis states that the eradication of infections has altered the immune homeostasis and promote allergic and other harmful immune responses

Hygiene Hypothesis

Infections Allergies

Asthma has a global distribution with a relatively higher burden in North America and Middle East

Among people aged less than 45 years most of the burden of disease is due disability.

Burden of Asthma


The burden of asthma measured by disability and premature death is greatest in children approaching adolescence and the elderly.

Burden of Asthma


Pathophysiology of Asthma

Asthma is clinically defined as:

“A chronic inflammatory reversible disorder with air way hyper reactivity and variable air obstructions”

Definition

Asthma is associated with

Palpitations Breathlessness Wheezing Chest tightness Cough Increased mucus secretion


Indoor and outdoor allergens Microbial exposure Diet Vitamins Tobacco smoke Air pollution

Environmental Factors Triggering Asthma

Asthma is divided into:◦ Extrinsic Asthma ◦ Intrinsic Asthma

Less common types include:◦ Drug-induced asthma (most commonly from Aspirin)◦ Occupational Asthma

Classification

Asthma is clinically divided into 4 categories for the purposes of treatment:

◦ Intermittent Asthma◦ Mild Persistent Asthma◦ Moderate Persistent Asthma◦ Severe Persistent Asthma

Clinical Classification

Early and Late Mediators of Asthma Early Mediators

◦ Histamine◦ Proteases◦ Chemotactic Factors◦ Prostaglandins ◦ Leukotrienes

Late Mediators◦ Cytokines

(IL4, IL5, IL13)

Extrinsic Asthma (Atopic Asthma):◦ It is the most common type of asthma.◦ It is a Type 1 Hypersensitivity reaction due to

exposure to extrinsic allergens.


Pathogenesis of Extrinsic Asthma:

Sensitization of airway to allergens: Stimulates production of subset 2 helper T cells

(CD4 TH2) CD4 TH2 release interleukins IL-4 and IL-5 IL-4 stimulates isotype switching to IgE production IL-5 stimulates production and activation of eosinophills

Extrinsic (Atopic) Asthma

Re-exposure of airway to allergen:◦ Exposure stimulates IgE antibodies that illicit

two responses: Acute Response:

1. Antigen cross link IgE antibodies on mast cells. 2. This results in release of histamine and other

mediators. 3. Histamine causes bronchoconstriction. 4. Other mediators cause mucus production and

leucocyte influx


Late Response: Occurs 4-8 hours later

Mediated by leucocytes recruited by chemo tactic factors and cytokines

Results in damage to epithelial cells and airway constriction


After chronic attacks of asthma there is airway remodeling characterized by: Hypertrophy of bronchial smooth muscle There is mucous production and Increased vascularity There is deposition sub epithelial

collagen

Airway Remodelling

This is asthma not associated with allergy. It is commonly seen in old age group It has unknown mechanism but may be

caused by: Viral Respiratory Infections Stress Exercise Cold Temperature

Intrinsic Asthma

Asthma attack that occurs in response to intake of certain drugs

Aspirin and NSAIDs are commonly implicated in sensitive people.

Drug Induced Asthma

Mechanism: Aspirin inhibits cyclooxygenase

pathway of arachidionic acid metabolism. But it does not effect the lipooxygenase route.

Thus Aspirin shifts the balance of factors towards leukotrienes thus causing bronchospasm

Drug Induced Asthma

Asthma in response to fumes and chemicals.

Epoxy resins, chemical dusts, penicillin products are implicated/

Occupational Asthma

This type of asthma comes in the form of acute attack following exercise and stops after 30-40 minutes

It worsens in cold and dry climate

Exercise Induced Asthma

IgE Mediated Type 1 HS

Clinically defined as◦ “An acute exacerbation of asthma that remains

unresponsive to initial treatment with bronchodilators.”

1. It is a medical emergency2. It has very life threatening complications like

hypercapnia

Status Asthmaticus

Wheezing Coughing Shortness of breath Chest tightness/pain

Clinical Features of Asthma

Diagnosis is established when following criteria is fulfilled◦ Episodic symptoms of airflow obstruction are

present◦ Airflow obstruction or symptoms are at least

partially reversible◦ Exclusion of alternative diagnoses

Diagnosis

Investigations Of Asthma

Investigations that can help in the diagnosis of Asthma can be broadly divided into 3 categories:◦Physical Exam: This includes a “Complete Physical

Examination” as well as patient interview about S&S.

◦Pulmonary Function Tests: This includes Spirometry & Peak Flow studies.

◦Miscelleaneous: 1. Chest X-Ray2. Methacholine Challenge Test3. Allergy Tests4. Sputum Eosinophills

Investigations Useful For Asthma

A physical exam of respiratory system is the first investigation.

Physical exam begins with a detailed interview about the patient’s signs and symptoms.

The physician has to note chest wall movements, any external deformities etc.

Auscultation can provide very useful clues in reaching the diagnosis.

Physical Exam

Chest X-Ray is the initial investigation for asthma.

In most asthmatic patients X-Ray findings are normal.

The value of chest radiography is in revealing complications or alternative causes of wheezing.

Chest X-Ray

Pulmonary function tests determine how much air moves in and out as a person breathes.

The most common test done in this category is Spirometry.

Pulmonary Function Tests

In spirometry patient is asked to breath deeply and then exhale forcefully.

Patient’s nose is blocked using a nose clip. Test is repeated 3 times to ensure accurate

test results. Spirometry is not useful for very young

children or comatose adults.

Spirometry

Video Demonstration of Spirometry

In this test patient breathes nebulized methacholine or histamine

Methacholine causes contraction of bronchioles in asthmatic patients

This test can help in differentiation between COPD and Asthma

Methacholine Challenge Test

Sputum eosinophills are a good indicator of severity of asthma.

Eosinophilia can indicate active asthma. This count is specially elevated in atopic

asthma. Blood eosinophilia greater than 4% is

supportive of a diagnosis of asthma. Inflammation in asthma is characterized by

influx of eosinophils.

Sputum/Blood Eosinophills

Anti-Asthma Drugs

It is said about Asthma that it is a disease in which with the ◦ right patient ◦ the right clinician◦ right drug regimen patient can be completely free

of symptoms

DRUGS USED IN TREATMENT OF ASTHMA

Mechanism of Action: These drugs attach to B2 Receptors and dilate the bronchioles

Form: Available in inhaler and pill configuration

Sympathomimetics

Side Effects: Tremors, Palpitations, Dizziness

Commonly used drugs: Salbutamol, Formetrol

Sympathomimetics

Mechanism of Action: Anticholinergic drugs inhibit bronchospasm caused by Vagus Nerve stimulation

Form: Available in inhaler and pill configuration

Anticholinergic Drugs

Side Effects: Dry mouth and mouth edema

Common Drugs: Ipratropium, Tiotropium etc

Anticholinergic Drugs

Mechanism of Action: Methylxanthines are derivatives of plants. They cause relaxation of bronchial smooth muscle

Form: Pills

Methylxanthines

Side Effects: Palpitations, tremors, arrythmias

Common Drugs: Theophylline, Aminophylline

Methylxanthines

Mechanism of Action: Corticosteroids reduce the hyper reactivity of the respiratory tract to various stimuli. They also reduce inflammation.

Form: Pill and Inhaler

Corticosteroids

Side Effects: Weakness, weight gain, oral thrush

Common Drugs: Beclomethasone, Fluticasone

Corticosteroids

Mechanism of Action: These drugs inhibit the leukotrienes which are mediators of inflammation. They are effective in bronchial asthma.

Form: Pills

Leukotriene Antagonists

Side Effects: Allergic Reactions, edema, irritablility and drowsiness

Common Drugs: Montelukast, Zafirlukast

Leukotriene Antagonists

Mechanism of Action: They inhibit the release of histamine from mast cells.

Form: Inhaler and pills

Mast Cell Inhibitors

Side Effects: Allergic Reactions, edema, irritablility and drowsiness

Common Drugs: Nedocromil, Cromolyn sodium

Mast Cell Inhibitors

Mechanism of Action: It is a new type of asthma treatment, it is prepared in genetically modified mice. It inhibits the binding of IgE on mast cells.

Form: IV/SC Injections Side Effects: Reaction to antibody can

occur

Anti IgE Antibody - Omalizumab

Clinically for the purposes of treatment Asthma is divided into 4 different categories.

Intermittent Asthma Symptoms less than 2 days per week

Mild Persistent Asthma Symptoms more twice a week

Moderate Persistent Asthma Daily Symptoms

Severe Asthma Continual Symptoms

Treatment Guidelines for Asthma

Intermittent AsthmaSymptoms less than 2 days per week

Mild Persistent AsthmaSymptoms more than twice a week

Moderate Persistent AsthmaDaily Symptoms

Severe AsthmaContinual Symptoms

Status Asthmaticus is an acute attack of asthma that is un responsive to bronnchodilators.

It is a medical emergency It carries a very high risk of death Lets discuss the management of Status

Asthmaticus

Status Asthmaticus

Management Guidelines Patient is admitted in ICU and put on oxygen

therapy. Oxygen saturation should not come below 95%

Patient is given IV or SC Adrenaline to dilate the bronchioles.

Patient is then given systemic Salbutamol infusion. If there is stabilization of patient then he is allowed

to go home with prescription of 2 weeks of:◦ Systemic Corticosteroids (Prednisone 50mg daily)◦ Inhaled Corticosteroids◦ Inhaled B2 Agonists◦ Inhaled Anticholinergics

Patient must strictly come for follow up every 2nd day until his condition improves.

If these treatments fail then patient is given general anesthesia through use of Ketamine and Succinyl Choline. This relaxes the muscles and the condition may stabilize.

Management Guidelines

Many patients do not even require any drug treatment

Every case of asthma is unique and has their own precipitating factors.

Patients are advised to avoid these precipitating factors, and avoid allergens etc.

Preventative Measures

Asthma is a serious health problem that is increasing in incidence worldwide.

Although no cure is possible it can be managed well if the patient strictly adheres to the treatment regimen.

A short video summary to summarize asthma.

Ending notes.

Summary

Video Summary

Thankyou

Pathology Conference on Asthma

Health & Medicine

Transcript of Pathology Conference on Asthma