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CASE DISCUSSION RIVERA, JOANNA GRACE ASMPH BATCH 2013 OBJECTIVES 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 GENERAL INFORMATION EPYN Female 3 years old Filipino Roman Catholic Mandaluyong City Informant: Father Reliability: 80% CHIEF COMPLAINT Difficulty of Breathing (two days duration) HISTORY OF PRESENT ILLNESS Two days PTA • Nonproductive cough • Difficulty of breathing • (-) colds and fever • Nebulized with salbutamol with improvement of DOB HISTORY OF PRESENT ILLNESS Few hours PTA • Worsening of cough and DOB • Unrelieved by salbutamol nebulization • No other associated symptoms DAY OF ADMISSION 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 History GROSS MOTOR 6 months: sits with support 10 months: stands with support 1o months: walks with support 15 months: walks well alone 2 years: runs well, can climb up and down stairs, jumps 3 : throws balls, downstairs on one foot per step, hops on one foot FINE MOTOR 9 months: holds bottle 1 year and 3 months: can drink from cup 2 years old: can imitate a circle; 3 years old: imitates cross LANGUAGE 9 months: can speak mama and papa 1 and ½ year: can indicate needs; can speak three-word sentences 2 years old: can point to parts of the body and can follow directions; names on pictures 3 years old: tells little stories about experiences, gives full name and sex; recognizes 3 or more colors, counts to ten SOCIAL 2 years: can remove garment; toilet trained; uses spoon 3 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 Casino dealer Call center agent 40 18 41 3 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 APPEARANCE Alert, quiet, weak-looking, in respiratory distress VITAL SIGNS BP: 100/70 HR: 110 RR: 40 Temp: 37º C ANTHROPOMETRICS: Height: 106 cm (2 to 3) BMI: 20.11 (3) O2 Sat (room air): 89% Weight: 22.6kg (3) PHYSICAL EXAMINATION SKIN warm skin, good skin color and turgor HEENT no 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 HEENT No alar flaring, nasal septum midline, with minimal nasal discharge dry lips, moist tongue, no circumoral cyanosis, no buccal mucosal lesions, no TPC no masses in the neck, (-) CLAD, flat neck veins PHYSICAL EXAMINATION RESPIRATORY can talk in sentences, (+) subcostal retractions, symmetric chest expansion, wheezes on both lung fields, no crackles or rhonchi HEART adynamic precordium, no thrills, heaves or lifts, PMI at 5th ICS, MCL, normal rate, regular rhythm, distinct S1 and S2 sounds, no murmurs PHYSICAL EXAMINATION ABDOMEN Flabby abdomen, normoactive bowel sounds, soft, no organomegaly, no tenderness EXTREMITIES full and equal pulses, no edema, no cyanosis, no atrophy/hypertrophy, no deformities NEUROLOGIC EXAMINATION Intact cranial nerves, no sensory and motor deficits, normoreflexive, (-) Babinski, (-) clonus SALIENT FEATURES SUBJECTIVE 3/F Asthmatic Difficulty of breathing Cough Audible wheeze Relieved by Salbutamol nebulization initially unresponsive OBJECTIVE 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 Emergency Treatment 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 Day 1 Subjective (+) cough (+) audible wheeze (-) difficulty of breathing (-) fever (+) Good activity and good appetite Objective • 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 1 Assessment Bronchial Asthma in Acute Exacerbation, resolving Plan • Revise nebulization to Salbutamol + Ipatropium every 8 hours Salbutamol every 8 hours • Shift to IV Hydrocortisone 100 mg/IV every 6 hours Day 2 Subjective (+) occassional cough (-) audible wheeze (-) difficulty of breathing (-) fever (+) Good activity and good appetite Objective • 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 1 Assessment Bronchial Asthma in Acute Exacerbation, resolving Plan • Revise nebulization to Salbutamol 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 obstruction o Airway hyperresponsiveness Excessive Contraction of the smooth muscle Uncoupling Thickening of the airway wall Sensitized sensory nerves INFLAMMATORY INFLAMMATORY CELLS INFLAMMATORY CELLS MEDIATORS Mast cells Airway epithelial cells Airway smooth muscle Eosinophils Chemokines cells T-lymphocytes Cysteinyl Leukotrienes Endothelial cells Dendritic Cells Cytokines Fibroblasts Histamine Macrophages Myofibroblasts Nitric oxide Neutrophils Prostaglandin D2 Airway nerves Smooth muscle Mucus Airway hypersecretion Edema thickening contraction SMOOTH MUSCLE INCREASE BLOOD VESSEL WALL PROLIFERATION MUCUS HYPERSECRETION Clinical Signs and Symptoms Wheezing Cough Breathlessness Nocturnal 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% Diagnostic Examinations 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 Treatment and Management 1. 2. 3. 4. Regular Assessment and monitoring Patient Education Control of Factors Contributing to Asthma Severity Principles of Asthma Pharmacotherapy Component 1 Regular Assessment and Monitoring Levels of Asthma Control for Children CHARACTERISTIC Daytime symptoms Limitation of activities Nocturnal symptoms/ awakenings Need for reliever/rescue treatment CONTROLLED (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) None More than twice/week More than twice/week None Any Any None Any Any ≤2 days/week >2 days/week >2 days/week Component 2 Patient Education Component 3 Control of Factors Contributing to Asthma Severity Eliminating and reducing problematic environmental exposures Annual influenza vaccination Treat co-morbid conditions Gastroesophageal Reflux Rhinitis Sinusitis Component 4 Principles of Asthma Pharmacotherapy Asthma education Environmental 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 CONTROLLER OPTIONS Continue as needed rapid-acting beta-2 agonists Low-dose inhaled glucocorticosteroids Double low-dose inhaled glucocorticosteroids Leukotriene modifier Low-dose inhaled glucocorticosteroid plus leukotriene modifier 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 Controller Medications 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). Management of Acute Asthma Exacerbation Symptoms 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 Controller medications 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 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 Management 2 puffs of salbutamol (given 20-minute interval for an hour) Recurrence within 2-3 hours 2-3 puffs hourly (max: 10 puffs/day) + oral glucocorticosteroid Hospital No recurrence within 1 to 2 hours No further treatment Repeat 2 puffs after 34hours Prednisone 1-2 mg/kg/day (max: 20 mg in children <2 30 mg in children 3-5 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) Prognosis and Follow-up 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)