Download Bronchial Asthma


Identify pertinent findings from the history
and physical examination that would
contribute to the diagnosis of asthma
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Provide an approach in diagnosing patients
with ashtma
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Learn how to manage patients with ashtma
G.B., 35/F, from Quezon City, married,
Roman Catholic
 DOA: 06.11.12
 CC: DOB of 3 hours
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1.2
1
0.8
0.6
Salbutamol Nebulization TID
Guaiafenesin
BID x 7 days
Prednisone
BID x 5 days
DOB
0.4
0.2
0
3 weeks 2weeks
1 week
3 hours
30 mins
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No fever, chest pain, palpitations, edema
Noted with chronic productive cough since
February 2012 –
February – greenish sputum, consult at Lung
Center, given Procaterol HCL (Meptin) 50
mcg/tab BID x 5 days
April-May – whitish sputum, ENT consult
(Impression: Laryngitis), given Prednisone 10
mg/tab BID
June – yellow sputum
Noted with weight loss - ~ 10 kg in 5 months
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CAP – January 2012, admitted at Sta.
Ana Hospital for 1 month, intubated for
20 days, sputum CS: (+) Klebsiella sp.,
given unrecalled antibiotics and home
medications
Asthma – maternal side
 HTN – both sides
 Leukemia – paternal uncle
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Non-smoker, does not consume alcohol
 Exposed to a sibling with PTB (treated for
6 months)
 Works as an accountant in a private
company
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Awake, coherent, ambulatory but weak-looking, labored
breathing
BP: 120/80 mmHg HR: 101 bpm RR: 28 cpm T: 36.8°C
Fair complexion, good skin turgor and mobility
Anicteric sclera, pink palpebral conjunctivae, no
tonsillopharyngeal congestion, no cervical
lymphadenopathies, neck veins not distended
Symmetrical chest expansion but with use of accessory
muscles for respiration, tachypneic, with wheezes on all lung
fields, harsh breath sounds
Adynamic precordium, tachycardic, regular rhythm, distinct
S1 and S2, no murmur, PMI at the 5th ICS LMCL
Flat abdomen, normoactive bowel sounds, soft, non-tender,
no mass
Full and equal pulses, no cyanosis, no edema
DOB x 3 weeks, temporarily and slightly
relieved by Salbutamol Nebulization,
Guaiafenesin BID x 7 days, Prednisone 110
mg/tab BID x 5 days
 Chronic productive cough (5 months)
 History of asthma on the maternal side
 PE: weak looking, on labored breathing,
tachypneic, with use of accessory muscles
of respiration, noted with wheezing on all
lung fields
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Bronchial Asthma in Acute Exacerbation
02 Supplementation at 2 lpm via NC
 Salbutamol Nebulization x 6 doses
(continuous) then q1
 Budesonide Nebulization q12
 Hydrocortisone 50 mg/tab IV q6
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ECG: ST
 CXR: CLF
 Na/K: 140/3.2
 CBC: 150/43/13.1/58/40/E2/N/N
 ABGs: 7.38/45/27.20/147/99% at 2 lpm
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Syndrome characterized by airflow
obstruction that varies markedly , both
spontaneously and with treatment.
 Narrowing of airways is usually reversible,
but in some chronic cases, there could
be irreversible airflow obstruction
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Exposure to allergens
Occupational irritants (asbestos)
Tobacco smoke
Respiratory (viral) infections
Exercise
Strong emotional expression
Chemical irritants (aerosols)
Drugs (ASA, B Blocker)
Family history of asthma
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Episodic airway obstruction
Dyspnea, “difficulty filling lungs with air”
Coughing: increased mucus production in some
with typically tenacious mucus that is difficult to
expectorate; in some, non-productive
 Increased ventilation and use of accessory
muscles
 Prodomal Sx: itching under the chin, discomfort
between the scapulae, inexplicable fear
 Wheezing, rhonchi on all lung fields
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*maybe worse at night; patients typically awake in
early morning hours
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Has the patient had an attack or recurrent
attacks of wheezing?
Does the patient have troublesome cough at
night?
Does the patient wheeze or cough after an
exercise?
Does the patient experience wheezing, chest
tightness, or cough after exposure to airborne
allergens or pollutants?
Does the patient’s colds “go to chest” or take
more than 10 days to clear up?
Are symptoms improved by asthma treatment?
Lung Function Tests
 Airway Responsiveness
 Hematologic Tests
 Imaging
 Skin tests
 Non-Invasive Markers
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REVERSIBILITY - rapid improvements in
FEV1 (or PEF), measured within minutes
after inhalation of rapid-acting
bronchodilator or more sustained
improvement over days or weeks after
the introduction of effective controller
treatment such as inhaled corticosteroids
 VARIABILITY- improvement or
deterioration in symptoms and lung
function occurring over time
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SPIROMETRY – confirms airflow limitation
with a reduced FEV1 (12% and 200 ml
increase from the pre-bronchodilator
value), FEV1/FVC ratio (< 0.75-0.80)
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The duration in the reduction of FEV1
value depends on the type of
broncholdilator used: 15 mins for shortacting B2 agonist, 2-4 weeks for oral
glucocorticoid
PEAK EXPIRATORY FLOW –
 Advantage: can aid both in diagnosis
and monitoring, inexpensive, portable,
ideal for home settings for day-to-day
objective measurement of airflow
limitation.
 Disadvantage: can underestimate the
degree of airflow limitation as the
limitation and gas trapping worsen
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METHODS OF DESCRIBING PEF
% of the Daily Mean PEF:
-difference b/w the max and min value for the day,
averaged for 1-2 weeks
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% of the Recent Best (Min%Max):
-minimum morning pre-bronchodilator PEF over 1
week is measured
-best PEF index of airway lability
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ASTHMA =60 L/min (20% or more of prebronchodilator PEF) improvement after inhalation of
bronchodilator
Flow Volume Loops – reduced peak flow
and reduced maximum expiratory flow
 Body Plethysmography – increased
airway resistance, total lung capacity,
and residual volume
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METACHOLINE OR HISTAMINE CHALLENGE –
measures increase in AHR with calculation
of the provocative concentration of the
agonist that reduces FEV1 by 20%
 EXERCISE TESTING – demonstrates postexercise bronchoconstriction
 ALLERGEN CHALLENGE – rarely necessary,
should only undertaken by specialist if
specific occupational agents are to be
identified
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TOTAL SERUM IgE to inhaled allergens –
not usually helpful
CXR – usually normal; hyperinflated lungs
in severe cases; pneumothorax in
exacerbations
 HIGH-RESOLUTION CHEST CT – areas of
broncheictasis and thickening of
bronchial walls in severe cases (not
diagnostic of asthma)
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SKIN PRICK TESTS
- (+) in allergic asthma but (-) in intrinsic
ashtma
-not helpful in the diagnosis but is the
primary diagnostic tool in determinning
allergic status
-Main Limitation: a positive test does not
necessarily mean that the disease is
allergic in nature or that it is causing
asthma
Examining spontaneously produced or
hypertonic saline –induced sputum for
eosinophilic or neutrophilic inflammation
 Nitric oxide
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Assessment of current clinical control
(preferably 4 weeks)
B. Assessment of future risks (risk of
exacerbations, instability, rapid decline
in lung function, side-effects)
A.
Characteristics
Controlled
Partly Controlled Uncontrolled
Daytime
Symptoms
None (twice or
less/week)
More than twice
a week
Limitations of
Activities
None
Any
Nocturnal
None
symptoms/Awak
ening
Any
Need for
reliever/rescue
treatment
None (twice or
less/week)
More than twice
a week
Lung Function
(PEF or FEV1)
Normal
<80% predicted
or personal best
(if known)
3 or more
features of partly
controlled
asthma +
exacerbation in
any week
(should prompt
review of
maintenance
treatment to
ensurethat it is
adequate
Features that are associated with
increased risk of adverse invents in the
future:
 Poor clinical control
 Frequent exacerbations in the past year
 Ever admission for critical care asthma
 Low FEV1
 Exposure to cigarette smoke
 High dose medications
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Chronic cough as the principal, if not
only symptom
 common in children
 commonly more problematic at night
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Rule-In
Rule-Out
Upper airway
obstruction (tumor,
laryngeal edema)
DOB
Stridor localized to
large airways
Endobronchial
obstruction with
foreign body
DOB
Persistent wheezing in
specific area of the
chest
LV Failure
Wheezing
Basilar crackles
COPD
DOB, wheezing
Less variability of
symptoms, never
completely remit,
much less or no
reversibility to
bronchodilators
One of the most common chronic
diseases
 Approximately 300 million people are
affected
 Can present at any age, with a peak
age of 3 y/o
 In childhood, M:F 2:1
 In adulthood, M:F 1:1
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Children with asthma usually become
asymptomatic during adolescence but that
asthma returns during adult life.
 Adults with asthma, rarely become
permanently asymptomatic.
 Prevalence is increased in very young
persons and very old persons because of
airway responsiveness and lower levels of
lung function.
 Deaths from asthma are uncommon.
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ENDOGENOUS FACTORS
TRIGGERS
ENVIRONMENTAL
FACTORS
Genetic predisposition
Allergens
Atopy
Airway
hyperresponsiveness
Upper respiratory tract Outdoor allergens
viral infections
Exercise and
Occupational sensitizers
hyperventilation
Gender
Cold air
Passive smoking
Ethnicity?
Sulfur dioxide and
irritant gases
Drugs ( Beta blockers,
aspirin)
Stress
Respiratory infections
Obesity?
Early viral infections?
Irritants (household
sprays, paint fumes
Indoor allergens
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Involves the following components:
› Airway inflammation
› Intermittent airflow obstruction
› Bronchial hyperresponsiveness