RIVERA, 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

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

Two days PTA
• Nonproductive cough
• Difficulty of breathing
• (-) colds and fever
• Nebulized with salbutamol with improvement of DOB

Few hours PTA
• Worsening of cough and
DOB
• Unrelieved by salbutamol nebulization
• No other associated symptoms
DAY OF ADMISSION

• 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

• 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

• 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

• GU: (-) urinary frequency, urgency, hesitancy, nocturia
• Musculoskeletal: (-) joint stiffness, pain, swelling, cramps, muscle pain, weakness, wasting
• Endocrine: (-) heat-cold intolerance, polyuria, polydipsia

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

• 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


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

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

• Breastfed until 2 months
• Formula fed with Nestogen (3 ounces/bottle)
• Weaning age: 6 months (Cerelac); 9 months (rice)

• 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

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

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

Casino dealer
Call center agent
40 41
18 3


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

GENERAL APPEARANCE
Alert, quiet, weak-looking, in respiratory distress
VITAL SIGNS
BP: 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)

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

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

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
5 th ICS, MCL, normal rate, regular rhythm, distinct S1 and
S2 sounds, no murmurs

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

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

• Bronchiolitis
• Pneumonia
• Upper Respiratory Tract Infection


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

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

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

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

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

• 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 CELLS
Mast cells
INFLAMMATORY CELLS
Airway epithelial cells
Eosinophils
T-lymphocytes
Dendritic Cells
Macrophages
Neutrophils
Cytokines
Histamine
Nitric oxide
Prostaglandin D2 cells
Endothelial cells
Fibroblasts
Myofibroblasts
Airway nerves

contraction

SMOOTH MUSCLE
INCREASE
BLOOD VESSEL WALL
PROLIFERATION
MUCUS
HYPERSECRETION


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

1.
Regular Assessment and monitoring
2.
Patient Education
3.
Control of Factors Contributing to Asthma Severity
4.
Principles of Asthma Pharmacotherapy

Component 1

CHARACTERISTIC
CONTROLLED
(All of the following)
PARTLY
CONTROLLED
(Any measure present in any week)
More than twice/week
UNCONTROLLED
(3 or more of features of partly controlled asthma in any week)
More than twice/week
Daytime symptoms
Limitation of activities
Nocturnal symptoms/ awakenings
Need for reliever/rescue treatment
None
None
None
Any
Any
Any
Any
≤2 days/week >2 days/week >2 days/week

Component 2

Component 3


Eliminating and reducing problematic environmental exposures

Annual influenza vaccination

Treat co-morbid conditions

Gastroesophageal Reflux

Rhinitis

Sinusitis

Component 4

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
Continue as needed rapid-acting beta-2 agonists
CONTROLLER OPTIONS
Low-dose inhaled glucocorticosteroids
Double low-dose inhaled glucocorticosteroids
Leukotriene modifier Low-dose inhaled glucocorticosteroid plus leukotriene modifier


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


Leukotriene Modifier

Cysteinyl-leukotrienes: potent bronchoconstrictors
 cause microvascular leakage, and increase eosinophilic inflammation

Antileukotrienes (montelukast and zafirlukast)
 block cys-LT
1
-receptors and provide modest clinical benefit in asthma


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 .


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


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).


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


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
Altered consciousness
Oximetry on presentation (SaO2)
Talks in
Pulse rate
Central cyanosis
Wheeze intensity
MILD
No
≥94%
SEVERE
Agitated, confused or drowsy
<90%
Sentences Words
<100 bpm >200 bpm (o-3 years)
>180 bpm (4-5 years)
Absent Likely to be present
Variable May be quiet

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 3-
4hours
Prednisone 1-2 mg/kg/day
(max: 20 mg in children <2
30 mg in children 3-5


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


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


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


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)