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‘Wind taken out of the sails’
Vinothini Apok & Rebecca
Houghton
History of Mrs GW
82 yr old
Caucasian
female
A&E referral
Difficulty in breathing
Sudden onset
History (contd)
Felt ‘something trapped in windpipe’
unable to breathe
neighbours called for ambulance
On arrival in A&E…..
Severe DIB
tachycardic/tachypnoeic
unable to complete sentences
Past Medical History
Known asthmatic
- uses inhalers
- no home oxygen
- has never been admitted to ITU for
exacerbation of her asthma
non-smoker
left-sided pneumonectomy in 1950s for
TB
- 12 months of treatment with oral anti-TB meds
- good recovery
Drug History
Salbutamol inhaler bd
Atenolol 25mg od
Social History
Lives alone in house
independent
no home help
usual exercise tolerance ~50yards
Systems Review
No CNS signs
no GI signs
no GU signs
On examination….
Post nebulisers/hydrocortisone/MgSO4
alert and attentive, GCS 15/15
talking in full sentences
afebrile
warm and well-perfused
BP - 156/87, pulse 110 reg
HS I and II
Examination (contd)..
Resp rate - 24/min
Decreased air entry on left side
good air entry on right side
no tracheal deviation
slightly wheezy
abdomen - soft and non-tender
Summary
 82 yr old woman
 non-smoker
 History of TB and asthma
 Previous left pneumonectomy
Differentials
CHRONIC LUNG DISEASE
• Asthma
• COPD
• Fibrotic lung disease due to previous TB infection
ACUTE S.O.B.
• PULMONARY
– Asthma attack
– Chest infection
– Aspiration
• CARDIAC
– Left Ventricular failure
– Arrythmia
– MI
Arterial Blood and ECG
 ARTERIAL BLOOD GASES
PaO2
5.5
PaCO2
6.42
pH
7.31
HCO3
22.6
 ECG
Sinus tachycardia
No S-T elevation
>10.6KPa
4.7-6KPa
7.34-7.43
20-24
Radiology
 CHEST X RAY
Patchy opacification
Shadowing of R lung base
left Pneumonectomy
Full Blood Count
 BLOOD
Hb
MCV
Platelets
Albumin
WBC
14.6
86fL
231
36
16
Neutrophils
8.2
Lymphocytes
Monocytes
6.1
1. 2
Troponin
<0.01
11.5-16g/dL
76-96fL
150-400x10^9/L
35-50g/L
4-11x10^9/L
U&Es and LFTs
 U&Es
Na
K
Cr
Urea
Corrected Ca
140
4.6
180
7.9
2.31
135-140mmol/L
3.5-5mmol/L
70-150umol/L
2.5-6.7mmol/L
2.2-2.52mmol/L
11
114
24
11
6.4
3-35iu/L
55-150iu/L
0-50
0-17umol/L
<10mg/L
 LFTs
ALT
ALP
Gamma GT
Bilirubin
CRP
MSU and serum glucose
 URINALYSIS
Blood
Protein
Glucose
Leukocytes
Nitrites
 SERUM GLUCOSE
+1
+2
+1
+1
+1
9.7
Normal fasting 3.5-5.5mmol/L
Acute Treatment
 OXYGEN
 BRONCHODILATORS
Salbutamol
Atrovent
Aminophylline
5mg
500mg
500ml in
250ml saline
neb
neb
i/v
4 hourly
4 times daily
 GLUCOCORTICOIDS
Hydrocortisone
200mg
i/v
 INTUBATIONnot required, PaO2 improved with
brochodilators
Ward Treatment
 OXYGEN WHEN REQUIRED
 BRONCHODILATORS
Salbutamol
Atrovent
 GLUCOCORTICOIDS
Prednisolone
 ORAL ANTIBIOTICS
Amoxicillin
Metronidazole
 STOP ATENOLOL
5mg
Inhaler
500mg Inhaler
4 hourly
4 times
40mg
oral
3 times daily
500mg
400mg
oral
oral
3 times daily
3 times daily
Treatment Continued...
 ASTHMA MANAGEMENT
Assess inhaler technique, use of spacer?
Peak flow chart
Adherence to treatment
 FOLLOW UP IN 4-6 Wks
 Interesting patient
 Pneumonectomy
 Asses how patient is coping at home
 RENAL ULTRASOUNDto assess renal function
Asthma
Background
Lower respiratory tract disease
Common, chronic, inflammatory airway
disease
three characteristics:
- reversible airflow limitation
- airway hyperresponsiveness to stimuli
- inflammation of bronchi
increasing prevalence, esp. in second
decade of life
Asthma (contd)
Geographical variation
- more common in New Zealand
- rarer in Far Eastern countries
Aetiology
- atopy : IgE antibodies readily produced against
common environmental antigens
- increased airway responsiveness
Pathogenesis...
Complex and not fully understood
involves cells,mediators of inflammation
and vascular leakage activated by
exposure to allergens
Clinical features
Episodic wheezing
cough (may be only presenting symptom)
shortness of breath (typically worse at
night and early morning)
during an attack:
- reduced chest expansion,
- prolonged expiratory time
- expiratory polyphonic wheezes
Diagnosis
History
response to bronchodilators
lung function tests
- >15% improvement in FEV1 following
bronchodilator inhalation
peak flow charts
- obvious diurnal variation, with lowest values in
early morning (‘morning dip’)
Diagnosis (contd)
Skin-prick tests
- to identify allergens
Histamine/Metacholine provocation tests
- reserved for difficult diagnostic cases
- response to very low doses
Management
Patient education
Avoidance of precipitating factors
- discouraged from smoking
- avoid allergens (eg. Pets)
Specific drug treatment
- B2-agonists, eg. Salbutamol, terbutaline
- anticholinergics, eg. Ipratropium bromide
- corticosteroids eg. Beclomethasone
- anti-inflammatory agents eg. Sodium
cromoglycate
Acute severe asthma
Medical emergency
severe progressive asthmatic symptoms
over hours/days
1500 patients die annually
life-threatening features:
-
silent chest, cyanosis
bradycardia, hypotension
PEFR < 33% of predicted
exhaustion, confusion or coma
Questions?