Transcript JAMES CASE

Asthma practical cases
Asthma practical cases
Asthma differential diagnosis - Questions
What is the differential diagnosis in the following cases:
•
5 years old child with single episode of cough and wheeze
in September of the first year at school.
Asthma practical cases
Asthma differential diagnosis – answers
What is the differential diagnosis in the following cases:
•
Acute bronchitis
Asthma practical cases
Asthma differential diagnosis - Questions
What is the differential diagnosis in the following cases:
•
2 ½ years child who developed a fit of coughing during a
birthday tea at a friends house
Asthma practical cases
Asthma differential diagnosis – answers
What is the differential diagnosis in the following cases:
•
FB
Asthma practical cases
Asthma differential diagnosis - Questions
What is the differential diagnosis in the following cases:
•
55 years lifelong smoker with history of increasing
breathlessness on exertion
Asthma practical cases
Asthma differential diagnosis – answers
What is the differential diagnosis in the following cases:
•
COPD
Asthma practical cases
PFM case – question
You take PFM from 20 years old male, height 175 cm
A. what is his predicted reading?
B. Over the next 3 days his readings are:
– day 1 am=400, pm 550
– day 2 am=410, pm 555
– day 3 am=395, pm 550
– is this abnormal?
Asthma practical cases
PFM case - answer
A. 590 L/min
B. Abnormal variability
550-400/550=27%
555-410/555=26%
550-395/550=28%
Asthma practical cases
Asthma diagnostic tests - questions
Choose the most appropriate diagnostic test for the following
patients:
• 14 years boy who finds he gets breathless when playing
football, PFM is normal when come to your clinic
Asthma practical cases
Asthma diagnostic tests - answers
Choose the most appropriate diagnostic test for the following
patients:
• Exercise test
Asthma practical cases
Asthma diagnostic tests - questions
Choose the most appropriate diagnostic test for the following
patients:
• 35 years old man who presents for the first time, and has
PFM of 250 in the clinic
Asthma practical cases
Asthma diagnostic tests - answers
Choose the most appropriate diagnostic test for the following
patients:
• Reversibility test
Asthma practical cases
Asthma diagnostic tests - questions
Choose the most appropriate diagnostic test for the following
patients:
• 60 years old heavy smoker who has not responded to high
dose B2 agonists
Asthma practical cases
Asthma diagnostic tests - answers
Choose the most appropriate diagnostic test for the following
patients:
• Steroid trial
Asthma practical cases
Asthma diagnostic tests - questions
Choose the most appropriate diagnostic test for the following
patients:
• 23 years old who had worse symptoms since starting his job
at a bakery
Asthma practical cases
Asthma diagnostic tests - answers
Choose the most appropriate diagnostic test for the following
patients:
• Serial PEF for 2w
Asthma practical cases
Delivery systems case - questions
Choose the appropriate delivery systems in the followings
(one or more):
B2 agonists for18 month baby?
Asthma practical cases
Delivery systems case - answers
Spacer device with facemask
Asthma practical cases
Delivery systems case - questions
Choose the appropriate delivery systems in the followings
(one or more):
B2 agonist for 18 year who is unable to use MDIs correctly?
Asthma practical cases
Delivery systems case - answers
DPI/breathe actuated MDI
Asthma practical cases
Delivery systems case - questions
Choose the appropriate delivery systems in the followings
(one or more):
B2 agonist for 27 year old, successfully controlled since
childhood on MDI
Asthma practical cases
Delivery systems case - answers
MDI
Asthma practical cases
Delivery systems case - questions
Choose the appropriate delivery systems in the followings
(one or more):
B2 stimulant reversibility testing in the clinic
Asthma practical cases
Delivery systems case - answers
Spacer + MDI or nebulizer
Asthma practical cases
Delivery systems case - questions
Choose the appropriate delivery systems in the followings
(one or more):
B2 stimulant in acute sever asthma
Asthma practical cases
Delivery systems case - answers
Spacer/nebulizer
Asthma practical cases
JAMES CASE
James is 18 month old and is presenting for the first time
with intermittent cough and wheeze, the history suggest
URTI which is possible trigger. In the clinic his symptoms
relieved by high dose ventoline via LVS
A- If ventoline via LVS had not produce response what you
will do?
Asthma practical cases
JAMES CASE - answers
Send to hospital
Asthma practical cases
JAMES CASE
James is 18 month old and is presenting for the first time
with intermittent cough and wheeze, the history suggest
URTI which is possible trigger. In the clinic his symptoms
relieved by high dose ventoline via LVS
B- His mother is anxious, asks you is it asthma? How do
you reply?
Asthma practical cases
JAMES CASE - answers
Yes it may be asthma, but it can be difficult to be sure at
this age because there is no special test can be done,
viral infections can cause wheezing in young children.
This effect often improve as child get older
Asthma practical cases
JAMES CASE
James is 18 month old and is presenting for the first time
with intermittent cough and wheeze, the history suggest
URTI which is possible trigger. In the clinic his symptoms
relieved by high dose ventoline via LVS
C. What treatment do you recommend?
Asthma practical cases
JAMES CASE - answers
High dose inhaled bronchodilator + rescue PO
Prednisolone to gain rapid control (10 mg up to 3 days)
Asthma practical cases
JAMES CASE
James is 18 month old and is presenting for the first time
with intermittent cough and wheeze, the history suggest
URTI which is possible trigger. In the clinic his symptoms
relieved by high dose ventoline via LVS
D. What inhaler system is appropriate?
Asthma practical cases
JAMES CASE – answers
LVS + mask if necessary eg volumatic/nebuhaler
Asthma practical cases
JAMES CASE
James is 18 month old and is presenting for the first time
with intermittent cough and wheeze, the history suggest
URTI which is possible trigger. In the clinic his
symptoms relieved by high dose ventoline via LVS
E. How you will respond to James mother questions?
1. (will he grow out of it)?
2. I think the dog make him wheeze, should we get
rid of the dog?
3.
Can we test to see what's he is allergic to?
Asthma practical cases
JAMES CASE – answers
E- my response will be:
1.
2.
3.
Not all children “grow out of asthma”. Some improves as they
get older and they may have periods when they have no
symptoms. However asthma can recur at any time because its
variable disease
Wait and see. It should be possible to control symptoms,
without getting rid of the dog. Removing a pet may cause more
distress. Give general advice on keeping the dog out of the
bedroom etc
SPT may be unreliable at this age. It will not affect choice of the
treatment. Good history may pinpoint the specific allergen.
Invasive procedures in children should be avoided if possible
Asthma practical cases
JENNY CASE
Jenny is 7 years old and has asthma. She has recently
had an asthma attack and was admitted to hospital.
She is about to start a new school, and her mother is
worried about school attendance. Jenny is worried in
case she has another asthma attack and she will not
have access to her inhalers
A.
What treatment does jenny need? What is an
appropriate dose for jenny?
Asthma practical cases
JENNY CASE – answers
Inhaled steroids 100mcg/twice/day - maximum 400mcg/day
Asthma practical cases
JENNY CASE
Jenny is 7 years old and has asthma. She has recently
had an asthma attack and was admitted to hospital.
She is about to start a new school, and her mother is
worried about school attendance. Jenny is worried in
case she has another asthma attack and she will not
have access to her inhalers
B. What inhaler deliver system is suitable for jenny?
Asthma practical cases
JENNY CASE – answers
LVS or DPI
Asthma practical cases
JENNY CASE
Jenny is 7 years old and has asthma. She has recently
had an asthma attack and was admitted to hospital.
She is about to start a new school, and her mother is
worried about school attendance. Jenny is worried in
case she has another asthma attack and she will not
have access to her inhalers
C.
Give 2 advantages, 2 disadvantages of starting PEF
monitoring
Asthma practical cases
JENNY CASE – answers
PEF monitoring gives a regular objective indication of asthma
control. It can demonstrate a response to treatment.
If technique is poor the measurement is unreliable. Regular
PEF monitoring can become a tedious chore for many
children and is often forgotten
Asthma practical cases
JENNY CASE
Jenny's mother is concerned by treatment prescribed.
You spend time reassuring her. At jenny's next
appointment 2 weeks later, you find that her PEF is still
below her previous best and her symptoms persist
D.Suggest 2 reasons why the treatment has not been
successful
Asthma practical cases
JENNY CASE – answers
Poor inhaler technique dosage and medication not taken as
prescribed
Asthma practical cases
JENNY CASE
Jenny's mother is concerned by treatment prescribed.
You spend time reassuring her. At jenny's next
appointment 2 weeks later, you find that her PEF is still
below her previous best and her symptoms persist
E.Give 2 advantages, disadvantages of inhaled steroids
Asthma practical cases
JENNY CASE – answers
Effective anti-inflammatory treatment twice/day delivered
directly to lung etc. oral candidiasis, dysphonia (parents
sometimes don’t accept)
Asthma practical cases
EDNA CASE
Edna is 70 years old ex-smoker with chronic bronchitis.
She was always chesty as a child. Her breathlessness
and cough are worse in cold air and after URTI. PEF is
200L/minute. Twenty minutes after 400mcg of inhaled
ventoline there is no change
A.
what further tests do you consider? Give dosage
where drugs are used
Asthma practical cases
EDNA CASE - answers
A.
Higher dose up to 2.5mg salbutamol (or equivalent via
nebulizer, detailed LFT, oral steroid trial
30mg/day/2weeks
Asthma practical cases
EDNA CASE
Edna is 70 years old ex-smoker with chronic bronchitis.
She was always chesty as a child. Her breathlessness
and cough are worse in cold air and after URTI. PEF is
200L/minute. Twenty minutes after 400mcg of inhaled
ventoline there is no change
B.
Inhaled steroids are prescribed. What delivery system
do you recommend?
Asthma practical cases
EDNA CASE - answers
B.
LVS/small volume spacers and MDI
Asthma practical cases
EDNA CASE
Edna is 70 years old ex-smoker with chronic bronchitis.
She was always chesty as a child. Her breathlessness
and cough are worse in cold air and after URTI. PEF is
200L/minute. Twenty minutes after 400mcg of inhaled
ventoline there is no change
C.
What is significant about EDNAS past history?
Asthma practical cases
C.
EDNA CASE - answers
EDNAS past history indicates that she probably had
asthma as a child. It may not have been treated
because there were no effective asthma treatments
available when she was young. She may have mixed
airway disease because of her smoking/bronchitis
history
Asthma practical cases
RICHARD CASE
Richard 45 new patient recently hospitalized for acute
sever asthma. His record show regular inhaled
steroids (800mcg daily) and inhaled bronchodilators
PRN, and frequent exacerbation of symptoms
A.
How can Richards asthma control be improved?
Asthma practical cases
RICHARD CASE – answers
- Review medication requirements, dosage,
compliance, techniques.
- Add in a long acting bronchodilator.
- Teach PEF self monitoring,
- prescribe him a home supply of oral steroids and
advice should he need to take them.
- Advise that his asthma needs regular review
Asthma practical cases
RICHARD CASE
Richard 45 new patient recently hospitalized for acute
sever asthma. His record show regular inhaled
steroids (800mcg daily) and inhaled bronchodilators
PRN, and frequent exacerbation of symptoms
B.
What would help Richards manage an acute attack in
the future?
Asthma practical cases
RICHARD CASE – answers
He needs a written personalized asthma action plan.
Discuss with him what to look for, and what to do if
asthma control deteriorates
Asthma practical cases
SARAH CASE
Sarah is 20 years old girl who has just come to your clinic
for the first time when you see her you note she is slightly
wheezy
A.
What are the important issues to be covered when taking
history from her? Justify your answers
Asthma practical cases
A.
SARAH CASE - answers
History include:
•
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•
•
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•
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Respiratory symptoms – try to exclude acute sever asthma
Current symptoms
Personal history of asthma, atopy
Severity of symptoms – frequency, seasonal, episodic etc
Previous hospital admissions for asthma if any
FH of asthma, atopy
Asthma triggers
Other health issues
Current, past medications
Previous inhaler advice
Occupation – current, previous
Smoking status
Asthma practical cases
SARAH CASE
Sarah is 20 years old girl who has just come to your clinic
for the first time when you see her you note she is slightly
wheezy
B. You find out she has had asthma since childhood but has
not had any treatment for the last few years. Explain what
assessments you will do and mention their relevance
Asthma practical cases
SARAH CASE – answers
B.
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Asthma diagnosis has been made since childhood but
she needs further work to identify severity of current
symptoms and test:
Current PEF reading, compare against predicted peak
flow for age, height
Consider reversibility test specially she is slightly
wheeze. This is not a diagnostic test but to see if there
is any airway reversibility.
Serial peak flow.
Asthma practical cases
SARAH CASE
Sarah is 20 years old girl who has just come to your clinic
for the first time when you see her you note she is slightly
wheezy
C. Discuss the possible reasons for her asthma re-occurrence
Asthma practical cases
SARAH CASE - answers
C.
The natural asthma history needs to be explained to her
and why her asthma symptoms have recurred, it may be
hormonal effect, smoking, occupation etc. she is likely to
have concerns about the recurrence of her symptoms.
Please address any concerns from her then answer them.
Asthma practical cases
SARAH CASE
Sarah is 20 years old girl who has just come to your clinic
for the first time when you see her you note she is slightly
wheezy
D. How you will manage, what information you will give her?
Asthma practical cases
SARAH CASE - answers
D.
She needs to start inhaled asthma drugs. Explain the aims
of treatment to her. She needs short acting bronchodilator,
mention what device you suggest to her. If she has
persistent symptoms she will need to have inhaled steroids
as well.
she may need rescue course oral steroids to gain rapid
control, with review to re-assess control again
give asthma action plan, FU appointment
extra points: give her literatures (NAC booklet), NAC
website