Transcript bronchial asthma in acute exacerbation

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)