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Bronchial

Asthma

Casin, Elaine Gonzales Dr. CantimbuhanSenior Intern Moderator

27 Januar 2012

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GENERAL OBJECTIVES:-To present a patient with Bronchial Asthma-DifferentialDiagnosis for Bronchial Asthma-To diagnose patients with Bronchial Asthma- Management for patients with BronchialAsthma

SPECIFIC OBJECTIVES:-To present a clinical history & PE of patients withbronchial asthma in exacerbation-To present the Classifications by asthma severity and

asthma control used to diagnose patients with BronchialAsthma-To present the Specific Management (pharmacologic andControl-Avoidance)

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL

IMPRESSIONMANAGEMENT

G

E

NE

R

AL

DA

T

A

D.D

-8 y/o, female

-Buddhist

-Filipino- Born and is currently residing in

Dasmarinas, Cavite

- Admitted: January 04, 2012, 4pm

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


C

H

IE

F

CO

M

P

LA

I

N

T

³Difficulty of Breathing´

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL

IMPRESSIONMANAGEMENTHx

OF

P

R

E

S

EN

T

I

LL

N

E

S

S

3 days PTA

- (+) productive cough,

whitish phlegm, worse

at night

- (-) colds, fever, headache,dysphagia, nausea or

vomiting, dyspnea

- (-) meds/ consult

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


OF

P

R

E

S

EN

T

I

LL

N

E

S

S

1 day PTA

- (+) persistence of productive

cough, whitish phlegm worse

at night

- (+) undocumented fever, dyspnea- (-) colds, headache, dysphagia, nausea

or vomiting

- (-) limitation of daily activity

(attended dance practice)- (+) Salbutamol Nebulization

Q4: provided temporary relief

- (-) consult

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


OF

P

R

E

S

EN

T

I

LL

N

E

S

S

Few hours PTA

- (+) persistence of symptoms with

anorexia & progressivedyspnea & chest tightness- (+) Consult with nearby clinic:

Combivent Neb. 1 dose no relief

- (+) Consult at DL-UMC ER:Persistent & progressive

dyspnea when W ALKING

- (+) Admitted

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL

IMPRESSIONMANAGEMENTP

A

ST

M

ED

I

C

AL

Hx

(+) Bronchial Asthma since 3

years old-Last Attack: November 2011

- Salbutamol Inhaler PRN

(+) Allergy : shrimp

(-) previous HOSPITALIZATION/

surgery, allergic rhinitis,atopy

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL

IMPRESSIONMANAGEMENTF

A

MI

L

Y

ME

D

I

CA

L

Hx

(+) Bronchial Asthma:maternal

(+) Allergic Rhinitis:

maternal

(+) Hypertension:

maternal

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


B

I

R

TH

&

M

A

T

E

R

N

A

L

Hx

Born term @ 37 weeks via LTCSdue to CPD

MOTHER: (+) regular prenatal

check-ups

(-) UTI or previous

infections during pregnancy

BW: 3 kg

(-) Maternal and neonatalcomplications

(-) Normal NEWBORN

SCREENING

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


D

E

V

EL

O

P

M

E

N

T

A

L

Hx

Gross Motor - Rolls over at 6 months

- Sits at 12 months

- Walks at 13 monthsFine Motor

- Scribbles at 4 years old

Language- Phrases at around 15 months

Personal and Social

- interactive play at 2 y/o

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


N

U

T

R

I

T

IO

N

A

L

Hx

Breastfed until 1 year old

Supplementary feeding at 8 months

old

Cerelac

Promil for a year, then shifted toProgress from 3 to 4 years old.

Good appetite with no food

preference

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


(+) BCG (+) 3 doses of Hep. B, DPT,

OPV

(+) MMR (+) Hib

(+) pneumococcal

No serious reactions

I

M

MU

N

I

ZA

T

I

O

N

Hx

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


Grade 3 student

Active member of Buddhist Church

Regularly attend dance practice and

perform during worship

Usual Diet: chips, meat, rice

Lives in a 2-storey( SUBDIVISION) with her

parents and a sibling.

MOTHER: 30 Y/O, HOUSEWIFE, NON-

SMOKER,

NON- ALCOHOLIC

BEVERAGE

DRINKER.

FATHER: 32 Y/O, EMPLOYEE, OCCASIONAL

SMOKER AND ALCOHOLIC BEVERAGE

DRINKER

P

E

R

SO

N

A

L

S

O

C

I

A

L

Hx

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


POSITIVEDyspnea

Fever, undoc.

weakness

Prod. Cough

Anorexia

chest tightness

ColdsChills

Abdominal pain

Body malaise

Loss of

cosciousness

R

E

V

I

E

W

OF

S

Y

S

T

E

M

S

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


I. GENERAL SURVEYPatient is awake, mesomorph, and in moderate

respiratory distress. Patient appeared her

chronological age of 8.

II. VITAL SIGNSBP: 110/70mmHg

RR: 36 cpm

HR: 140

TEMP: 36.8 C

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


EXAMINATION OF THE SKIN

(-) pallor

(-) jaundice(-) primary or secondary skin lesions

(+) good skin turgor

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


EXAMINATION OF THE HEENT

(+) Pink palpebral conjunctiva

(-) eye discharge or tearing(-) icteric sclera

(-) CLAD

(+) supraclavicular retractions

(+) alar flaring

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


EXAMINATION OF THE CHEST AND LUNGS

(+) symmetric chest expansion

(+) tachypneic

(+) tight airways per auscultation(+) equal lung sounds

(+) wheezes

(-) crackles

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


CARDIOVASCULARSYSTEM

(+) tachycardic,

regular rhythm.(-) murmur

ABDOMEN

(+) Flat and

symmetrical

(-) visible veins,

pulsations or peristalsis.

(+) Normoactive

bowel sounds(+) soft and non-

tender .

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


EXAMINATION OF THE EXTREMITIES

(+) Full & equal peripheral pulses

(-) cyanosis(-) edema

(-) deformities

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


NEUROLOGIC

- Awake, conscious, coherent, oriented

to 3 spheres, speaks in sentences,ambulant.

-Cranial Nerves: intact

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SALIENT FEATURES

CLINICAL HISTORY

(+) productive cough, whitishphlegm, worse at night

(+) dyspnea ( shortness of breathwhen walking)

(+) undocumented fever (+) anorexia (+) chest tightness (+) dyspnea responded with anti-

asthma therapy (salbutamol

nebulization) (+) history of diagnosis of bronchialasthma

(+) family history of bronchialasthma

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SALIENT FEATURES

PHYSICAL EXAMINATION

tachycardic ( 140 bpm) tachypneic ( 36 cpm) (+) alar flaring (+) supraclavicular

retractions (+) tight airways per auscultation

(+) wheezes

(-) cyanosis speaks in words and inmoderate respiratory distress

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL


PRIMARY WORKINGIMPRESSION:

Bronchial Asthma,partly controlled, in

acute moderateexacerbation

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BRONCHIAL ASTHMA:

Clinically - Widespread airway narrowingwhich changes in severity over short

periods of time, either spontaneously or

in response to treatment Physiologically - Bronchial

Hyperresponsiveness

Pathologically - Airway inflammation

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BRONCHIAL ASTHMA:

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BRONCHIAL ASTHMA:

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BRONCHIAL ASTHMA:

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DIFFERENTIAL DIAGNOSES:1. PNEUMONIA

RULE IN RULE OUT

-Dyspnea

-Productive cough

- undocumented

fever

- anorexia

-Tachypneic (36cpm)- (+) supraclavicular

retractions

-(-) crackles

- can not be totally ruledout

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DIFFERENTIAL DIAGNOSES:1. bronchiolitis

RULE IN RULE OUT

-Dyspnea

-Productive cough

- anorexia

-Tachypneic (36cpm)

- (+) alar flaring

-(+) wheezes- (+) supraclavicular retractions

-Severe symptoms

usually evident in infants

(3-6mons.)

- (-) coryza, congestion,

pharyngitis, colds

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DIFFERENTIAL DIAGNOSES:1. bronchitis

RULE IN RULE OUT

-Dyspnea

-Productive cough

- anorexia

-Tachypneic (36cpm)

- (+) alar flaring

-(+) wheezes- (+) supraclavicular retractions

-(-) increased sputum volume

- (-) clad, sore throat, runny

nose, headache, muscleaches, extreme fatigue

- smoking is the predominant

cause

- affects male> fem- chronic bronchitis affects

more adults> children

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL

IMPRESSIONMANAGEMENTM

A

N

A

G

E

M

E

N

T

AT

THE

E.R

SUPPORTIVE:

O2 SPOT CHECK: 86%-> 96%->99%O2 support via face mask @ 6LPM

IVF: D5 0.3 NaCl 500cc x 28-29gtts/min

(Mild in 8)

THERAPEUTICS:

Continuous Nebulization with Ipatropium

bromide + Salbutamol (Duavent) for 1hour

Hydrocortisone 100 mg IV

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PHYSICAL

EXAMINATION

CLINICAL

HISTORY

CLINICAL

IMPRESSIONMANAGEMENTM

A

N

A

G

E

M

E

N

T

AT

THE

E.R

DIAGNOSTICS:

CBC PC

Chest Xray APL

Advised Admission

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COURSE IN THE WARDS1. DAY 0-1

S> (+) D YSPNEA, shortness of breath, chesttightness

O> HR: 126 RR32 TEMP36.8 C

O2 SAT: 96%

(+) WHEEZES, (+) SUPRACLAVICULAR

RETRACTIONS

(-) PALLOR, (-) RETRACTIONS, (-)

CRACKLES, (-) MURMUR, (-) DECREASED

BREATH SOUNDS, (-) CYANOSIS

A> BRONCHIAL ASTHMA IN ACUTE MODERATE

EXACERBATION;

PNEUMONIA

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P> IVF:D5

0.3 NACL

500 CC X 28-29GTTS/MIN (MILD IN 8 HOURS)

DIAGNOSTICS:

- CBCPC: hgb 160, hct 0.48, wbc16.8segmenters 0.86

lymph0.11

monocytes0.02

platelet542

- CXR-APL: NON-SPECIFIC

PNEUMONITIS

COURSE IN THE WARDS

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P> THERAPEUTICS:- Hydrocortisone 90 mg iv q6

- salbutamol neb, alternate with

ipatropium bromide+salbutamol neb.

Q4- cefuroxime 700 mg iv q8 anst

SUPPORTIVE:

- 02 via face mask @ 5-6lpm hooked to continuous pulse oximeter

monitored vs q1 with fmrr

diet: hypoallergenic

COURSE IN THE WARDS

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S> (+) D YSPNEA

O> HR: 124 RR28 TEMP37.5 C

O2 SAT: 99%

(+) WHEEZES

(-) PALLOR, (-) RETRACTIONS, (-)CRACKLES,

(-) MURMUR, (-) DECREASED BREATH

SOUNDS, (-) CYANOSIS


EXACERBATION;

PNEUMONIA

COURSE IN THE WARDS

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P> IVF:D5

NM500CC X 17-18GTTS/MIN(FM)

THERAPEUTICS:

- Hydrocortisone 90 mg iv q6

- cefuroxime 700 mg iv q8 anst- ipatropium bromide+salbutamol

nebulization Q4

- discontinued salbutamolnebulization

COURSE IN THE WARDS

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P> SUPPORTIVE:- 02 shifted to nasal cannula @

2-3lpm

hooked to continuous pulse

oximeter Monitored vs q4 with fmrr

diet: small frequent feedings

with sap

COURSE IN THE WARDS

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S> (+) slight dyspneaO> HR: 108 RR25 TEMP36.2 C

O2 SAT: 96%

(-) PALLOR, (-) RETRACTIONS, (-) wheezes(-

)CRACKLES, (-) MURMUR, (-) DECREASEDBREATH SOUNDS, (-) CYANOSIS


EXACERBATION;

PNEUMONIA

COURSE IN THE WARDS

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P> IVF:D5

NM500CC X 17-18GTTS/MIN(FM)

THERAPEUTICS:


- cefuroxime 700 mg iv q8 anst- ipatropium bromide+salbutamol

nebulization Q4

- started salmeterol+fluticasone 1 puff bid

(gargled every after use)

COURSE IN THE WARDS

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P> SUPPORTIVE:- 02 support shifted to PRn basis

hooked to continuous pulse

oximeter

Monitored vs q4 with fmrr diet: small frequent feedings

with sap

COURSE IN THE WARDS

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S> Slight dyspnea, occasionalO> HR: 108 RR25 TEMP36.2 C

O2 SAT: 96%

(+) WHEEZES

(-) PALLOR, (-) RETRACTIONS, (-)CRACKLES,(-) MURMUR, (-) DECREASED BREATH

SOUNDS, (-) CYANOSIS


EXACERBATION;

PNEUMONIA

COURSE IN THE WARDS

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P> IVF:D5

NM500CC X KVO

THERAPEUTICS:


- cefuroxime 700 mg iv q8 anst

- ipatropium bromide+salbutamolnebulization Q4

- salmeterol+fluticasone 1 puff

bid (gargled every after use) SUPPORTIVE:

- discontiued 02 support & pulse

oximeter .

COURSE IN THE WARDS

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P> MAY GO HOME:- CEFUROXIME 250mg/5ml, 6ml BID

for 7 more days

- clarithromycin 250mg/5ml, 3ml

bid for 7 days- ipatropium bromide+salbutamol

nebulization q6

- salmeterol+fluticasone 25mg/125mg inhaler, 2 puffs bid

- prednisone syrup 10mg/5ml, 5ml

xbid for 3 days

CASE DISCUSSION

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CASE DISCUSSION

BRONCHIAL ASTHMA

- A chronic inflammatory disease of the airways.

-REVERSIBLE AIRWAY OBSTRUCTION

(bronchoconstriction, mucus plugs & increased

inflammation), INCREASED BRONCHIAL REACTIVITY,

AIRWAY INFLAMMATION

-Asthma attacks are episodic, but airway inflammation is

chronically present

-300 million individuals affected worldwide; prevalence is

increasing especially in children

CASE DISCUSSION

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CASE DISCUSSION

CONFIRM BRONCHIAL ASTHMA DIAGNOSIS

CASE DISCUSSION

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CASE DISCUSSION

Measurements of lung function provide an

assessment of repairability, and variability of

airflow limitation, and help confirm the

diagnosis of asthma.

SPIROMETRY: An increase in FEV1 of >12%

and >200 ml after administration of a

bronchodilator (reversible airflow limitation

consistent with asthma)

CASE DISCUSSION

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CASE DISCUSSION

PEAK EXPIRATORY FLOW

Measurements can be an important aid in

both diagnosis and monitoring of asthma

AN improvement of 60L/min (or > 20% of

the pre-bronchodilator PEF), after inhalationof a bronchodilator

CASE DISCUSSION

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CASE DISCUSSION

STEPSMANAGEMENT FOR PATIENTS WITH BRONCHIAL ASTHMA

Advice avoidance to triggering factors:

Tobacco smoke

drug, food, additives

House dust mites and cockroahes

Animals with furOutdoor pollens and mold

Indoor mold

Exercise

Pharmacologic Therapy

CASE DISCUSSION

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CASE DISCUSSION

BRONCHIAL ASTHMA

-CONTROLLER: taken daily to prevent

symptoms, improve lung function, and

prevent attacks. Inhaled glucocorticosteroids

Systemic glucocorticosteroids

Cromones

Methylxanthines Long-acting inhaled 2-agonists

Long-acting oral 2-agonists

Leukotriene modifiers

Anti-IgE

CASE DISCUSSION

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CASE DISCUSSION

BRONCHIAL ASTHMA

-RELIEVER: Treats acute symptoms such as

wheezing, chest tightness, and cough

Rapid-acting inhaled 2-agonists

Systemic glucocorticosteroids

Anticholinergics

Methylxanthines

Short-acting oral 2-agonists

CASE DISCUSSION

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CASE DISCUSSION

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FF22++ MechanismMechanism of Actionof Action

o muco-ciliary clearence

q v ascular permeability

Inhibition of transmitter release from mastcells

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FF22 AgonistsAgonists

Selectiv e (Terbutaline, Salbutamol) ± First line therapy ± Short onset of action (2-5 min)

± Long duration of action (3-6 h) ± Different routes of administration

Non selectiv e (epinephrine) ± Vasoconstricting agent ± Short duration of action ± Side effects

A ti h li iA ti h li i

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AnticholinergicsAnticholinergicsMechanismMechanism of Actionof Action

Ach competitiv e inhibitors

muscarinic receptors antagonists

Bronchodilators

Inhibitors of the bronchoconstriction induced byirritant agents

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CorticosteroidsCorticosteroids

q hospital admission if administered within the 1st hour

Equal benefit of orally and IV administration ± Rowe et al. Cochrane Database Syst Rev, 2000

Dose ranging from 30-400 mg methylprednisolone :

± Manser et al. Cochrane Database Syst Rev, 2000 Inhaled vs systemic corticosteroids: (Edmonds et al. Cochrane

Database Syst Rev. 2003) ± o PEFR and FEV1 as compared with placebo

± as effective as systemic corticosteroids ?

± Combination better than systemic route alone ?

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MethylxanthinesMethylxanthines

No benefit from adding methylxanthines to F2+

More adv erse effects ± Parameswaran et al. Cochrane Database Syst Rev 2000

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MgSOMgSO44

Inhalation: ± Improv ement in clinical score (Fischl), o PEFR, o PP

± Nannini LJJr. Am J Med 2000

± Mangat HS Eur Respir J 1998 o PEFR

IV: ± Boonyav orakul C. Respiratology 2000

Hospital admission = NS; score = NS ± Rowe BH. Ann Emerg Med 2000

q admission rate in sev ere asthma exacerbations

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AntibioticsAntibiotics

Graham et al. Cochrane Database Syst Rev .2001 ± No benefit when comparing antibiotics to placebo

Indications: GOLD-guideline (Pauwels et al.Respir Care 2001)

± Worsening dyspnea and cough ± Increased sputum v olume and purulence

± Infiltrates on the chest X-ray

CONTROLLERS

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CONTROLLERS

CONTROLLERS

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CONTROLLERS

CONTROLLERS

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CONTROLLERS

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COMBINATION MEDICATIONS

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RELIEVERS

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RELIEVERS

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RELIEVERS

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REFERENCES

GLOBAL INITIATIVE FOR ASTHMA (2011)

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THANK YOU

GOD BLESS

Date post:	06-Apr-2018
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