Abstract

Asthma is a chronic inflammatory disorder of the airways whereby it involves many cells and
cellular elements. It may be exacerbated mostly due to cold air, viral infection, exercise and
air pollution. This case report will describe a young lady who presented with bronchial
asthma exacerbated by infection. This case also highlights the management in acute setting of
exacerbation of bronchial asthma.

Introduction
Asthma is a common, chronic respiratory disease affecting 1-18% of the population in
different countries. The symptoms are wheeze, shortness of breath, chest tightness and/or
cough and by variable expiratory airflow limitation. Both symptoms and airflow limitation
characteristically vary over time and in intensity. These variations are often triggered by
factors such as exercise, allergen or irritant exposure, change in weather or viral respiratory
infections. Symptoms and airflow limitation may resolve spontaneously or in response to
medication, and may sometimes be absent for weeks or months at a time. Patients can also
have episodic exacerbations of asthma that may be life threatening and carry a significant
burden to patients and the community. The disease is usually associated with airway hype
responsiveness to direct or indirect stimuli, and with chronic airway inflammation. These
features usually persist, even when symptoms are absent or lung function is normal, but may
normalize with treatment.

Case report
History
Miss A, 27 years old Malay female, non smoker, underlying asthma for past 14 years,
presented to Emergency Department of Hospital Ampang with gradual onset of shortness of
breath 2 hours prior to admission.

She was apparently well until recently she complained having sudden onset of intermittent
cough for the past 2 weeks, productive with whitish sputum, associated with runny nose and
sore throat. It is worsening during night, brief walking and also in cold. She took metered
dose inhaler salbutamol to relieve the symptoms. She had pleuritic chest pain and epigastric
pain and it is worsening during severe attack of the cough. As the symptoms become
progressively worse, she had gradual onset of shortness of breath 2 hours prior to admission.
She described the feeling as tightness of chest. She complaint having wheezing, dizziness,
sweating, vomiting and palpitations during asthmatic attack. The dypsnoea is not relieved
despite taking metered dose inhaler salbutamol and she was rushed to Emergency
Department by her sister and upon arrival she could not speak in full sentence and has
reduced effort tolerance whereby she cannot walk and need to use wheelchair. She is given
oxygen therapy via nasal prong 3L/min, nebulisers salbutamol, combivent and also
intravenous hydrocortisone. She had been sleeping in propped up condition ever since been
diagnosed with asthma and she complaint having Paroxysmal Nocturnal Dyspnoea (PND)
and orthopnoea.

Otherwise, no fever, no dizziness, no chest pain, no palpitations, no hemoptysis, no

abdominal pain, no bilateral leg swelling.

She had been diagnosed with asthma for the past 14 years, she is allergic to cats and dusts, on
metered dose inhaler salbutamol which she took on average 2 puffs thrice in a week
everytime she had asthmatic attack. For the budesonide, she took 2 puffs twice daily to
prevent recurrent attack. She is compliant to medication, but not on follow up. She gets
exacerbation even with mild cough, usually 4 times in a month but it is relieved with
nebulizers that she regularly gets at Klinik Kesihatan. Otherwise, no history of intubation.
She had been diagnosed with pneumonia last month, on amoxicillin medication, compliant
but not on follow up. Otherwise, no known medical illness and no known surgical illness. She
had no food or drug allergy. She had the attacks every time she is exposed to dust, cats fur,
pollen and cold air.

She is the fifth out of six siblings. There is no positive family history of asthma. However,
both of her parents are diagnosed with Diabetes Mellitus and on metformin for past 10 years.
Otherwise, no other complication from the disease. She claimed all other family members are
healthy.

She is single. She works at PERKESO in air conditioned office, no carpet in her office.
Currently, she is staying in flat in Pandan Indah with her sister. She is not an active or passive
smoker and non alcoholic. There is no cats in her house.

Physical examination

Physical examination was done on the day of admission. Upon physical examination, she is
alert, conscious and sitting comfortably on bed. Her GCS score was 15/15. She is tachypneic
and her respiratory rate is 20 breaths per minute. She is able to speak in full sentence. There
is no nasal prong attached or nebulisers. The hands is warm to touch, no finger clubbing, no
tar staining, no peripheral cyanosis, there is fine tremor. Pulse beat is 80 beats per minute
regularly regular with good volume. Her blood pressure is 130/70 mmHg and oxygen
saturation is 95% on room air. Her oral mucosa were normal and good hygiene. No cervical
lymphadeopathy noted. The jugular venous pressure was not elevated. There is no pitting
oedema. Respiratory examination revealed there is no surgical scar, no abnormal chest wall
deformity seen, no barrel shaped chest. The chest was moving with inspiration and chest
expansion was equal bilaterally and symmetrical, the accessory muscle were not active. The
trachea is centrally located without any deviation which is normal, no remarkable findings in
vocal fremitus and vocal resonance, upon auscultation lungs is clear with vesicular breath
sounds, equal air entry and no added breath sound. Cardiovascular examination revealed the
apex beat is palpable at 5th intercostal space mid clavicular line with no deviation. No heaves
or thrills palpated. Heart sound is normal, dual rhythm no murmur. Abdominal examination
revealed the abdomen was moving with inspiration, the umbilicus was centrally located and
inverted. No abdominal scars and visible veins noted. On plapation, abdomen is soft and non
tender, there is no splenomegaly or hepatomegaly, kidney is also not ballotable. The bowel
sounds were present and no renal bruit noted. On CNS examination there was no abnormal
movement, no ptosis, no dsyarthria, no dysphasia. Cranial nerves were normal. Both upper
limbs and lower limbs examination revealed a normal tone and reflexes, power on both upper
limb and lower limb were 5/5. Babinsky reflexes were normal.

Diagnosis and differential diagnosis

The provisional diagnosis is acute exacerbation of asthma because based on history taking,
she have exacerbations due to infections which is Upper Respiratory Tract Infection (URTI).
The symptoms of URTI in this patient are runny nose and productive cough. First differential
diagnosis is pneumothorax because the symptoms of shortness of breath and pleuritic chest
pain. The patient has underlying asthma and may develop pneumothorax due to chronic lung
disease. However there is no sign of pneumothorax found upon physical examination which
make the diagnosis unlikely. Second differential diagnosis is pulmonary embolism. She
complained to have shortness of breath and plueritic chest pain which are also the symptoms
of pulmonary embolism. However, upon futher questioning she does not have any risk factor
to develop the disease so the diagnosis is unlikely. Third differential diagnosis is cardiac
failure. Shortness of breath is a common symptoms in cardiac failure. On top of that she had
few failure symptoms for example PND and orthopnoea. However there is no bilateral leg
swelling. He also do not have any underlying cardiac problems that may lead to the
condition. So the diagnosis is also unlikely.

Relevant investigation, management and progression

Upon arrival to emergency department, electrocardiograph is done and the results are sinus
tachycardia. There is no right bundle branch block, right ventricular strain or even classical SI
QIII TIII pattern. An arterial blood gas was taken to determine if the patient is in type I or II
respiratory failure and to monitor the CO2 level. If patients is in type II respiratory distress,
need to treat the underlying cause first which is the asthma that causing the patient to be
hypoxic. From the results, it shows the ph : 7.422/ pco2 : 31.6/ po2 : 68.1/ hco3 : 21.9/ lactate
: 2.0. So, she is under type I respiratory failure. Next, chest X ray had been done and it shows
hyperinflation of lungs bilaterally with increased perihilar haziness, with left side opacity.
There are no cardiomegaly or signs of pulmonary embolism.

Investigations to be done are :

1) Peak Expiratory Flow Rate of pre and post nebulizers

- To confirm diagnosis of asthma. It is increased for 12% in PEFR post-
bronchodilator.
2) Full blood count
- To find out the white cell count, leucopenia or leukocytosis
- To rule out if patients is anemic or not that causing him to have the shortness of
breath
3) Baseline blood glucose
- Routine monitoring if patient have underlying Diabetes Mellitus or newly
diagnosed Diabetes Mellitus
4) Baseline liver and renal function
- Monitor liver and renal function.
5) Sputum culture

MANAGEMENT

1) Check patient’s technique of using metered dose inhaler

2) Inhaled salbutamol 5mg nebulized with oxygen
3) Intravenous hydrocortisone 100 mg or tablet prednisolone 40-50mg
 4) Oxygen nasal prong if oxygen saturation less than 92% (check ABG)
5) Continuously monitor peak flow and oxygen status, aim for 94-98%
6) Antiobiotics to cover the upper respiratory tract infection

Discussion

Asthma affects 300 million people worldwide, with predicted 100 million people affected by
2025. The socioeconomic impact is enormous, as poor control leads to days lost from school
or work, unscheduled health-care visits and hospital admission.

According to global initiative for asthma (GINA) guideline, asthma is based on few
phenotypes. First, allergic asthma, the most easily recognized asthma phenotype, often
commences in childhood and is associated with a past and/or family history of allergic
diseases. Second one is non-allergic asthma, as the name suggests it is not associated with
allergy. However, it can be recognized with cellular profile of sputum which may be
neutrophilic, eosinophilic or contain only few inflammatory cells. Patients usually less
responsive to inhaled corticosteroids. Third is late onset asthma, particularly common in
adults especially women whereby they present with asthma for the first time in adult life.
Patients are non allergic and need higher doses of inhaled corticosteroids. Next is asthma
with fixed airflow limitation which may be due to airway all remodeling. Last one is asthma
with obesity. Patients usually have prominent respiratory symptoms and little eosinohilic
airway inflammation.

The diagnosis of asthma is predominantly clinical and based on a characteristics history.

Commencement of respiratory symptoms in childhood, a history of allergic rhinitis or
eczema, or a family history of asthma or allergy increases the probability that respiratory
symptoms are due to asthma. Patients with allergic rhinitis should be specifically asked about
the symptoms. The symptoms of asthma are wheezing, shortness of breath, chest tightness or
cough and variable airflow limitation. Supportive evidence is provided by demonstration of
variable airflow obstruction, preferably using spirometry to measure FEV and VC. This
identifies the obstructive defects, defines its severity and provides baseline for bronchodilator
reversibility. Patients should be instructed to record peak flow readings after rising in the
morning and before retiring in the evening. A diurnal variation of PEF of more than 20% is
considered diagnostic and magnitude of variability provides some indication of severity of
disease.
To access the asthma control in patients, ask about following in past four weeks: frequency of
asthma symptoms (days per week), any night waking due to asthma, limitation of activity and
frequency of reliever use. In general, do not include reliever taken before exercise since this
is routine. Poor asthma symptoms control increases the risk of exacerbations. However,
several additional risk factors have been identified i.e, factors that when present increase the
patient’s risk of exacerbations even if the symptoms are few. These risk factors include a
history more than 1 exacerbations in previous year, poor adherence, incorrect inhaler
technique and smoking.

Islamic perspective

Regular smoking was associated with increased risk of new-onset asthma. Children who
reported smoking 300 or more cigarettes per year had a relative risk (RR) of 3.9 (95%
confidence interval [95% CI], 1.7–8.5) for new-onset asthma compared with nonsmokers.
The increased risk from regular smoking was greater in nonallergic than in allergic children.
Regular smokers who were exposed to maternal smoking during gestation had the largest risk
from active smoking (RR, 8.8; 95% CI, 3.2–24.0).1 Thus, It is very important to note that in
Islamic law’s there is general prohibition of all actions that result in harm. This is based on
the Koran says, “And spend of your substance in the cause of God, and make not your own
2
hands contribute to your own destruction (2; 195) In conclusion, people should stop
smoking to reduce the incidence of asthma and prevent episodes of exacerbations in
asthmatic patients.

Reference

1. Ghouri, N., Atcha, M. and Sheikh, A. (2006) Influence of Islam on smoking among
Muslims
2. Frank D. Gilliland, Talat Islam, Kiros Berhane, W. James Gauderman, Rob
McConnell, Edward Avol, and John M. Peters "Regular Smoking and Asthma
Incidence in Adolescents", American Journal of Respiratory and Critical Care
Medicine, Vol. 174, No. 10 (2006), pp. 1094-1100.
3. Walker R. Brian, Colledge R. Nicki, (2014). Davidson’s Principles and Practice of
Medicine. Chapter 19, Respiratory Disease
4. Global initiative for asthma (GINA) guideline
5. Oxford Handbook of clinical medicine