Bronchial Asthma

Casin, Elaine Gonzales

Senior Intern
27 January 2012

Dr. Cantimbuhan
Moderator

GENERAL OBJECTIVES:
-To present a patient with Bronchial Asthma -Differential Diagnosis for Bronchial Asthma -To diagnose patients with Bronchial Asthma - Management for patients with Bronchial Asthma

SPECIFIC OBJECTIVES:
-To present a clinical history & PE of patients with bronchial asthma in exacerbation -To present the Classifications by asthma severity and asthma control used to diagnose patients with Bronchial Asthma -To present the Specific Management (pharmacologic and Control-Avoidance)

G E N E R A L

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

D.D -8 y/o, female -Buddhist -Filipino - Born and is currently residing in Dasmarinas, Cavite D - Admitted: January 04, 2012, 4pm A T A

C H I E F C O M P L A I N T

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

Difficulty of Breathing

Hx OF
P R E S E N T I L L N E S S

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

3 days PTA - (+) productive cough, whitish phlegm, worse at night - (-) colds, fever, headache, dysphagia, nausea or vomiting, dyspnea - (-) meds/ consult

Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

OF 1 day PTA
P R E S E N T I L L N E S S

- (+) 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

Hx OF
P R E S E N T I L L N E S S

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

Few hours PTA

- (+) persistence of symptoms

with anorexia & progressive dyspnea & chest tightness

- (+) Consult with nearby clinic: Combivent Neb. 1 dose no relief

- (+) Consult at DL-UMC ER: Persistent & progressive dyspnea when WALKING - (+) Admitted

P A S T M E D I C A L Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

(+) Bronchial Asthma since 3 years old

-Last Attack: November 2011

- Salbutamol Inhaler PRN

(+) Allergy : shrimp

(-) previous HOSPITALIZATION/ surgery, allergic rhinitis, atopy

F A M I L Y M E D I C A L Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

(+) Bronchial Asthma: maternal (+) Allergic Rhinitis: maternal (+) Hypertension: maternal

B I R T H & M A T E R N A L Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

Born term @ 37 weeks via LTCS due to CPD MOTHER: (+) regular prenatal check-ups (-) UTI or previous infections during pregnancy BW: 3 kg (-) Maternal and neonatal complications (-) Normal NEWBORN SCREENING

D E V E L O P M E N T A L Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

Gross Motor - Rolls over at 6 months - Sits at 12 months - Walks at 13 months Fine Motor - Scribbles at 4 years old Language - Phrases at around 15 months Personal and Social - interactive play at 2 y/o

N U T R I T I O N A L Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

Breastfed until 1 year old Supplementary feeding at 8 months old Cerelac Promil for a year, then shifted to Progress from 3 to 4 years old. Good appetite with no food preference

I M M U N I Z A T I O N
Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

(+) BCG (+) 3 doses of Hep. B, DPT, OPV (+) MMR (+) Hib (+) pneumococcal No serious reactions

P E R S O N A L S O C I A L Hx

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

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, NONSMOKER, NON-ALCOHOLIC BEVERAGE DRINKER. FATHER: 32 Y/O, EMPLOYEE, OCCASIONAL SMOKER AND ALCOHOLIC BEVERAGE DRINKER

R E V I E W OF S Y S T E M S

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

POSITIVE Dyspnea Fever, undoc. weakness Prod. Cough Anorexia chest tightness

Colds Chills Abdominal pain Body malaise Loss of cosciousness

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

I. GENERAL SURVEY
Patient is awake, mesomorph, and in moderate respiratory distress. Patient appeared her chronological age of 8.

II. VITAL SIGNS

BP: 110/70mmHg RR: 36 cpm HR: 140 TEMP: 36.8 C

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

EXAMINATION OF THE SKIN

(-) pallor (-) jaundice (-) primary or secondary skin lesions (+) good skin turgor

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

EXAMINATION OF THE HEENT

(+) Pink palpebral conjunctiva (-) eye discharge or tearing (-) icteric sclera (-) CLAD (+) supraclavicular retractions (+) alar flaring

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

EXAMINATION OF THE CHEST AND LUNGS

(+) symmetric chest expansion (+) tachypneic (+) tight airways per auscultation (+) equal lung sounds (+) wheezes (-) crackles

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

CARDIOVASCULAR SYSTEM (+) tachycardic, (-) visible veins, regular rhythm. pulsations or peristalsis. (-) murmur (+) Normoactive bowel sounds ABDOMEN (+) soft and non(+) Flat and tender. symmetrical

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

EXAMINATION OF THE EXTREMITIES (+) Full & equal peripheral pulses (-) cyanosis (-) edema (-) deformities

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

NEUROLOGIC -Awake, conscious, coherent, oriented to 3 spheres, speaks in sentences, ambulant. -Cranial Nerves: intact

SALIENT FEATURES
CLINICAL HISTORY (+) productive cough, whitish phlegm, worse at night (+) dyspnea ( shortness of breath when walking) (+) undocumented fever (+) anorexia (+) chest tightness (+) dyspnea responded with antiasthma therapy (salbutamol nebulization) (+) history of diagnosis of bronchial asthma (+) family history of bronchial asthma

SALIENT FEATURES
PHYSICAL EXAMINATION tachycardic ( 140 bpm) tachypneic ( 36 cpm) (+) alar flaring (+) supraclavicular retractions (+) tight airways per auscultation (+) wheezes (-) cyanosis speaks in words and in moderate respiratory distress

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

PRIMARY WORKING IMPRESSION:

Bronchial Asthma, partly controlled, in acute moderate exacerbation

BRONCHIAL ASTHMA:
Clinically - Widespread airway narrowing

which changes in severity over short periods of time, either spontaneously or in response to treatment Physiologically - Bronchial Hyperresponsiveness Pathologically - Airway inflammation

BRONCHIAL ASTHMA:

BRONCHIAL ASTHMA:

BRONCHIAL ASTHMA:

DIFFERENTIAL DIAGNOSES: 1. PNEUMONIA

RULE IN -Dyspnea -Productive cough - undocumented fever - anorexia -Tachypneic (36cpm) - (+) supraclavicular retractions RULE OUT -(-) crackles - can not be totally ruled out

DIFFERENTIAL DIAGNOSES: 1. bronchiolitis

RULE IN -Dyspnea -Productive cough - anorexia -Tachypneic (36cpm) - (+) alar flaring -(+) wheezes - (+) supraclavicular retractions RULE OUT -Severe symptoms usually evident in infants (3-6mons.) - (-) coryza, congestion, pharyngitis, colds

DIFFERENTIAL DIAGNOSES: 1. bronchitis

RULE IN -Dyspnea -Productive cough - anorexia -Tachypneic (36cpm) - (+) alar flaring -(+) wheezes - (+) supraclavicular retractions RULE OUT
-(-) increased sputum volume - (-) clad, sore throat, runny nose, headache, muscle aches, extreme fatigue - smoking is the predominant cause - affects male> fem - chronic bronchitis affects more adults> children

PHYSICAL CLINICAL CLINICAL MANAGEMENT M HISTORY EXAMINATION IMPRESSION A N SUPPORTIVE: O2 SPOT CHECK: 86%-> 96%->99% A G O2 support via face mask @ 6LPM E IVF: D5 0.3 NaCl 500cc x 28-29gtts/min M (Mild in 8) E N T THERAPEUTICS:

AT THE E.R

Continuous Nebulization with Ipatropium bromide + Salbutamol (Duavent) for 1 hour Hydrocortisone 100 mg IV

M A N A G E M E N T AT THE E.R

CLINICAL HISTORY

PHYSICAL EXAMINATION

CLINICAL IMPRESSION

MANAGEMENT

DIAGNOSTICS: CBC PC Chest Xray APL Advised Admission

COURSE IN THE WARDS 1. DAY 0-1

S> O> (+) DYSPNEA, shortness of breath, chest tightness HR: 126 RR32 TEMP36.8 C O2 SAT: 96% (+) WHEEZES, (+) SUPRACLAVICULAR RETRACTIONS (-) PALLOR, (-) RETRACTIONS, (-) CRACKLES, (-) MURMUR, (-) DECREASED BREATH SOUNDS, (-) CYANOSIS BRONCHIAL ASTHMA IN ACUTE MODERATE EXACERBATION; PNEUMONIA

A>

COURSE IN THE WARDS 1. DAY 0-1

P> IVF: D5 0.3 NACL 500 CC X 28-29 GTTS/MIN (MILD IN 8 HOURS) DIAGNOSTICS: - CBCPC: hgb 160, hct 0.48, wbc16.8 segmenters 0.86 lymph0.11 monocytes0.02 platelet542 - CXR-APL: NON-SPECIFIC PNEUMONITIS

COURSE IN THE WARDS 1. DAY 0-1

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 1. DAY 1-2

S> O> (+) DYSPNEA HR: 124 RR28 TEMP37.5 C O2 SAT: 99% (+) WHEEZES (-) PALLOR, (-) RETRACTIONS, (-)CRACKLES, (-) MURMUR, (-) DECREASED BREATH SOUNDS, (-) CYANOSIS BRONCHIAL ASTHMA IN ACUTE MODERATE EXACERBATION; PNEUMONIA

A>

COURSE IN THE WARDS 1. DAY 1-2

P> IVF: D5NM 500CC X 17-18GTTS/MIN (FM)

THERAPEUTICS: - Hydrocortisone 90 mg iv q6 - cefuroxime 700 mg iv q8 anst - ipatropium bromide+salbutamol nebulization Q4 - discontinued salbutamol nebulization

COURSE IN THE WARDS 1. DAY 1-2

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 1. DAY 2-3

S> O> (+) slight dyspnea HR: 108 RR25 TEMP36.2 C O2 SAT: 96% (-) PALLOR, (-) RETRACTIONS, (-) wheezes()CRACKLES, (-) MURMUR, (-) DECREASED BREATH SOUNDS, (-) CYANOSIS

A>

BRONCHIAL ASTHMA IN ACUTE MODERATE EXACERBATION; PNEUMONIA

COURSE IN THE WARDS 1. DAY 2-3

P> IVF: D5NM 500CC X 17-18GTTS/MIN (FM)

THERAPEUTICS: - Hydrocortisone 90 mg iv q6 - 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 1. DAY 2-3

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 1. DAY 3-4

S> O> Slight dyspnea, occasional HR: 108 RR25 TEMP36.2 C O2 SAT: 96% (+) WHEEZES (-) PALLOR, (-) RETRACTIONS, (-)CRACKLES, (-) MURMUR, (-) DECREASED BREATH SOUNDS, (-) CYANOSIS BRONCHIAL ASTHMA IN ACUTE MODERATE EXACERBATION; PNEUMONIA

A>

COURSE IN THE WARDS 1. DAY 3-4

P> IVF: D5NM 500CC X KVO

THERAPEUTICS: - Hydrocortisone 90 mg iv q6 - cefuroxime 700 mg iv q8 anst - ipatropium bromide+salbutamol nebulization Q4 - salmeterol+fluticasone 1 puff bid (gargled every after use) SUPPORTIVE: - discontiued 02 support & pulse oximeter.

COURSE IN THE WARDS 1. DAY 3-4

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
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 CONFIRM BRONCHIAL ASTHMA DIAGNOSIS

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
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 inhalation of a bronchodilator

CASE DISCUSSION
STEPS MANAGEMENT

FOR PATIENTS WITH BRONCHIAL ASTHMA

Advice avoidance to triggering factors: Tobacco smoke drug, food, additives House dust mites and cockroahes Animals with fur Outdoor pollens and mold Indoor mold Exercise Pharmacologic Therapy

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 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

F2+ Mechanism of Action

o muco-ciliary clearence q vascular permeability Inhibition of transmitter release from mast cells

F2 Agonists
Selective (Terbutaline, Salbutamol)
First line therapy Short onset of action (2-5 min) Long duration of action (3-6 h) Different routes of administration

Non selective (epinephrine)

Vasoconstricting agent Short duration of action Side effects

Anticholinergics Mechanism of Action

Ach competitive inhibitors muscarinic receptors antagonists Bronchodilators Inhibitors of the bronchoconstriction induced by irritant agents

Corticosteroids
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 ?

Methylxanthines
No benefit from adding methylxanthines to F2+ More adverse effects
Parameswaran et al. Cochrane Database Syst Rev 2000

MgSO4
Inhalation:
Improvement in clinical score (Fischl), o PEFR, o PP Nannini LJJr. Am J Med 2000 Mangat HS Eur Respir J 1998
o PEFR

IV:
Boonyavorakul C. Respiratology 2000
Hospital admission = NS; score = NS

Rowe BH. Ann Emerg Med 2000

q admission rate in severe asthma exacerbations

Antibiotics
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 volume and purulence Infiltrates on the chest X-ray

CONTROLLERS

CONTROLLERS

CONTROLLERS

COMBINATION MEDICATIONS

RELIEVERS

RELIEVERS

RELIEVERS

REFERENCES
GLOBAL INITIATIVE FOR ASTHMA (2011)

THANK YOU
GOD BLESS