CASE DISCUSSION RIVERA, JOANNA GRACE ASMPH BATCH 2013.
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Transcript of CASE DISCUSSION RIVERA, JOANNA GRACE ASMPH BATCH 2013.
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CASE DISCUSSIONRIVERA, JOANNA GRACE
ASMPH BATCH 2013
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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
OBJECTIVES
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EPYN Female 3 years old Filipino Roman Catholic Mandaluyong City Informant: Father Reliability: 80%
GENERAL INFORMATION
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CHIEF COMPLAINT
Difficulty of Breathing(two days duration)
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Two days PTA
HISTORY OF PRESENT ILLNESS
• Nonproductive cough• Difficulty of breathing• (-) colds and fever• Nebulized with
salbutamol with improvement of DOB
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Few hours PTA
HISTORY OF PRESENT ILLNESS
DAY OF ADMISSION
• Worsening of cough and DOB
• Unrelieved by salbutamol nebulization
• No other associated symptoms
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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
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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
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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
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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
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Review of Systems
• Hematopoietic: (-) abnormal bleeding, (-) bruising• Neurologic: (-) headache, seizure, mental status
changes, head trauma
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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
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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
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IMMUNIZATION HISTORY
BCG (1 dose) DPT/IPV (3 doses) Hepa B (3 doses) Measles (1) Rotavirus (2)
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NUTRITIONAL HISTORY
• Breastfed until 2 months• Formula fed with Nestogen (3
ounces/bottle)• Weaning age: 6 months (Cerelac); 9
months (rice)
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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
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Developmental HistoryGROSS MOTOR
6 months: sits with support10 months: stands with support1o months: walks with support15 months: walks well alone2 years: runs well, can climb up and down stairs, jumps3 : throws balls, downstairs on one foot per step, hops on one foot
FINE MOTOR9 months: holds bottle1 year and 3 months: can drink from cup2 years old: can imitate a circle; 3 years old: imitates cross
LANGUAGE9 months: can speak mama and papa1 and ½ year: can indicate needs; can speak three-word sentences2 years old: can point to parts of the body and can follow directions; names on pictures3 years old: tells little stories about experiences, gives full name and sex; recognizes 3 or more colors, counts to ten
SOCIAL2 years: can remove garment; toilet trained; uses spoon3 years: dry by night; play interactive games; dresses with supervision; tells tail tales
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FAMILY HISTORY
• Asthma (Maternal grandmother and cousins)• Hypertension and Diabetes (paternal)• (-) Allergies
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GENOGRAM
40 41
18 3
Casino dealer Call center agent
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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
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Physical Examination
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PHYSICAL EXAMINATION
GENERAL APPEARANCEAlert, quiet, weak-looking, in respiratory distress
VITAL SIGNSBP: 100/70 RR: 40 O2 Sat (room air): 89% HR: 110 Temp: 37º C
ANTHROPOMETRICS:Height: 106 cm (2 to 3) Weight: 22.6kg (3) BMI: 20.11 (3)
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PHYSICAL EXAMINATION
SKINwarm skin, good skin color and turgor
HEENTno lesions or matting of the eyelids, no eye discharge, no swellling, anicteric sclerae, pink palpebral conjunctiva, No tragal tenderness, no ear discharge, intact TM
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PHYSICAL EXAMINATION
HEENTNo alar flaring, nasal septum midline, with minimal nasal dischargedry lips, moist tongue, no circumoral cyanosis, no buccal mucosal lesions, no TPCno masses in the neck, (-) CLAD, flat neck veins
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PHYSICAL EXAMINATION
RESPIRATORYcan talk in sentences, (+) subcostal retractions, symmetric chest expansion, wheezes on both lung fields, no crackles or rhonchi
HEARTadynamic precordium, no thrills, heaves or lifts, PMI at 5th ICS, MCL, normal rate, regular rhythm, distinct S1 and S2 sounds, no murmurs
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PHYSICAL EXAMINATION
ABDOMENFlabby abdomen, normoactive bowel sounds, soft, no organomegaly, no tenderness
EXTREMITIESfull and equal pulses, no edema, no cyanosis, no atrophy/hypertrophy, no deformities
NEUROLOGIC EXAMINATIONIntact cranial nerves, no sensory and motor deficits, normoreflexive, (-) Babinski, (-) clonus
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SALIENT FEATURES
SUBJECTIVE OBJECTIVE
3/F Asthmatic Difficulty of breathing Cough Audible wheeze Relieved by
Salbutamol nebulization initially unresponsive
Respiratory distress Tachypnea Desaturation
(87%) Retractions
Wheeze Normal cardiac
findings
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PRIMARY WORKING IMPRESSION
BRONCHIAL ASTHMA IN ACUTE
EXACERBATION
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Differential Diagnosis
• Bronchiolitis• Pneumonia• Upper Respiratory Tract Infection
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Course in the wards
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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
Emergency Treatment
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Day 1Subjective Objective
(+) cough(+) audible wheeze(-) difficulty of breathing(-) fever(+) Good activity and good
appetite
• 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
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Day 1Assessment Plan
Bronchial Asthma in Acute Exacerbation, resolving
• Revise nebulization toSalbutamol + Ipatropium every 8 hoursSalbutamol every 8 hours
• Shift to IV Hydrocortisone 100 mg/IV every 6 hours
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Day 2Subjective Objective
(+) occassional cough(-) audible wheeze(-) difficulty of breathing(-) fever(+) Good activity and good
appetite
• 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
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Day 1Assessment Plan
Bronchial Asthma in Acute Exacerbation, resolving
• Revise nebulization toSalbutamol every 6 hours
• Start Prednisone 10 mg/5 mL, 7.5 mL twice a day
• May go home
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DISCUSSION
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Bronchial Asthma
• Chronic inflammatory condition of the lung airways resulting in episodic airflow obstructiono Airway hyperresponsiveness
Excessive Contraction of the
smooth muscleUncoupling
Thickening of the airway wall
Sensitized sensory nerves
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INFLAMMATORY CELLS
Mast cellsEosinophils
T-lymphocytesDendritic CellsMacrophagesNeutrophils
INFLAMMATORY CELLS
Airway epithelial cells
Airway smooth muscle cells
Endothelial cellsFibroblasts
MyofibroblastsAirway nerves
INFLAMMATORY MEDIATORS
ChemokinesCysteinyl
LeukotrienesCytokinesHistamine
Nitric oxideProstaglandin D2
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Smooth muscle contraction
EdemaAirway
thickeningMucus
hypersecretion
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BLOOD VESSEL WALL
PROLIFERATION
SMOOTH MUSCLE INCREASE
MUCUS HYPERSECRETIO
N
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Clinical Signs and Symptoms
WheezingCough
BreathlessnessNocturnal symptoms/awakenings
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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%
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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
Diagnostic Examinations
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1. Regular Assessment and monitoring2. Patient Education3. Control of Factors Contributing to Asthma
Severity4. Principles of Asthma Pharmacotherapy
Treatment and Management
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Regular Assessment and Monitoring
Component 1
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Levels of Asthma Control for Children
CHARACTERISTICCONTROLLED
(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)
Daytime symptoms None More than twice/week
More than twice/week
Limitation of activities None Any Any
Nocturnal symptoms/awakenings
None Any Any
Need for reliever/rescue
treatment≤2 days/week >2 days/week >2 days/week
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Patient Education
Component 2
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Control of Factors Contributing to Asthma Severity
Component 3
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Eliminating and reducing problematic environmental exposures Annual influenza vaccination
Treat co-morbid conditions Gastroesophageal Reflux Rhinitis Sinusitis
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Principles of Asthma Pharmacotherapy
Component 4
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CONTROLLER OPTIONSContinue as needed rapid-acting beta-2
agonists
Low-dose inhaled glucocorticosteroids
Double low-dose inhaled
glucocorticosteroidsLeukotriene modifier Low-dose inhaled
glucocorticosteroid plus leukotriene
modifier
Asthma educationEnvironmental 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
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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
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Inhaled glucocorticosteroids Leukotriene modifiers Theophylline Long-acting beta-2 agonists Cromolyn and nedocromil sodium
Controller Medications
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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
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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
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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
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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).
Controller medications
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Management of Acute Asthma Exacerbation
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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
Symptoms
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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
Controller medications
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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
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Management2 puffs of salbutamol
(given 20-minute interval for an hour)
Recurrence within 2-3 hoursNo recurrence within 1 to 2
hours
2-3 puffs hourly (max: 10 puffs/day)
+ oral glucocorticosteroid
No further treatment
Repeat 2 puffs after 3-4hours
Prednisone 1-2 mg/kg/day(max: 20 mg in children <2
30 mg in children 3-5Hospital
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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
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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
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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)
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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
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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)
Prognosis and Follow-up