Oral Presentation Asthma
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Transcript of Oral Presentation Asthma
HSM/ 6.2 yrs/ Malay girl◦ Past medical history of bronchial asthma
Presented to A&E with cough and shortness of breath of 1/7◦ Cough preceded SOB by a few hours
no sputum production, no haemoptysis◦ Symptoms worse during the night therefore
transported to ED◦ Admitted to B3
Patient particulars
Other associated features:+Fever : low grade without chills and rigors+Runny nose +Sore throat +Wheeze
Negative findings◦ Haemoptysis◦ Facial pain◦ Post-tussive vomiting◦ Chest pain, Palpitations◦ Gastrointestinal symptoms (nausea, vomiting, diarhhoea)◦ Neurological manifestations (headache, syncope,
dizziness)◦ Genitourinary symptoms ◦ No LOW or LOA
PMH◦ Bronchial asthma since the age of 2◦ Frequency of exacerbations: 1 in 3 months◦ Last exacerbation: one month ago where the GP provided
nebuliser◦ Not on medication◦ First time requiring hospitalization◦ Triggers :
Cold air Respiratory infection Smoke, dust , pollution NOT exercise
◦ Symptoms: No day time or night time symptoms No hindrance to daily activity (plays as normal)
◦ History of atopy Has allergic rhinitis no eczema
PSH: none Drugs and allergies: none Family history:
◦ Mother, 34, secretary. No known medical illnesses◦ Father, 38, sales executive
History of childhood asthma Perinatal history:
◦ Uncomplicated SVD, to term, 3.1kg. Immunisation: up to date Development:
◦ Attending school◦ Alert. Good relationship with mother
Social history:◦ Adult diet◦ Father smokes in the house◦ Lives in an apartment with her parents and
elder sister (8 years, healthy)◦ No pets or carpets in the house◦ Her neighbor (cousin) had the “flu” few days
ago◦ Close quarters.
BP: 100/60 RR: 45 bpm HR : 140 bpm spO2: 98% Temp: 37.3C
Nebuliser administered 3X but no resolution Admitted to B3
Vital statistics at A&E
General appearance:◦ Patient propped in bed.◦ Patient looks tired and using accessory muscles to breathe. Can
talk few words at a time. ◦ Good nutritional status◦ On nasal prong O2◦ Tachypnoeic ◦ Branula inserted in left hand
Hands:◦ No peripheral cyanosis or clubbing◦ Warm peripheries◦ Tachycardia (120bpm)
Good volume◦ CRT<2s
Physical Examination
Face ◦ No conjunctival pallor◦ No engorged turbinates
Mouth◦ Mildly injected pharynx◦ No tonsillar hypertrophy◦ Tongue: mild dehydration, no cyanosis
Lymph node enlargement◦ bilateral; anterior cervical chain
Chest ◦ Lungs:
No chest wall deformities No tracheal deviation Air entry equal into both lungs Widespread rhonchi Occasional crepitations (more on R side)
◦ Cardiac: S1&S2 – no murmurs
Abdomen ◦ Soft and non-tender◦ No organomegaly
No skin lesions Other systems examination unremarkable
Relevant Investigations:◦ Pulse oxymetry: 98%◦ FBC
WBC 24.8 Neutrophils 91.9%
◦ BUSE ◦ CXR : hyperinflated lungs
PVD: acute exacerbation of asthma secondary to a upper respiratory tract infection
Monitor vital stats◦ to maintain sPO2 >95%
Nasal prong O2
Nebulised salbutamol every 4 hrs Prednisolone (15mg) Sy Penicillin 225mg QID
No signs of improvement! Repeat pulse oximetry showed sPO2: 91%
◦ IV hydrocortisone (QID)◦ Neb ipratropium (atrovent) 4hrly◦ Neb salbutamol 2hrly
Treatment
Can the addition of Montelukast help reduce the dosage of oral corticosteroid required for maintenance?
QUESTION 1
Anti-inflammatory properties◦ Less adverse side effects compared to
corticosteroids Relieves symptoms of seasonal allergies
Benefits of Montelukast
Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial
J Pediatr2009;155:795-800
Sept 2005- Feb 2008 Randomized double blind double dummy trial 130 children (ages 2-17 yrs) Mild to moderate acute asthma Subjects: stabilised in the ED and discharged by
the 8th hour Randomized into 2 groups
Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial
J Pediatr2009;155:795-800
Each patient receiving 2 tablets per dosage.◦ 63 patients: Oral Prednisolone + placebo◦ 67 patients: Oral Montelukast + placebo
Drugs to be taken at days 1,2,3,4, and 5 after randomization
Inhaled 500mcg albuterol every 4 hourly for 5 days
Inhaled 100mcg of fluticasone twice a day from day 7
Home visit at 48 hours to assess respiratory status
Home visit on the 8th day to assess primary outcome
PRIMARY OUTCOME:Treatment failure within 8 days Hospitalization Unscheduled visit related to asthma The need for additional corticosteroid
therapy
Conclusion from study:◦ No comparable outcome for Montelukast◦ Montelukast has a higher rate of treatment failure
when compared to oral prednisolone
Children with mild-moderate asthma should continue oral corticosteroid after ssdischarge
Anti-Leukotriene Rc Antagonist has a milder anti-inflammatory effect.◦ Prednisolone exerts effect on T cell, eosonophils
and other inflammatory cells
Synergistic effect with LABA for optimum efficacy.
Discussion
Would the influenza vaccine benefit my patient in reducing future exacerbations of asthma?
QUESTION 2
Influenza is a common cause of hospitalization in asthmatic children.
The inactivated vaccine is 80% effective in preventing influenza in the general population.
However it is used only in approximately 10% of asthma patients
Influenza and asthma
-American Journal of Respiratory and Critical Care Medicine. 2004;169:488–493
Objective : to determine whether parenteral influenza vaccination is more effective than placebo in 6–18-year-old children with asthma.
DESIGN: randomized, double-blind, placebo-controlled trial◦ 347 children: vaccine, 349: placebo◦ Airway symptoms recorded in a diary and
according to a pre-defined severity score. At the score of 4, a throat swab was taken
Influenza Vaccination in Children with AsthmaRandomized Double-Blind Placebo-Controlled Trial
Primary outcome:◦ Number of asthma exacerbations associated with
virologically proven influenza infection. Throat swab
Secondary outcome :◦ Duration and the severity of each exacerbation◦ Adverse reactions to vaccine◦ Any upper respiratory tract symptoms◦ Unscheduled visit to family doctor
Results◦ Primary outcome:
It was 31% less in the placebo group (95% CI: -34% to 161% increase)
◦ Secondary outcome: Similar severity in both groups. 3.1 days shorter duration in the vaccine group.
(95% CI: -6.2 to 0.002 days) Adverse reactions seen significantly more in the vaccine
group (injection site erythema, stiffness of arm, myalgia)
Influenza vaccination did not result in asignificant reduction of the number, severity,
or duration of asthma exacerbations caused by influenza