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Bronchial Asthma

Bronchial Asthma. Rucci Copian Clar Coronado Kayson Credo. Objectives . Identify pertinent findings from the history and physical examination that would contribute to the diagnosis of asthma Provide an approach in diagnosing patients with ashtma Learn how to manage patients with ashtma.

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Bronchial Asthma

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  1. Bronchial Asthma RucciCopian Clar Coronado Kayson Credo

  2. Objectives • Identify pertinent findings from the history and physical examination that would contribute to the diagnosis of asthma • Provide an approach in diagnosing patients with ashtma • Learn how to manage patients with ashtma

  3. Case • G.B., 35/F, from Quezon City, married, Roman Catholic • DOA: 06.11.12 • CC: DOB of 3 hours

  4. Temporal Profile

  5. ROS • No fever, chest pain, palpitations, edema • Noted with chronic productive cough since February 2012 – • February – greenish sputum, consult at Lung Center, given Procaterol HCL (Meptin) 50 mcg/tab BID x 5 days • April-May – whitish sputum, ENT consult (Impression: Laryngitis), given Prednisone 10 mg/tab BID • June – yellow sputum • Noted with weight loss - ~ 10 kg in 5 months

  6. Past Medical History • CAP – January 2012, admitted at Sta. Ana Hospital for 1 month, intubated for 20 days, sputum CS: (+) Klebsiella sp., given unrecalled antibiotics and home medications

  7. Family History • Asthma – maternal side • HTN – both sides • Leukemia – paternal uncle

  8. Social History • Non-smoker, does not consume alcohol • Exposed to a sibling with PTB (treated for 6 months) • Works as an accountant in a private company

  9. Physical Examination Upon Admission • Awake, coherent, ambulatory but weak-looking, labored breathing • BP: 120/80 mmHg HR: 101 bpmRR: 28 cpmT: 36.8°C • Fair complexion, good skin turgor and mobility • Anicteric sclera, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathies, neck veins not distended • Symmetrical chest expansion but with use of accessory muscles for respiration, tachypneic, with wheezes on all lung fields, harsh breath sounds • Adynamicprecordium, tachycardic, regular rhythm, distinct S1 and S2, no murmur, PMI at the 5th ICS LMCL • Flat abdomen, normoactive bowel sounds, soft, non-tender, no mass • Full and equal pulses, no cyanosis, no edema

  10. Salient Features • DOB x 3 weeks, temporarily and slightly relieved by SalbutamolNebulization, Guaiafenesin BID x 7 days, Prednisone 110 mg/tab BID x 5 days • Chronic productive cough (5 months) • History of asthma on the maternal side • PE: weak looking, on labored breathing, tachypneic, with use of accessory muscles of respiration, noted with wheezing on all lung fields

  11. Impression: • Bronchial Asthma in Acute Exacerbation

  12. ER • 02 Supplementation at 2 lpm via NC • SalbutamolNebulization x 6 doses (continuous) then q1 • BudesonideNebulization q12 • Hydrocortisone 50 mg/tab IV q6

  13. Laboratory Procedures • ECG: ST • CXR: CLF • Na/K: 140/3.2 • CBC: 150/43/13.1/58/40/E2/N/N • ABGs: 7.38/45/27.20/147/99% at 2 lpm

  14. Asthma • Syndrome characterized by airflow obstruction that varies markedly , both spontaneously and with treatment. • Narrowing of airways is usually reversible, but in some chronic cases, there could be irreversible airflow obstruction

  15. Risk Factors • Exposure to allergens • Occupational irritants (asbestos) • Tobacco smoke • Respiratory (viral) infections • Exercise • Strong emotional expression • Chemical irritants (aerosols) • Drugs (ASA, B Blocker) • Family history of asthma

  16. Main Physiological Feature • Episodic airway obstruction

  17. Clinical Features • Dyspnea, “difficulty filling lungs with air” • Coughing: increased mucus production in some with typically tenacious mucus that is difficult to expectorate; in some, non-productive • Increased ventilation and use of accessory muscles • ProdomalSx: itching under the chin, discomfort between the scapulae, inexplicable fear • Wheezing, rhonchi on all lung fields *maybe worse at night; patients typically awake in early morning hours

  18. Questions to Consider in the Diagnosis of Asthma • Has the patient had an attack or recurrent attacks of wheezing? • Does the patient have troublesome cough at night? • Does the patient wheeze or cough after an exercise? • Does the patient experience wheezing, chest tightness, or cough after exposure to airborne allergens or pollutants? • Does the patient’s colds “go to chest” or take more than 10 days to clear up? • Are symptoms improved by asthma treatment?

  19. Diagnostics • Lung Function Tests • Airway Responsiveness • Hematologic Tests • Imaging • Skin tests • Non-Invasive Markers

  20. Lung Function Tests • REVERSIBILITY - rapid improvements in FEV1 (or PEF), measured within minutes after inhalation of rapid-acting bronchodilator or more sustained improvement over days or weeks after the introduction of effective controller treatment such as inhaled corticosteroids • VARIABILITY- improvement or deterioration in symptoms and lung function occurring over time

  21. Lung Function Tests • SPIROMETRY – confirms airflow limitation with a reduced FEV1 (12% and 200 ml increase from the pre-bronchodilator value), FEV1/FVC ratio (< 0.75-0.80) • The duration in the reduction of FEV1 value depends on the type of broncholdilator used: 15 mins for short-acting B2 agonist, 2-4 weeks for oral glucocorticoid

  22. Lung Function Tests • PEAK EXPIRATORY FLOW – • Advantage: can aid both in diagnosis and monitoring, inexpensive, portable, ideal for home settings for day-to-day objective measurement of airflow limitation. • Disadvantage: can underestimate the degree of airflow limitation as the limitation and gas trapping worsen

  23. Lung Function Tests • METHODS OF DESCRIBING PEF • % of the Daily Mean PEF: -difference b/w the max and min value for the day, averaged for 1-2 weeks • % of the Recent Best (Min%Max): -minimum morning pre-bronchodilator PEF over 1 week is measured -best PEF index of airway lability • ASTHMA =60 L/min (20% or more of pre-bronchodilator PEF) improvement after inhalation of bronchodilator

  24. Lung Function Tests • Flow Volume Loops – reduced peak flow and reduced maximum expiratory flow • Body Plethysmography – increased airway resistance, total lung capacity, and residual volume

  25. Airway Responsiveness • METACHOLINE OR HISTAMINE CHALLENGE – measures increase in AHR with calculation of the provocative concentration of the agonist that reduces FEV1 by 20% • EXERCISE TESTING – demonstrates post-exercise bronchoconstriction • ALLERGEN CHALLENGE – rarely necessary, should only undertaken by specialist if specific occupational agents are to be identified

  26. Hematologic Tests • TOTAL SERUM IgE to inhaled allergens – not usually helpful

  27. Imaging • CXR – usually normal; hyperinflated lungs in severe cases; pneumothorax in exacerbations • HIGH-RESOLUTION CHEST CT – areas of broncheictasis and thickening of bronchial walls in severe cases (not diagnostic of asthma)

  28. Skin Tests • SKIN PRICK TESTS - (+) in allergic asthma but (-) in intrinsic ashtma -not helpful in the diagnosis but is the primary diagnostic tool in determinning allergic status -Main Limitation: a positive test does not necessarily mean that the disease is allergic in nature or that it is causing asthma

  29. Non-Invasive Markers of Airway Inflammation • Examining spontaneously produced or hypertonic saline –induced sputum for eosinophilic or neutrophilic inflammation • Nitric oxide

  30. Levels of Asthma Control • Assessment of current clinical control (preferably 4 weeks) • Assessment of future risks (risk of exacerbations, instability, rapid decline in lung function, side-effects)

  31. Assessment of Current Clinical Control

  32. Assessment of Future Risk • Features that are associated with increased risk of adverse invents in the future: • Poor clinical control • Frequent exacerbations in the past year • Ever admission for critical care asthma • Low FEV1 • Exposure to cigarette smoke • High dose medications

  33. Cough-Variant Asthma • Chronic cough as the principal, if not only symptom • common in children • commonly more problematic at night

  34. Differential Diagnosis

  35. Prevalence of Asthma • One of the most common chronic diseases • Approximately 300 million people are affected • Can present at any age, with a peak age of 3 y/o • In childhood, M:F 2:1 • In adulthood, M:F 1:1

  36. Prevalence of Asthma • Children with asthma usually become asymptomatic during adolescence but that asthma returns during adult life. • Adults with asthma, rarely become permanently asymptomatic. • Prevalence is increased in very young persons and very old persons because of airway responsiveness and lower levels of lung function. • Deaths from asthma are uncommon.

  37. Etiology

  38. Pathophysiology of Asthma • Involves the following components: • Airway inflammation • Intermittent airflow obstruction • Bronchial hyperresponsiveness

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