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Asthma Case Study

Asthma Case Study. Group 7. Courtney Ramsey Jennifer Martin Lisa G. Castro Ning Huang Stella Cooremans - Pena Rosimeire Sawyer. An Asthma Attack. Background. Jenny, 14 yr old female Spent the night at a friends house Exposures: Friends father smokes Current Medications:

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Asthma Case Study

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  1. Asthma Case Study Group 7 Courtney Ramsey Jennifer Martin Lisa G. Castro Ning Huang Stella Cooremans-Pena Rosimeire Sawyer

  2. An Asthma Attack

  3. Background • Jenny, 14 yr old female • Spent the night at a friends house • Exposures: • Friends father smokes • Current Medications: • Fluticasone inhaler BID • Albuterol HFA PRN • Allergies: Sulfa (rash)

  4. Patient Histories • Past Medical History • Asthma: • Well controlled • Diagnosed at age 10 • Sinusitis: • Gets 2-3 times per year • Past Surgical History • None • Social History • Lives at home with parents • No regular exposure to 2ndhand smoke • Family History • Grandfather: COPD • Secondary to smoking • No longer smokes

  5. November 7, 2013 • Patient presented to an emergency walk in clinic in the middle of the night • Chief complaint: • “I’m having trouble breathing” • Physical Exam: • Neuro: Anxious, Difficulty Speaking, PERRLA • CV: Tachycardia, no murmur • Resp: Bilateral high-pitched, diffuse expiratory wheezing • Using accessory muscle • Moderate resp. distress • GI/GU/Oral: Mild Oral Thrush • All other systems normal • Vital Signs: • Temp: 36 C • HR 110 BP 124/70 • Pulse Ox : 88% on Room Air • Precipitating Events: • Patient had spent the night at a friends house • Recent exposure to 2nd hand smoke • Woke up with severe SOB and nonproductive cough • Did not have her bronchodilator medication with her

  6. Analyze the pathophysiology of asthma and relate it to the category of obstructive vs. restrictive pulmonary disorder. Question 1

  7. Obstructive vs. Restrictive Pulmonary Disease

  8. Pathophysiology of Asthma Genetic predisposition to type 1 hypersensitivity Exposure to environmental triggers (second hand smoke)

  9. Pathophysiology of Asthma Inhaled allergen simulates induction of TH2 cells. Kumar (2010) et al: Fig 6-11, p195

  10. Pathophysiology of Asthma • TH2 cells secrete cytokines that promote allergic inflammation and stimulate B cells to produce IgE and other antibodies.

  11. Pathophysiology of Asthma Priming or sensitization

  12. Pathophysiology of Asthma • IgE coats submucosal mast cells and repeat exposure to the allergen triggers the mast cells to release granules contents and produce cytokines and other mediators which induce the early phase reaction and the last phase reaction.

  13. Early phase reaction: • Result within one hour • Mast cells release mediators (histamine, leukotriene, prostaglandins, enzymes). • Bronchoconstriction • Increased vascular permeability • Increased mucus production Pathophysiology of Asthma Kumar (2010) et al: Fig 15-10D, p690

  14. Late-phase reaction: • Mast cells, epithelial cells, T cells, and other cytokines produce chemokines to recruit leukocytes • Inflammation with recruitment of leukocytes • Mediators released from leukocytes, endothelium and epithelial cells in late reaction Pathophysiology of Asthma • Kumar (2010) et al: Fig 15-10 E, p690

  15. Pathophysiology of Asthma • Repeated bouts of allergen exposure and immune reactions result in structural changes in the bronchial wall called airway remodeling

  16. Pathophysiology of Asthma • Excess mucus • Intense inflammation • Smooth muscle hyperplasia and hypertrophy

  17. Pathophysiology of Asthma • Over thickening of airway wall • Increase in size of submucosal glands • Sub-basement membrane fibrosis • Increased vascularity • Hypertrophy and/or hyperplasia of the bronchial wall muscle • Kumar (2010) et al: Fig 15-10 B, p690

  18. Discuss the hypersensitivity trigger of asthma and contrast with the risk factors in this teenager. Question 2

  19. Common Asthma Triggers • Tobacco Smoke • Tobacco smoke is unhealthy for everyone, especially people with asthma • If you have asthma, people should never smoke near you • Dust Mites • Cockroaches Allergen • Cockroaches and their droppings can trigger an asthma attacks • Outdoor air pollution • Pets • Mold • Smoke – burning wood or grass • Other Triggers • Infections: Flu, RSV, Sinus Infections • Bad Weather, Physical Exercise • Acid Reflux, Strong Fragrances • Strong Emotions

  20. Asthma Triggers History of Asthma Diagnosed at Age 10 Frequent Sinusitis Exposure to secondhand smoke Spent the night at a friends house whose father is a smoker Family History Grandfather: COPD Secondary to smoking No longer smokes Patient Risk Factors

  21. Question 3 Compare and contrast the typical manifestations of asthma with those seen in this case. Include pathologic etiology of each manifestation.

  22. Manifestations of Asthma Typical Manifestations Patient’s Manifestations • Wheezing • Coughing • Chest tightness • Shortness of breath • Severe shortness of breath with difficulty speaking • Unproductive cough • Tachycardia, heart rate 110 • Tachypnea, respiratory rate 24 • Anxiety • Hypoxia, oxygen saturation on room air 88% • Bilateral high-pitched, diffuse expiratory wheezing • Use of accessory muscles Typical manifestations data (Kumar et al., 2010)

  23. Etiology of Manifestations Asthma is a disease that inflames and narrows the airways of your lungs. (1) Inflammation • Inflammation is triggered by anything in the environment that causes a person’s airway to hyper-react and make breathing difficult. • Jenny’s trigger was tobacco smoke. • The inhaled smoke elicited a TH2 dominated response. • “TH2 cells secrete cytokines that promote allergic inflammation and stimulate B cells to produce IgE and other antibodies. These cytokines include IL-4,which stimulates the production of IgE; IL-5, which activates locally recruited eosinophils; and IL-13, which stimulates mucus secretion from bronchial submucosal glands and also promotes IgE production and B cells” (Kumar et al., 2010, p. 689).

  24. Etiology of Manifestations Asthma is a disease that inflames and narrows the airways of your lungs. (1) Inflammation • Early reaction • Bronchoconstriction/reversible bronchospasm (triggered by direct stimulation of subepithelial vagal receptors • Increased mucus production • Variable degrees of vasodilation with increased vascular permeability (Kumar et al., 2010)

  25. Etiology of Manifestations Asthma is a disease that inflames and narrows the airways of your lungs. (1) Inflammation • Late reaction • Inflammation with recruitment of leukocytes (eosinophils), neutrophils and T cells • Leukocyte recruitment is stimulated by chemokines produced by mast cells, epithelial cells and T cells • Increased airway constriction (Kumar et al., 2010) Image obtained from www.gene.com

  26. Etiology of Manifestations Asthma is a respiratory disease that inflames and narrows the airways of your lungs. Swelling Bronchoconstriction Image obtained from nlm.nih.gov

  27. Asthma at a glance

  28. Facts on second hand smoking and asthma • Exposure to secondhand smokingcan trigger asthma attacks and make asthma symptoms more severe (EPA, 2013). • Second hand smoking contributes to children/adolescent’s asthma attacks more than adults due to their narrower airways (Salmun et al., 2007). • Cotinine is a nicotine byproduct that has been found in saliva, urine, and blood of children/adolescent exposed to secondhand smoking (Salmun et al., 2007). • Children with asthma who are exposed to secondhand smoking have asthma that is harder to control, even with medication (Jarvey et al., 2008)

  29. Question 4 Discuss the results of the diagnostic studies in this case and the relationship to asthma.

  30. Chest X-ray • Hyperluscent • Hyperinflated lungs • No infiltrates present • Lab Values : Patient Value :: Normal Value • Chemistry : WNL • H&H : WNL • WBC : 8.0 x 103/mm : 4-10 X 103mm • PMN : 56% : 50 – 65% • Bands :1% : 0 – 5 % • Eosinophils : 4% : 0 – 3 % • Basophils : 2 : 1 – 3 % • Lymphocytes : 32 % : 25 – 35 % • Monocytes : 5% : 2 – 6 % Patient’s Diagnostic Studies

  31. Abnormal Chest X-Ray • Related to air-trapping due to bronchial constriction • Increased air volume is due to: • Bronchial constriction and air trapping • This causes the image to become hyperluscent • Eosinophils • Slightly elevated • Possibly due to allergies • These are the predominate inflammatory cells in allergic reactions • Causes of eosinophilia • Allergic reactions • Asthma • Hay fever • Hives Correlating The Abnormal Lab Values and Patient “Jenny”

  32. Question 5 What is the FEV1/FVC ratio?  Discuss what these means in this case and analyze the results as they related to obstructive vs. restrictive lung disorders.

  33. Forced Vital Capacity FVC (Forced Vital Capacity) -- This is the total volume of air expired after a full inspiration. Patients with obstructive lung disease usually have a normal or only slightly decreased vital capacity. Patients with restrictive lung disease have a decreased vital capacity. FEV1 (Forced Expiratory Volume in 1 Second) -- This is the volume of air expired in the first second during maximal expiratory effort. The FEV1 is reduced in both obstructive and restrictive lung disease. The FEV1 is reduced in obstructive lung disease because of increased airway resistance. It is reduced in restrictive lung disease because of the low vital capacity. FEV1/FVC -- This is the percentage of the vital capacity which is expired in the first second of maximal expiration. In healthy patients the FEV1/FVC is usually around 70%. In patients with obstructive lung disease FEV1/FVC decreases and can be as low as 20-30% in severe obstructive airway disease. Restrictive disorders have a near normal FEV1/FVC. DLCO (Diffusing Capacity of the Lung for Carbon Monoxide) -- Carbon monoxide can be used to measure the diffusing capacity of the lung. The diffusing capacity of the lung is decreased in parenchymal lung disease and COPD (especially emphysema) but is normal in asthma.

  34. Spirometry Should be done on: Initial diagnosis After treatment is started & symptoms have stabilized Every 1 to 2 years Spirometry is used to measure the rate of airflow during maximal expiratory effort after maximal inhalation. Can be useful in differentiating obstructive and restrictive lung disorders. In asthma (obstructive disorder): forced expiratory volume in 1 second (FEV1) is: decreased forced vital capacity (FVC) is : normal ratio FEV1/FVC is : decreased. In restrictive disorders: The FEV1 and FVC are both decreased Leaving a normal FEV1/FVC. With the use of a bronchodilator will demonstrate: An increase in FEV1 of 12% or 200 ml. Patients with severe asthma may need a short course of oral steroid therapy before they demonstrate reversibility. Provides an objective assessment of airflow obstruction and is important in staging asthma severity.

  35. Lab Results Before Receiving Treatment After receiving bronchodilator : • Tidal Volume (TV)                               350 cc • Inspiratory Reserved Volume (IRV)    1600 cc • Expiratory Reserved Volume (ERV)    400 cc • IRV + ERV                                            1900cc • Forced Vital Capacity (FVC)                2300 cc   • FEV1                                                     950 cc   • FEV1/FVC ratio                                    0.41     • Less than .7 is accepted as being diagnostic of significant airflow obstruction • DLCO                                                   Normal • IRV + ERV   900 cc • Forced Vital Capacity (FVC) 2800 cc • FEV1 2200 cc • FEV1/FVC ratio 0.79

  36. Videos • Good, Long, Detailed Asthma Review • An Asthma Attack • Basic Asthma Information • Asthma Animation

  37. References • Allen, J. Interpretation of pulmonary function tests. Retrieved October 17, 2013, from www2.kumc.edu/internalmedicine/...InterpretofPulmFunctionTests.doc‎ • Altinsoy,B., Altintas,N. (2011). Diagnostic approach to unilateral hyperlucent lung. Journal of the Royal Society of Medicine, 2 (12), 95-98. • Jarvie, J., & Malone, R. (2008). Children’s secondhand smoke exposure in private homes and cars: An ethical analysis. American Journal of Public Health, 98 (12),2140-2145. • Kumar, V., Abbas, A.K., Fausto, N., Aster, J.C. (2010). Robbins and Cotran pathologic basis of disease (8th ed.). Philadelphia, PA: Saunders Elsevier. • Salmun, L., Chilmonczyk, B., Megathlin, K., Haddow, J., & Pulkkinen, A. (2007). Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. Journal of Medicine, 328 (23), 165-169.

  38. References • The Centers for Disease Control and Prevention. (2013).  Asthma basic information: frequently asked questions. Retrieved from http://www.cdc.gov/asthma/faqs.htm. • UC San Diego School of Medicine. (1998). Pulmonary function tests. Retrieved October 17, 2013, Retrieved from meded.ucsd.edu/isp/1998/asthma/html/spirexp.html • United States Environmental and Protection Agency (EPA). (2013). Secondhand smoke and its affects in children. Retrieved from http://www.epa.gov • Wai, Y.C., Sau, F.N., Emily, T.L., Yiu, Y.C., Kwok, K.C., Yui., Cheuk, T.M., and Yuk, Y.k. (2013). Spirometry is underused in the diagnosis and monitoring of patients with chronic obstructive pulmonary disease (COPD). International Journal of Chronic Obstructive Pulmonary Disease, 8, 389-395.

  39. References: Images and Videos Images Videos • Genentech. (n.d.). www.gene.com • Kumar (2010) et al: Fig 6-11, p195 • Kumar (2010) et al: Fig 15-10C, p690 • Kumar (2010) et al: Fig 15-10D, p690 • Kumar (2010) et al: Fig 15-10 E, p690 • Kumar (2010) et al: Fig 15-10 A&B, p690 • Kumar (2010) et al: Fig 15-10 B, p690 • UC San Diego School of Medicine. (1998). Pulmonary function tests. Retrieved October 17, 2013, Retrieved from meded.ucsd.edu/isp/1998/asthma/html/spirexp.html • U.S. National Library of Medicine. (n.d.). nlm.nih.gov • Asad, F. (2010). Asthma- YouTube. Retrieved October 17, 2013, from www.youtube.com/watch?v=8gimcs19mxq • CPRFreak. (2010). Grace's asthma attack - YouTube. Retrieved October 17, 2013, from www.youtube.com/watch?v=ipg4rkikefq • NHS Choices. (2010). Asthma: An animation – YouTube. Retrieved October 17, 2013, from www.youtube.com/watch?v=7edo9puyvpe • World Medical School. (2012). Asthma- USMLE step 2 review - YouTube. Retrieved October 17, 2013, from www..youtube.com/watch?v=3d6Oyt32gpe

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