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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

Bronchial Asthma

RucciCopian

Clar Coronado

Kayson Credo

objectives
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
slide3
Case
  • G.B., 35/F, from Quezon City, married, Roman Catholic
  • DOA: 06.11.12
  • CC: DOB of 3 hours
slide5
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
past medical history
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
family history
Family History
  • Asthma – maternal side
  • HTN – both sides
  • Leukemia – paternal uncle
social history
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
physical examination upon admission
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
salient features
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
impression
Impression:
  • Bronchial Asthma in Acute Exacerbation
slide12
ER
  • 02 Supplementation at 2 lpm via NC
  • SalbutamolNebulization x 6 doses (continuous) then q1
  • BudesonideNebulization q12
  • Hydrocortisone 50 mg/tab IV q6
laboratory procedures
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
asthma
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
risk factors
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
main physiological feature
Main Physiological Feature
  • Episodic airway obstruction
clinical features
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

questions to consider in the diagnosis of asthma
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?
diagnostics
Diagnostics
  • Lung Function Tests
  • Airway Responsiveness
  • Hematologic Tests
  • Imaging
  • Skin tests
  • Non-Invasive Markers
lung function tests
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
lung function tests1
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
lung function tests2
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
lung function tests3
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
lung function tests4
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
airway responsiveness
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
hematologic tests
Hematologic Tests
  • TOTAL SERUM IgE to inhaled allergens – not usually helpful
imaging
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)
skin tests
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

non invasive markers of airway inflammation
Non-Invasive Markers of Airway Inflammation
  • Examining spontaneously produced or hypertonic saline –induced sputum for eosinophilic or neutrophilic inflammation
  • Nitric oxide
levels of asthma control
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)
assessment of future risk
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
cough variant asthma
Cough-Variant Asthma
  • Chronic cough as the principal, if not only symptom
  • common in children
  • commonly more problematic at night
prevalence of asthma
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
prevalence of asthma1
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.
pathophysiology of asthma
Pathophysiology of Asthma
  • Involves the following components:
    • Airway inflammation
    • Intermittent airflow obstruction
    • Bronchial hyperresponsiveness