Case Bronchial Asthma Dr Adnan

Case Presentation – Bronchial Asthma Case Presentation – Bronchial Asthma November 4, 2006 Done by: Mohammed M. Al-Ghunaim Acute Severe Asthma 1) how would you define acute severe asthma? Severe asthma, although difficult to define, includes all cases of difficult/therapyresistant disease of all age groups and bears the largest part of morbidity and mortality from asthma. Acute, severe asthma, status asthmaticus, is the more or less rapid but severe asthmatic exacerbation that may not respond to the usual medical treatment. 2) what symptoms and signs will tell you that this patient is quite sick? • Use of accessory muscles (e.g. scalene, sternocledomastoid) • Tachypnea ( >20 breaths/min) • Tachycardia (bradycardia in late stages) • Abdominal paradox (the variation between chest movement and abdominal movement; the abdomen moves more. It occurs in severe asthma) • Peak flow rate <100 L/min • Pulses paradox • Alkalosis (due to tachypnea) 3) What are the signs of life threatening asthma? • Absent of wheeze (silent chest) due to flow obstruction • Hyper-resonance on percution (due to either pneumothorax or hyperinflation of the lung) • Confusion • Central cyanosis • Bradycardia • Poor respiratory effort • High PCO2 (indicates respiratory muscle fatigue) 4) Certain features in asthma can mislead you in assessing the severity, can you explain? • Absent of wheeze • High PCO2 Stages of progression The 4 stages of blood gas progression in status asthmaticus are as follows:     The 1st stage is characterized by hyperventilation with a normal PO 2 The 2nd stage has hyperventilation but hypoxemia so that both PO 2 and PCO2 are low The 3rd stage gives a "false-normal" PCO2 as ventilation has decreased. This is extremely serious and indicates respiratory muscle fatigue with the need for admission to the ICU and, probably, intubation with mechanical ventilation The 4th stage has a low PO2 and a high PCO2 as respiratory muscles fail. This is even more serious and requires intubation and ventilatory support 1 Case Presentation – Bronchial Asthma 5) Factors predicting the risk of developing fatal or near fatal asthma? • Previous hospital addmition • ICU addmition • Using steroids • Other risk factors (female & age) 6) What advice will you give to this patient on discharge? • Self-assessment (PEF, symptoms score) • Follow-up appointment • Instructions for an action plan for managing recurrence of airflow obstruction • All patients should have inhaler technique checked before discharge • Avoid or control asthma triggers 7) Immediate management of acute severe asthma in the emergency. • O2 mask • Bronchodilators • Steroids • Intubation (if necessary) 8) Essential immediate investigations • Blood gases • Oximetery • Peak flow assessment • Chest x-ray: pneumothorax, hyperinflation, pneumonia • CBC: pneumonia 9) Hospital management of severe asthma • O2 • High doses of corticosteroid and bronchodilators • Mechanical ventilation and intubation 10) Role of magnesium sulphate in the management of asthma. Using magnesium sulfate as well as standard drugs when hospitalized for a severe asthma attack may provide extra relief, especially when standard treatments are not working well. In an asthma attack, the airways (passages to the lungs) narrow from muscle spasms and swelling (inflammation). Bronchodilator drugs (reliever inhalers) can be used to relax the muscles and open the airways, and corticosteroid drugs to reduce the inflammation. Magnesium sulfate is a drug that can also affect muscles, and may reduce inflammation as well. It can be given through a drip in the veins (intravenously). 2 Case Presentation – Bronchial Asthma 11) Identification of the factors responsible for the present attack, if possible. • Weather change (1st of April) • Pharmacy student (exposure to chemicals and drugs) • Other risk factors include smoke, viral infection and NSAID. 12) What factors in Mariam’s history ring alarm bells? female, age, history of previous addmitions 13) How would you define Mariam’s asthma attack? acute exacerbation of bronchial asthma 14) Was her management in the casualty appropriate? yes 15) Why was she given IV magnesium sulphate? see question 10 16) Why was she transferred to ICU? because her condition was severe and needed intensive care and monitor. Persistent Asthma 1) what is the definition of asthma? asthma is defined as a chronic inflammatory disorder of the airways, characterized by reversible airflow obstruction causing cough, wheeze, chest tightness and shortness of breath. Asthma has 3 characteristics: - airflow limitation - airway hyper-responsiveness - airway inflammation 2) In what category the above 2 cases you will classify the national heart, lung and blood institute classify asthma as follows: Symptoms frequency Mild intermittent Mild persistent Moderate persistent Severe persistent < 3 time/ week 3-6 time/week daily continual Nocturnal symptoms < 3 time/month 3-4 times/month 5 or more /month frequent FEV1 normal normal 60-80% of predicted < 60 of predicted Peak flow Vary less than 20% 20-30% Varies 30% or more Varies 30% or more 3 Case Presentation – Bronchial Asthma 3) What are the classes or groups of medications that are available for prescription to the above patients? • Inhaled bronchodilators - salbutamol - terbutaline - ipratropium bromide • Inhaled long acting β-agonist - salbutamol - formetrol • Inhaled steroids - betamethasane diproplnate - budesonide - fluticasone acetate • Nebulized medicine - salbutamole - iprompioum - budesonide - fluticasone • Oral agents - theophylline - salbutamole - oral steroids • Other drugs - disodium cormoglycat 4) Which of the medications are controller or reliever inhalers? controller (preventers): anti-inflammatory (e.g. steroids) (brown colored) relievers: bronchodilators (e.g. β-agonist) (usually in blue) 5) You should be familiar with the various inhaler devices available Meter dose inhaler (MDI) rotahalers 4 Case Presentation – Bronchial Asthma diskhalers Turbohalers Spacer devices nebuliser 6) Doses of the common drugs enumerated above 7) Can you identify what caused the worsening in the above two patients Bahiya: use of atenolol (β blocker) Hassan: suboptimal control of his condition 8) What all factors you will look for carefully in patient whose asthma is not well controlled before stepping up the treatment? • Gastro-esophageal reflux disease (GERD) • Sinusitis • Postnasal drip syndrome • Recent usage of NSAID • Non compliance with drugs • Improper technique 5 Case Presentation – Bronchial Asthma 9) Explain briefly the step up care of stable asthma and how will you advice these two patients? Bronchodilator inhaler when needed Low dose steroids (<800 mg/day) high dose steroids (800 - 2000 mg/day) Iprotropium or theophylline Long acting β-agonist 10) Role of home peak flow monitoring with home peak flow monitoring the patient can check his condition regularly and seek medical help before developing into a serious and live-threatening condition 11) Role of patient education in the management of asthma for better control of asthma and prevention of recurrent attacks 12) Basic investigations in asthma • Respiratory function tests (peak expiratory flow, spirometery) • Exercise test • Histamine or methacholine bronchial provocation test • Trial of corticosteroid • Blood and sputum test • Chest X-ray • Skin test • Allergen provocation tests 13) Classical pulmonary function abnormalities in asthma • Diurnal variation in PEF (peak expiratory flow) = morning dipping • >15% improvement in FEV1 or PEF after administering a bronchodilator • Prolonged expiration 6