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Bronchial asthma

BY
Sarah alatwi
Ranay khalf
Jamela
Gaoaher
ezdehar

Outlines
Introducation
Statistic
Case presentation
DEMOGRAPHIC DETAIL
SYSTEMIC REVIEW
PRESENTING COMPLAIN
histery
PHYSICAL EXAMINATION
DISCUSSION OF ASTHMA
Mangement
Drug study
Nursing care plan

Interducation:
Asthma is a chronic
respiratory disorder in
which there is
primarily swelling
ofairways in the lungs.
The airways are
therefore narrowed
making it difficult to
breathe Normal
Inflamed (untreated)
Regular Inhaled
Steroid Partly Treated.

Why focus only in asthma?


As per WHO, saoudi has 15 million

asthmatics which is 10% of the global


asthmatic population
The prevalence of asthma is higher in
children. Today, up to 1 out of 10 children in
saoudi has asthma.
Asthma is the most common chronic
condition in children.
As per a study, Asthma in children has
doubled over the past 5 years and is
rapidly increasing.
There will be an additional 100million

I.Case
presentation

DEMOGRAPHIC DETAIL
Initials : MH
Age

: 6 years and 8 months old


Ethnicity : saoudi
Gender : Male
DOA :8/5/1436
DOD : 10/5/1436
Informant : Grandmother

PRESENTING COMPLAIN
MH, a 6 years and 8 months old saoudi

boy, a known case of G6PD and asthma


was admitted to MCH due to fever, cough
and 1 episode of vomiting since one day
prior to admission and S.O.B and rapid
breathing 4 hours prior to admission.

SYSTEMIC REVIEW
CVS : No excessive night sweating, no

orthopnea.
CNS : No headache/dizziness, no episode
of fainting or fit
attack.
GIT : No constipation, no diarrhea, normal
bowel habit.
MSK : No muscle pain or join pain.
Urinary System: No dysuria or hematuria.
Skin : No rashes or itchiness.
ENT : No sore throat, no runny nose.

PAST MEDICAL/SURGICAL Hx
He has been diagnosed to have asthma since he

was 4 years old.


The pattern of the attack is once in 2 months
It occur mostly when px took cold drinks, cold
weather or do vigorous exercise
He also has the intervals symptoms of cough and
wheezing.
The last attack was on six month ago
Took nebulizer when attack occur but no
hospitalization required.
No hx of eczema.

DRUGS Hx
He is not on any medication
Doctor advice him to take MDI but mother

insist as she claimed that px did not know


how to handle the medication.

ALLERGIES
No known allergies

BIRTH Hx
Born at King Khlid Hospital
FTSVD
Weight : 2.5kg
Antenatal, intrapartum and postpartum hx

was uneventful
Admitted to NICU for 15 days due to neonatal
jaundice diagnosed to have G6PD

FEEDING Hx
Grandmother did not recall how long he had

exclusive breastfeeding
Currently he is on family diet with balance
and adequate amount of fish, meat and rice

IMMUNISATION Hx
Up to his age
Didnt have any complications after taking

the injections

DEVELOPMENTAL Hx
Up to his chronological age. He is currently at

preschool and his performance is good.


Gross motor
: Can walks heel to toe, Can
kick, climbs
and throwing, can ride
tricycle.
Fine motor
: Can imitate or copies pictures
like steps
with 10 cubes , can write his
name
Speech and language : Can speak fluently,
knows age, knows
ABC and numbers.
Social
:Can dresses and undresses alone.

FAMILY Hx
2nd child out of 3 siblings
Both father and mother have asthma and

currently on medication.
Grandmother in paternal side also have
asthma.
Elder sister is 3 years old and younger
sister is 13 months old. Both of them are
well
No history of consanguinity

PHYSICAL
EXAMINATION

1. GENERAL CONDITION
MH

was

sitting

grandmother

was

on

the

sitting

bed
next

comfortably.
to

him. He

His
was

conscious and cooperative and orientated to time and


place. He is not in pain. He was in respiratory distress
as there was suprasternal and subcostal recession.
His hydration and nutritional status were good. There
was a brannula attached to the dorsum of his left
hand. No gross deformities and abnormal movement
seen.

2. VITAL SIGNS
Temperature

: 38.50C

Blood pressure

and normal
Pulse rate

: 115/66 mmHg, regular rhythm

volume
: 110 beat per minute

Respiratory rate:

32 breaths per minute

Impression:
His vital signs are normal.

3.ANTHROPOMETRIC MEASUREMENTS
Height

: 110cm.

Weight

: 17kg.

BMI

: 14.05kg/m2.

Impression:
His growth is within normal.

SYSTEMIC EXAMINATION
1.RESPIRATORY SYSTEM

MH was having respiratory disorders evidenced


by suprasternal and subcostal recession and
presence of added breath sound, ronchi during
expiration on the upper zone of his chest.

2. CARDIOVASCULAR EXAMINATION
There were no abnormal findings during Inspection ,
Palpation , Auscultation.

3. ABDOMINAL EXAMINATION
No abnormal findings.

4. LYMPHATIC SYSTEM
Cervical / Supraclavicular Nodes Right submandibular

lymph node enlargement


Axillary Node- not palpable
Inguinal Nodes not palpable
Other groups of Lymphnodes (specify) not palpable

Impression: Infection causing enlarged lymph node.

III.DISCUSSION OF ASTHMA

DEFINITION:
Chronic inflammatory
disorder of airways that
causes recurrent episodes of
wheezing, breathlessness,
chest tightness and
coughing.

RISK FACTORS
Host Factors
Genetic predisposition
Atopy

Environmental

Factors

Airway hyper-

responsiveness
Gender
Race/Ethnicity

Indoor /allergens
Socioeconomic factors

Family size

weather changes

Obesity

TRIGGERS FACTORS

Allergens
Smoke (passive smoker)
Respiratory infections
Exercise and hyperventilation
Emotional upset or excitement
Food, additives, drugs

Pathogenesis of asthma
Enviromental factors

Genetic factors

Bronchial inflamation
Bronchial hyperactivity + trigger
factors
Oedema , bronchononstriction, & increase
mucous production
Airways narrowing
Symptoms:
-cough
-wheezing
-breathlessness
-chest tightness

CLINICAL FEATURES
Cough
Chest tightness
Wheezing sound of breath
Episodic shortness of
breath
Worsen during night

Various severities of asthma


Classification of asthma severity

Mild intermittent
Mild persistent
Moderate persistent
Severe persistent

*In this patient, it is mild intermittent.

*Patient only developed asthma once in two month .

DIAGNOSIS

History and patterns of symptoms

Physical examination

Measurements of lung function

Measurements of allergic status to identify risk


factors

INVESTIGATION
1)LUNG FUNCTION TEST
This can be done by using Peak Expiratory Flow
Rate(PEFR).

2)Blood and sputum test.

Asthmatic patient may have increase


number of neutrophils in pheripheral
blood

3)Chest X-ray.
Helpful in excluding a
pneumothorax / pneumonia.

Criteria for admission


failure to respond to standard home
treatment
2. Failure of those with mild or moderate acute
asthma to respond to nebulised B2-agonist.
3. Relapse within 4 hours of nebulised B2agonist.
4. Severe acute asthma
1.

* This patient was admitted to ward because failed

respond towards the nebuliser salbutamol given in the


ED.

Common management for


AEBA
Gives neb oxygen
+ neb salbutamol
+ neb ipratopium bromide
+ IV hydrocortisone
+ hydration IV normal saline
If symptoms not subside, gives IV

salbutamol
If symptoms still not subside, do
endotracheal intubation and gives
mechanical ventilation.

MANAGEMENT
Give drug treatment to the patient by following the

severity of the asthma.


Hydration-give maintenance fluid
Monitor pulse, colour, PEFR, VBG and SPO2. (4 hrly)
Antibiotic indicated only if bacterial infection
suspected
Avoids sedatives and mucolytics
Health education involving the parents and their
asthmatic child.
-how to recognized & treat worsening asthma
-when to seek for medical attention
-how to used MDI correctly

Impact of asthma

Night cough, disturbed sleep

Restriction in activity / exercise

Increased school absences (not able to

pay attention in the class, academic


performance will drop)

Ongoing symptoms may have a


detrimental effect on physical,
psychological and social well-being

* Patient only had continuous night cough


and sleeping disturbance during the attack.

Acute severe asthma


Inability to complete a sentence in one

breath.
Respiratory rate >50/min
Tachycardia >140/min
PEFR <50% from normal

LIFE-THREATENING ASTHMA
Silent chest and cyanosis.
Exhaustion,confusion or coma.
PEFR <33% of prediction.

PREVENTION
Education of the family members is a vital

role :
- teaching basic asthma facts

- explain role of medication given


- teaching environmental control measures
- improving parents skills in the use of
spacer device MDI.
*in this case, the parents of the patient did
not know how to use the device & his
father is a smoker

COMPLICATION
STATUS ASTHMATICUS

-Is an acute exacerbation of asthma


attack which do not respond adequately
to therapeutic measures and required
hospitalization

MANAGEMENT

2) Venous Blood Gas


Component
s

Result

Normal

Unit

pH

7.408

7.35-7.45

HCO3

22.5

22-29

mmol/L

Base excess

-1.5

(-3)-(+3)

mmol/L

Impression: Normal

1) Full Blood Count and automated differentials


Components

Result

Normal

White blood count

10.51x103/L

4.5-13.5

Red Blood Cell

4.17X106/L

4.0-5.4

Hemoglobin

11.4g/dL

11.5-14.5

Hematocrit

34.2%

37.0-45.0

MCV

82.0fL

76.0-92.0

MCH

27.3pg

24.0-30.0

Red Distribution
Width

14.5%

30.0-100.0

396x103/L

150-400

Neutrophil %

82.8%

40-75

Neutrophil #

8.71x103/L

2.9-7.9

Lymphocyte %

11.5%

20.0-50.0

Lymphocyte #

1.20x103/L

1.8- 4.0

Monocyte %

2.4%

0-8

Monocyte #

0.25x103/L

0.0- 1.6

Eosinophil %

1.9%

0-5

Eosinophil #

0.20x103/L

0.4- 2.1

Platelet

ED:
Salbutamol Nebulizer cont 1hour
Oxygen mask 2LPM
IV hydrocortisone 40mg q6h
Cefuroxime 500mg IV q12
Ipratropium bromide: 4hourly
IV fluid-maintainance
Blood investigation: FBC, VBG, electrolyte
If not, IV salbutamol or aminophyline
If the symptoms persist, intubation.
Monitoring: vital signs, SpO2, VBG
Syrup prednisolone 17mg OD 5/7
mdi fluticasone 125mcg BD
mdi salbutamol 200mg 4 hourly

At home:
Avoid allergens
syrup prednisolone
MDI Salbutamol

Drug study

Nursing care plan

Thank you