CATCH MY BREATH!

Case Presentation
Maureen Betty Braga
Kris Ayza Dialing
Rufaida Julhan
Michael Lapasaran
John Christopher Luces
M i k e e To n i S u n g a
Camille Uy
Post Graduate Interns
CASE OVERVIEW
M.C.
36 years old, Female
Married, Roman Catholic
Cabantian, Davao City

CC: Difficulty of breathing

 History of Present Illness
3 days PTC:
patient experienced non-productive cough and
nasal catarrh with watery discharge with no
other associated signs and symptoms
self-medicated with a total of 3 tablets of Bioflu
Patient has difficulty of sleeping and awakens at
night due to persistence of symptom
 History of Present Illness
1 days PTC:
Same symptoms persisted with night time
awakening, dizziness, facial numbness,
undocumented fever
 Day of consult:
Patients condition persisted with patient experiencing
a sudden onset of difficulty of breathing
self-medicated with a total of 2 tablets of Salbutamol,
but with no relief

Sought consult at the emergency room where she was

managed with 3 nebulizations of Salbutamol +
Ipratropium and Hydrocortisone 250mg IVTT
Condition still did not improve and she was subsequently
admitted
 Past Medical History
(+) Bronchial Asthma no maintenance inhaler meds
Self-medicates with salbutamol when as needed
Exacerbations 2x this year (Feb, May 2017)
(-) Diabetes Mellitus
(-) Hypertension
(-) Heart Problems
(-) Thyroid Problems
 Family Genogram
I

LEGEND

II

III

ASTHMA
Carin Family 2017 CHOLELITHIASIS
 Personal/ Social History
born in Davao but transferred to manila with her partner and 4
children
She Was an OFW in Dubai for 9 years. She started working there
when she was pregnant with her 2nd child. her recent work was at a
salon with more than the minimum wage (P60,000/month) salary.
She then resigned from her work and went back to davao to help
her aunt set up a mini restaurant business. She is currently preparing
to go to Japan to again work as an OFW.
(+) smoker: 6.75 pack year smoker occasional alcohol beverage
drinker
 OBSTETRIC AND GYNECOLOGIC HISTORY
GRAVIDITY MODE OF YEAR DELIVERED
DELIVERY
G1 NSVD 1998
G2 NSVD 2003
G3 CS SEC. TO 2005
PLACENTA PREVIA
G4 NSVD 2013

LAST MENSTRUAL PERIOD: AUGUST 30, 2017

MENARCHE: 12 YEARS OLD
INTERVAL: 26-32 DAYS
DURATION: 3 DAYS
NUMBER OF PADS CONSUMED: 2 PADS/DAY
ASSOCIATED SYMPTOMS: NONE
 Review of Systems
General (-) general weakness, (-) recent changes in weight

Skin (-) excessive sweating, rashes

Head, Eyes, Ears, Nose, Throat (-) dandruff, itchiness; (-) Tearing,
photophobia, eye pain, visual loss; (-) discharge, ear pain; (-)
discharge; (-) inflamed tonsils, (+) sore throat

Cardiovascular (-) Palpitations

 Review of Systems
Respiratory (+) Dyspnea, cough, coryza

Gastrointestinal (-) Increased bowel motility with increased

frequency of bowel movements

Genitourinary (-) dysuria, (-) burning sensation in urethra, (-)

frequency, urgency, nocturia, hematuria
 Review of Systems

Neuromuscular (-) hand tremors, (-) proximal muscle

weakness, (-) easy fatigability

Metabolic (-) Heat intolerance, (-) weight loss

Psychiatric (-) Restlessness, anxiety, irritability, insomnia

 VITAL SIGNS AND ANTHROPOMETRICS

ER Normal Value
BP 143/87 90/60 mm/Hg to 120/80 mm/Hg
Temp 37.5 36.5 37.6
Pulse Rate 90 60-100
Respiratory Rate 24 12-18
Weight 69 kg
Height 160 cm
BMI 26.95 18.5 to 24.9
 Physical Exam

General Survey:
conscious, coherent, in mild respiratory distress

Skin and Integument: skin is brown smooth, warm to touch.

no cyanosis. No rashes and skin lesions noted
 HEENT:
Head: normocephalic, hair dark brown and evenly distributed
Eyes: anicteric sclerae, pupils equally round and reactive to light and
accommodation
Ears: intact pinna, no deformities, able to hearing and respond when
name is called
Nose: pink nasal mucosa, midline septum, no sinus tenderness, no
polyps
Mouth: moist, smooth and pinkish oral mucosa, no ulcers or dental
caries, not inflamed tonsils, no exudates
Neck: no neck vein engorgement, no cervical lymphadenopathies, no
masses
 Thorax and lungs
Inspection: symmetrical chest expansion
Palpation: no tenderness nor masses
Percussion: hyperresonant on all fields
Auscultation: Bilateral wheezing on both lungs
 Heart
Inspection: No pulsations, a dynamic
precordium
Palpation: PMI at 5th ICS
Auscultation: regular rate, regular rhythm,
distinct heart sounds, no murmur
 Abdomen
Inspection: flat, umbilicus midline
Auscultation: normoactive bowel sounds
Palpation: no mass, no tenderness
 Genitourinary/Rectum: not assessed

Extremities: no deformities, no edema, no cyanosis,

full range of motion
 SALIENT FEATURES
SUBJECTIVE OBJECTIVE

Female, Filipino Vital Signs

T= 37.5 C
difficulty of breathing PR = 90 bpm
cough and colds RR = 24 cpm (tachypnea)
Nighttime awakening 2x BP = 140/80 mmHg
Sore throat PHYSICAL EXAMINATION
Chronic smoker (6.75 pack year) Bilateral wheezing and hyperresonant lungs
Previously worked at the salon now works
at a carinderia
(+) asthma since kindergarten- last known
attack was May 2017- uncompliant
Asthma attack triggered by change in
climate and stress
INITIAL WORKUP AT THE ER

CBC Chest Xray

Hgb 140
Hct 0.42
Unremarkable
RBC 4.58
WBC 18.78 (H) cardiopulmonary findings
Platelet 254 (N)
Neutro 89 (H)
Lympo 7 (N)
 INITIAL
IMPRESSION
BRONCHIAL ASTHMA IN ACUTE EXACERBATION;
LOWER RESPIRATORY TRACT INFECTION
DIFFERENTIALS
 CAP-LR
RULE IN RULE OUT

acute cough unproductive Normal cardiac rate

(3days) No crackles (only wheezing)
Dyspnea Unremarkable chest
Undocumented fever findings
RR: 24
 Chronic Obstructive Pulmonary Disease
RULE IN RULE OUT

Filipino known Asthmatic since

6.75 pack year Smoke kindergarten
dyspnea acute cough
(-) barrel chest
RR: 24 - Tachypnic
(-) coarse crackles with expiration
bilateral wheeze
 Upper Respiratory Tract Infection
RULE IN RULE OUT

Filipino known Asthmatic since childhood

dyspnea bilateral wheeze
cough and colds for 3 days (-) post nasal drip
(-) muffled dysphonia or loss of voice
duration (-) tripod or sniffing posture
RR: 24 - Tachypneic Normal chest xray
sore throat
Course in the Emergency Room
9/11 Salbutamol+Ipatropium 1 nab x 3 There was no relief of symptoms
doses Patient was admitted
Difficulty of breathing
Bilateral wheezing Hydrocortisone 250 mg IVTT now Admitting Orders
Cough and colds Diet as tolerated with strict aspiration
precaution
37 C Vital signs every 4 hours and record
94bpm Intake and output every shift
23cpm IVF: PNSS iL @120cc/hour
120/80mmhg Do peak flow meter once patient is at the
ward
Medications:
Salbutamol + ipratropium nebulization 1 neb
q8hours for dyspnea
Hydrocortisone 100mg IVTT q8 x 3 doses
Co-amoxiclav 1g 1tab P.O. BID PC
Budesonide + Formoterol 160/4.5mcg 2 puffs
daily

Watch out for any unusualities

COURSE IN THE WARD
DAY 1 (9/12/17)
9/12/17 36.8 C S/F peak flow meter
9:00AM 68bpm Start
Day 5 of illness 18cpm 1) Levocetirizine 5mg tab itab OD at HS
(+)dyspnea 110/70mmHg 2) Montelukast 10mg tab OD at HS
(+) productive cough and colds Continue medications
(+) muscle pain Refer
(-)fever BRONCHIAL ASTHMA IN
(-)abdominal pain ACUTE EXACERBATION
Awake alert NIRD
Equal chest expansion
(+) wheeze
(+)crackles BLF
Soft nontender abdomen
DAY 2 (9/13/17)
9/13/17 36.6 C For TSH, FT4, T3
7:30AM 82bpm 1) Increase Salbutamol + ipratropium nebulization 1
Day 6 of illness 21cpm neb q8hours for dyspnea q 6
(+)dyspnea 110/80 2) Increase Hydrocortisone 100mg IVTT q8 to q6
(+)cough Regulate IVF to 120 cc/hr
(+) tremors BRONCHIAL ASTHMA IN VS q 4hours
(+) muscle pain ACUTE EXACERBATION
(-)fever
(-)abdominal pain
Awake alert NIRD
Equal chest
expansion
(-) wheeze
(+)crackles BLF
Soft nontender
abdomen
DAY 3 (9/14/17)
9/14/17 36 C Continue present
11:00AM 70bpm medication
Day 7 of illness 20cpm Regulate IVF to 120 cc/hr
(+) slightly dyspneic 110/80 VS q 4hours
(+) cough
(-) muscle pain BRONCHIAL ASTHMA IN ACUTE
(-)fever EXACERBATION
(-)abdominal pain
Awake alert NIRD
Equal chest expansion
(-) wheeze
(+) minimal crackles BLF
Soft nontender abdomen

Labs:
Free T4= 15.16 (7.9-14.4)
T3= 1.68
TSH3= 2.0
CASE DISCUSSION
Asthma Burden in the World

Asthma is one of the most common chronic diseases

worldwide with an estimated 300 million affected
individuals
The prevalence of asthma has increased 61% over the
last two decades.
Asthma is the leading chronic illness among children.
Asthma results in 10 million lost school days and 3
million lost work days.
Deaths from asthma have increased by 31% since
1980.
Asthma Burden in the Philippines
approximately 11 million or 1 out 10 Filipinos are
suffering from asthma, yet 98 percent of Filipino
asthma patients continue to lack proper treatment
The Philippines is ranked 32nd in self-reported
asthma.
12.4 percent of children aged 14 to 15 years old are
afflicted with asthma. Most of these children come
from low-income families or communities
 ASTHMA
Chronic inflammatory condition of the airways characterized by;
- airflow limitation (reversible with treatment)
- airway hyper-responsiveness to a wide range stimuli
- inflammation of the bronchi

In chronic asthma, inflammation maybe accompanied by irreversible

airflow limitation

Symptoms are cough, wheeze, chest tightness, and shortness of

breath which often worse at night
 Simple Definition
A reversible chronic inflammatory airway disease which is
characterized by bronchial hyper-responsiveness of the
airways to various stimuli, leading to widespread
bronchoconstriction, airflow limitation and inflammation of
the bronchi causing symptoms of cough, wheeze, chest
tightness and dyspnoea.
 Classification
Extrinsic implying a definite external cause
more frequently in atopic inviduals
(atopic individual which tends to develop hypersensitivity by contact
with allergens)
often starts in childhood - accompanied by eczema

Intrinsic/cryptogenic no causative agent can be identified

starts in middle age
 Types of Asthma
According to pathophysiology
Allergic asthma

Occupational (allergic)

Intrinsic (Non-Allergic)

Exercise-induced

Steroid-resistant
 Pathogenesis

Complex, not fully understood

numbers of cells, mediators, nerves, and vascular leakage -
activated by expose to allergens or several mechanism
Inflammation
Eosinophils, T-lymphocytes, macrophages and mast cell
Remodeling
Deposition of repair collagens and matrix proteins-damage
Loss of ciliated columnar cells- metaplasia increase no of secreting
goblet cells
 Pathologic features of asthma
i. Inflammatory cell infiltration of the airways
ii. Increased thickness of the bronchial smooth muscle
iii. Partial or full loss of the respiratory epithelium
iv. Subepithelial fibrosis
v. Hypertrophy and hyperplasia of the submucosal glands and
goblet cells
vi. Partial or full occlusion of the airway lumen by mucous plugs
vii. Enlarged mucous glands and blood vessels
 Pathophysiology

Smooth muscle contraction

Thickening of airway cellular infiltration and inflammation
Excessive secrection of mucus
Genetic factor
Cytokine gene complex (chromosome 5)-IL-4 gene cluster control IL-3, IL-4 , IL-5 and IL-13
Environment factor
Childhood expose irritants or childhood infection
 Pathophysiology

Extrinsic asthma: Atopic/allergic, occupational, allergic

bronchopulmoary aspergillosis.
Atopic or allergic
Dust, pollens, animal dander, food etc. Family history of atopy.
serum IgE.
Skin test with Ag wheal, flare ( Classical IgE mediated response)
Exposure of pre-sensitised mast cells to the Ag stimulates chemical
mediators from these cells. Type 1 hypersensitivity.
 1.Early phase

Inhaled Antigen
Sensitised mast cells on the mucosal surface mediator
release.
Histamine bronchoconstriction, increased vascular
permeability.
prostaglandin D 2 bronchoconstriction, vasodilatation.
Leucotriene C4,D4, E4 Increased vascular permeability,
mucus secretion and bronchoconstriction.
Direct subepithelial parasympathetic stimulation
bronchoconstriction.
 2.Late phase
starts 4 to 8 hours later
Mast cell release additional cytokine
Influx of leukocytes(neutrophil,eosinophil)
Eosinophils are particularly important-
exert a variety of effect
 Pathophysiology
Atopic Asthma

IL5 Eosino
phil
Trigger
Eg.dust,pollen, TH2 cell
animal dander IL4

IgE B
cell
Mediators Mast
Eg.Histamine, cell
leukotrines IgE antibody

Immediate
Bronchospasm phase(minutes)
Increase vascular permeability
Mucus production
Environment factor Genetic prediposition

Bronchial inflammation

Bronchial hyperreactivity + trigger factors

Oedema
BronchoC
Mucus production

Airways narrowing

Cough, Wheeze, Breathlessness, Chest tightness

 Pathology of Asthma

Asthma
involves
inflammation of
the airways

Normal Asthma

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma
Created and funded by NIH/NHLBI, 1995
 Aetiology and triggers
Complex and multiple environmental and genetic
determinant
a) Genetic factors
b) Allergen exposure house dust mite, household pets, grass
pollen
c) Atmospheric polution sulphur dioxide, ozone, ciggerate
smoke, perfume
d) Dietary deficiency of antioxidants vit E and selenium
may protect asthma in children(freshfruits and vegetables)
Making the Diagnosis of
I. A HISTORY OF VARIABLE RESPIRATORY SYMPTOMS
II. DIAGNOSIS OF VARIABLE AIRFLOW
LIMITATION
CONFIRM PRESENCE OF OUTFLOW
LIMITATION

o Document that FEV1/FVC is reduced

(at least once, when FEV1 is low)

o Excessive bronchodilator reversibility

o Excessive diurnal variability from 1-2

weeks twice-daily PEF monitoring

o Significant increase in FEV1 or PEF

after 4 weeks of controller treatment
Methods of investigation
Objectively: Tachypnea with prolonged expiration, wheezing, dry rales
Sputum analysis: eosinophils, Kurshman spirals (mucus from small
bronchi), Charco-Leiden crystals (enzymes of eosinophils)
General blood analysis: mild leucocytosis, eosinophilia
Spirometry: decreased FVC, FEV1, FEV1/FVC, increased daily variability
III. PHYSICAL EXAMINATION:
The most frequent finding is wheezing on auscultation,
especially on forced expiration
Approach to
management
 MANAGEMENT
The long-term goals of asthma management are:

1. Symptom control: to achieve good control of symptoms and

maintain normal activity levels

2. Risk reduction: to minimize future risk of exacerbations, fixed

airflow limitation and medication side-effects
!ONLY IN THIS STAGE!
 Managing
exacerbations
 Mild Moderate Severe

Breathless Walking Talking At rest

Can lie down Prefer sitting Hunched forward

Talk in Sentences Phrases Words

Alertness May be Usually agitated Agitated

Central cyanosis Absent Absent Present

Use of accessory muscle Absent Moderate Marked

Sternal retraction Absent Moderate Marked

Wheeze on auscultation Moderate, often end Loud Loud Silent Chest

expiratory

Pulsus paradoxus Not palpable May be palpable Often palpable

Initial PEF More than 80% 60 80% Less than 60%

Oximetry on More than 95% 91 95% Less than 90%

presentation
-If it necessary hospitalization with i/v infusion of
glucocorticosteroids and euphyllin
 MANAGEMENT
The long-term goals of asthma management are:

1. Symptom control: to achieve good control of symptoms and

maintain normal activity levels

2. Risk reduction: to minimize future risk of exacerbations, fixed

airflow limitation and medication side-effects
 Treating to Control Symptoms and Minimize Risk
Establish a patient-doctor partnership Manage asthma in a continuous cycle:
o Assess

Adjust treatment (pharmacological and non-pharmacological)

o Review the response

Teach and reinforce essential skills

o Inhaler skills
o Adherence
o Guided self-management education
o Written asthma action plan
o Self-monitoring
o Regular medical review
 BETA 2 AGONISTS ADRENERGIC STIMULANTS

Bronchodilatation through stimulation of Badrenergic

receptors and activation of G proteins ) cAMP
Decrease release of mediators and improve mucociliary
clearance
Non bronchodilator effects - inhibit mast cell mediator release,
reduction in plasma exudation, & inhibition of sensory nerve
activation
No effects on inflammatory cells in airways hence no reduction
in AHR,
 Catecholamines - Short-acting beta 2 agonists (SABA) -
terbutaline, salbutamol
Resorcinols fenoterol
Major side effects - tremors
Active via all routes (oral, lV or inhalation)
Last 4-6 hours
lnhalation route is preferred - maximal bronchodilatation with
fewer side effects
 Long-acting beta 2 agonists (LABA)
o Salmeterol & Formoterol
lasting for 12 hours
 ANTICHOLINERGIC DRUGS

Cholinergic-induced bronchoconstriction involves the large

airways; b2 agonist relax small airways
Muscarinic receptors
Ml - within parasympathetic ganglia
M2 postganglionic sympathetic nerves/ act as negative
feedback
M3 - airway smooth muscles
 METHYXANTHINES-Theophylline
Mild to moderate bronchodilatation
Mechanism of action - uncertain
Convenient long-acting oral dosage forms & lV form
Therapeutic plasma concentration 5-15 ug/ml
Side effects - GIT symptoms (nausea, vomiting) most common
& CNS (stimulation/seizures) & cardiac tachycardia and
arrythmia
 LONG TERM CONTROL MEDICATIONS
agents that prevents/ reverse inflammation Glucocorticoids
o Long-acting beta 2 agonists (LABA)
o Mast-cell stabilizing agents
o Leukotriene modifiers
o Methylxanthines
 Corticosteriods
Reduction of symptoms
Diminish airway hyperresponsiveness
Prevention of exacerbations
Possibly prevention of airway remodelling
 INHALED CORTICOSTEROIDS
Agents - budesonide, fluticasone, beclomethasone,
triamcinolone, flunisolide
Oral steroid sparing effects
Combination with long acting beta2 agonists (LABA) -
synergistic
Seretide - salmeterol & fluticasone
Symbicort - formoterol & budesonide
 Local side effects:
o Oral thrush
o Cough/ hoarseness
Systemic:
o Mild adrenal suppression possible with higher doses
o Cataract formation
o decreased growth in children
o purpura
o interference with bone metabolism
 MAST CELL STABILIZING AGENT
Cromolyn sodium and nedocromil sodium
lnhibit degranulation of mast cells
Nonsteroidal
Effectively prophylactically inhibit both early and late phase
reactions
4-6 weeks trial therapy
Side effects of cromolyn - cough; nedocromil - unpleasant
taste, nausea/vomiting
 LEUKOTRIENE INHIBITORS
5 lipooxygenase (S-LO) inhibitor- zileuton
lnhibitors of LTD4 at receptor Montelukast (Sinoulair) and
Zafirlukast (Accolate)
Modest brochodilation, effective in exercise-induced asthma
(EIA) and nocturnal symptoms
Effective in aspirin-induced asthma
Limited effectiveness against allergens lnhaled CS (lCS)
superior to leukotriene inhibitors; add-on to'lCS improved lung
function
 WELLNESS PLANS
Avoidance of tobacco smoke exposure
Provide advice and resources at every visit
advise against exposure of children to environmental tobacco
smoke (house, car)
Encourage physical activties because of its general health benefits.
Occupational asthma
Ask patients with adult-onset asthma about work history.
Breathing techniques
 Self-monitoring of symptoms
Written asthma action plan
 Managing Asthma:
Asthma Management Goals

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as
possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
 Managing Asthma:
Asthma Action Plan
Develop with a physician

Tailor to meet individual needs

Educate patients and families about all aspects of plan

Recognizing symptoms
Medication benefits and side effects
Proper use of inhalers and Peak Expiratory Flow (PEF)
meters
National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the
Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.