Bronchical asthma case senario for medical students.pptx

Chronic inflammatory disorder of the airways resulting in episodes of reversible bronchospasm causing airflow obstruction.
Associated with reversible airflow limitation and airway hyper-responsiveness to endogenous or exogenous stimuli.
Inflamed airways undergo a variety of changes including hypertrophied smooth airway muscles and mucous producing goblet cells

1. Bronchical asthma case senario

2. A 16-year-old male presents to the emergency department with acute onset of breathlessness. He has had recurrent, episodic attacks of wheezing, cough, dyspnea, itchy red eyes, nasal discharge, and occasional chest tightness for past 2 years .

3. Initially, his symptoms were relieved by short-acting β-stimulant , albuterol. However, the frequency and the severity of the symptoms have increased for the past 1 month with the patient waking up with these symptoms. He has a history of eczema. His family history is significant for asthma in his mother

4. Physical examination reveals respiratory rate of 22/min and diffuse wheezing all over the lung fields. Pulmonary function test (PFT) shows FEV1/FVC (forced expiratory volume at 1 second [FEV1]/forced ventilatory capacity [FVC]) of 0.65. Forced expiratory volume at 1 second is 60% of predictive and post-bronchodilator therapy the FEV1 increases to 76% of predictive. Chest X-ray is normal.

5. When you breathe normally, muscles around your airways are relaxed, letting air move easily and quietly. During an asthma attack, three things can happen: Bronchospasm:  The muscles around the airways constrict (tighten). When they tighten, it makes your airways narrow. Air cannot flow freely through constricted airways. Inflammation:  The lining of your airways becomes swollen. Swollen airways don’t let as much air in or out of your lungs. Mucus production:  During the attack, your body creates more mucus. This thick mucus clogs airways What is an asthma attack?

6. Asthma is broken down into types based on the cause and the severity of symptoms. Healthcare providers identify asthma as: Intermittent:  This type of asthma comes and goes so you can feel normal in between asthma flares. Persistent:  Persistent asthma means you have symptoms much of the time. What types of asthma are there?

7. • Genetic factors: Asthma has strong genetic predisposition or familial tendency - Stimuli that incite Asthma: • Allergens: Seasonal allergens such as pollen green Non seasonal animal feathers, dust mites, molds. - Pharmacologic stimuli: • Aspirin, β-blockers (e.g. Propranolol). - Environmental and air pollution: • Industrial and heavily populated areas. • The common pollutants are ozone, nitrogen dioxide and sulfur dioxide. Etiology

8. - Infections: • Respiratory infections are the most common of the stimuli that evoke acute exacerbation of asthma. Respiratory viruses are the major factors. - Exercise: • A very common precipitant of acute episodes of asthma. - Emotional stress: • Psychological factors can worsen or ameliorate asthma. ockers (e.g. Propranolol). - Environmental and air pollution: • Industrial and heavily populated areas. • The common pollutants are ozone, nitrogen dioxide and sulfur dioxide. - Infections: • Respiratory infections are the most common of the stimuli that evoke acute exacerbation of asthma. Respiratory viruses are the major factors. - Exercise: • A very common precipitant of acute episodes of asthma. - Emotional stress: • Psychological factors can worsen or ameliorate asthma.

9. Symptoms of each asthmatic patient differ greatly in frequency and degree. Some asthmatics are symptom free, with an occasional episode that is mild and brief; others have mild coughing and wheezing much of the time, punctuated by severe exacerbations of symptoms following exposure to known allergens, viral infection, exercise etc. Symptoms

10. Psychological factors particularly those associated with crying, screaming or hard laughing may precipitate symptoms. An attack usually begins acutely with paroxysms of wheezing, coughing, and shortness of breath, or insidiously with slowly increasing manifestations of respiratory distress. The asthmatic first notices dyspnea, tachypnea, cough and tightness in the chest and may even notice audible wheezes.

11. Varying degrees of respiratory distress tachypnea, tachycardia, and audible wheezes are often present. Dehydration may be present because of sweating and tachypnea. Chest examination shows a prolonged expiratory phase with relatively high pitched wheezes throughout inspiration and most of expiration. In more severe episodes, patients may be unable to speak more than a few words without stopping for breath. Physical examination

12. Cyanosis is usually a late sign of hypoxia. Confusion and lethargy may indicate the onset of progressive respiratory failure. Less wheezing (silent chest) might indicate mucous plug or patient fatigue with less airflow. And it is a sign of impending respiratory failure. Presence, absence, or prominence of wheezes does not correlate precisely with the severity of the attack.

13. most reliable clinical signs include the degree of dyspnea at rest, cyanosis, difficulty in speaking and use of accessory muscles of respiration. This is confirmed by arterial blood gas analysis. • Between acute attacks , breath sounds may be normal during quiet respiration. However, low grade wheezing maybe heard at any time in some patients, even when they claim to be completely

14. Pneumothorax: • It may present as sudden worsening of respiratory distress, accompanied by sharp chest pain and on examination, hyperresonant lung with a shift of mediastinum. Chest x-ray confirms the diagnosis. - Mediastinal and subcutaneous emphysema due to alveolar rupture. - Atelectasis due to obstruction - Dilated right heart chambers ( Cor-pulmonale ) : • from chronic hypoxemia and pulmonary hypertension - Respiratory failure Complications

15. Avoid triggers. - Patient education: features of the disease, goals of treatment, self-monitoring - Pharmacological: • symptomatic relief in acute episodes: short-acting β2- agonist, anticholinergic bronchodilators, inhaled corticosteroids, addition of a long acting β2- agonist Treatment

16. • long-term maintenance: inhaled/oral corticosteroids, anti-allergic agents, long-acting β2- agonists (do not use LABA alone), long-acting anticholinergics , methylxanthine , Leukotriene Receptor Antagonist (LTRA), anti- IgE antibodies (e.g. omalizumab ), anti-IL5 drugs (e.g. mepolizumab ) Treatment

17. • Inhaled β2- agonist first line (MDI route and spacer device recommended) • Systemic steroids (PO or IV if severe) • If severe add anticholinergic therapy ± magnesium sulfate • Rapid sequence intubation in life-threatening cases (plus 100% O2, monitors, IV access) • SC/IV adrenaline if caused by anaphylaxis, IV salbutamol if unresponsive • Corticosteroid therapy at discharge Emergency Management of Asthma

18. Daytime symptoms <4 d/ wk - Night-time symptoms <1 night/ wk - Physical activity unimpaired by symptoms - Exacerbations mild, infrequent - No asthma-related absence from work/school - β2- agonist use <4 times/ wk - FEV1 or PEF >90% of personal best - PEF diurnal variation <10-15% Criteria for Determining if Asthma is Well Controlled::