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1. Breathing Complications CCBS MD4 Clinical Case Camille Renee
Dr. Mohamed Shata Dr. Rana Zeine May 26 2015
2. Setting Clinic: Milton Cato Memorial Hospital - Accident
& Emergency Department Supervising Physician: Dr. Rosmond Adams
Date of Examination: May 10 2015 Image Source: iwnsvg.com
3. Identification Data Male 11 years of age Onset of Condition:
12 hours prior to examination Image Source: nrls.npsa.nhs.uk
4. History of Present Illness Recent cold and cough Family
history of asthma Feelings of Malaise CC: Wheezing Image Source:
ligorilaw.com
5. History of Exposure and Treatment Medications taken in the
last 4 weeks: Salbutamol Prednisone Nebulizer (Ventolin/Salbutamol)
up to 3 times in hr. No recent contact with animals Home free of
dander No history of injections
6. Physical Examination Blood Pressure: 90/40 mmHg Temperature:
98.8 F Weight: 105 lbs Respiratory Rate: 28 Inspection, Palpation,
Percussion, Auscultation HEENT: normal CNS function, EOM/TM intact,
throat WNL, NC/AT Cardiac: chest pain, no wheezing, normal heart
sounds Info Source: Bates Pocket Guide to Physical Examination
8. Current Health Status Physician rated patients health status
at 3/5 (Good). Image Source: analytics-toolkit.com
9. Differential Diagnoses 1. Emphysema/COPD: Obstructive lung
disease with poor airflow and the inability to expire properly 2.
URTI: acute illness characterized by pharyngitis, rhinitis,
whooping cough, sneezing, and sore throat. There is invasion of the
mucosa by bacteria and/or viruses 3. Asthma: Obstructive and
reversible condition with infiltration of airway walls. Coughing,
wheezing, shortness of breath exacerbated by exercise, irritants,
and viral infections. Info Source: Medscape.com
10. 1. Emphysema Pink puffer, barrel-shaped chest Alevolar wall
destruction and enlarged air spaces 1. Centriacinar: associated
with smoking 2. Panacinar: associated with alpha1-antitrypsin
deficiency Increased elastase causes increased lung compliance
Patient will exhale through pursed lips to increase airway pressure
Source: First Aid 2014
11. 2. Upper Respiratory Tract Infection Most common acute
illness Infections: nasopharyngitis, GAS, rhinosinusitis,
epiglottitis, pertussis, laryngotracheitis, influenza, HSV,
gonococcal pharyngitis, mononucleosis Invasion of upper mucosa:
IgA- mediated and cellular immunity with inflammatory cytokines to
initiate immune response Can lead to asthmatic exacerbations Info
Source: Emedicine.Medscape.com Image Source:
ificanucan.files.wordpress.com
12. 3. Asthma Bronchial hyperresponsiveness causing reversible
bronchoconstriction Smooth muscle hypertrophy Curschmanns spirals
Charcot-Leyden crystals Can be triggered by viral URIs, allergens,
and stress Info Source: First Aid 2014Image Source:
HuffingtonPost.com
13. Patient Diagnosis Acute Acceleration of Bronchial Asthma
supported by patient history and current signs and symptoms. Tx:
Patient to be nebulized with prednisone and Ventolin
14. What is Asthma? Condition of bronchial hyperactivity and
smooth muscle hypertrophy Leads to chronic inflammation condition
of the airways associated with widespread reversible bronchospasm
Between 4-8% of all adults are asthmatic. The prevalence is higher
in children, elderly, and Hispanics/African Americans It is
responsible for 10 million+ lost school/work days and $30 billion
dollars spent on medical expenses per year
https://www.youtube.com/watch?v=S04dci7NTPk Info Sources: Case
Files: Internal Medicine & Emergency Medicine Image Source:
wallstreetotc.com
15. Two Phases, Two Types Early (immediate) Temporary and
reversible bronchoconstriction after 10 minute exposure to irritant
Peak bronchoconstriction occurs at 30 minutes and resolves within
hours Tx: beta-agonists Late (delayed) Continued exposure to the
irritant for 3-4 hours or refractory bronchoconstriction Presence
of inflammatory cells, bronchial edema, and mucosecretion Tx:
corticosteroids Info Source: Case Files: Emergency Medicine
16. Extrinsic Asthma Type 1 Hypersensitivity in response to
irritant 1. Sensitization: CD4 Th2 produces IL-4 and IL-5 cytokines
IL-4 allows class-switching to IgE antibody IL-5 will initiate
activation of eosinophils 2. Early Activation: Mast cells are
activated and release histamine, leukotrienes, and acetylcholine
Histamine causes bronchoconstriction, mucosecretion, and chemotaxis
Leukotrienes further induce bronchoconstriction (LTC4, LTD4, LTE4)
Acetylcholine causes parasympathetic-mediated bronchoconstriction
3. Late Activation: Eosinophils are activated Mediated by eotaxin
and produces major basic protein aka proteoglycan 2 to cause
bronchospasm and epithelial damage Source: MedBullets.com
17. Intrinsic Asthma Non-allergen mediated Induced by: Viral
infections: RSV, Rhinovirus, Parainfluenza, etc. Stress or Exercise
Chemical Sensitivities: NSAIDs, ASA, oozone-produced free radicals
May lead to Status asthmaticus Life-threatening asthma that does
not respond to standard treatments Source: MedBullets.com
18. Coughing is Usually the Only Symptom! Although wheezing is
considered a classic sign of reactive airway disease, cough is
often the only symptom (including during an asthmatic attack).
During an asthmatic attack, look for these symptoms: Anxiety or
fatigue Unable to speak in full sentences Use of accessory muscles
Tripod position Info Sources: Case Files: Internal Medicine &
Emergency Medicine Image Source: paramedicine.com
19. Other Asthmatic Manifestations People with asthma
eventually develop heightened sensitivity of their airways
https://www.youtube.com/watch?v=v-qr78Wj4xM
20. How To Diagnose Asthma Clinically Peak Expiratory Flow
Spirometry can confirm airflow obstruction (reduced FEV1 and
FEV1/FVC) Methacholine Challenge Used to diagnose bronchial
hyperreactivity (positive: reversible with increase in FEV1 of 12%
or more after administering bronchodilator) Severe asthma is
defined as an FEV1 of less than 50% (30 breaths/minute) because of
low I/E ratio Hypoxemia Pulsus paradoxus (decreased blood flow to
the left heart due to lung hyperinflation) Mucous plugging Remember
to assess: nature and duration of symptoms, medication and family
history, and possible triggers. Info Source: Case Files: Emergency
Medicine
23. Gross Examination Postmortem Info Source: Dail and Hammars
Pulmonary Pathology
24. Histological Findings in Sputum Charcot-Leyden crystals:
eosinophilic breakdown within mucous plugs Curschmanns spirals:
mucous plugs from shedded epithelium Source: First Aid 2014,
MedBullets.com
25. Making the Right Diagnosis DDx Vocal cord dysfunction
(exclude using laryngoscopy) Tracheal and Bronchial lesions or
tumours (exclude using CT scan) Foreign bodies Pulmonary migraine
Congestive heart failure (exclude by checking ECG and EF) Severe
Sinus Disease (exclude using CT scan) Aortic Arch anomalies (check
flow-volume) GERD (exclude by using scintigraph, PET, etc.)
Patients with a smoking history of 20-pack years or more should be
considered for COPD Info Source: Medscape.com Image Source:
ishareimage.com
26. What Can Trigger Asthma? Allergens (i.e. dust, mold,
pollen, dander) Viral Infections Physical Activity Cold weather
Stress GERD Changes in hormone levels Info Source: Case Files:
Emergency Medicine Image Source: healthclips.com
27. Managing Asthmatic Patients 1. Oxygen, Compressed Air, or
Heliox 2. Adrenergic Agents 3. Anticholinergic Agents 4.
Corticosteroids 5. LT Antagonists 6. Positive Pressure Ventilation
Info Source: Case Files: Emergency Medicine
28. 1. Oxygen Used to maintain SO2 of >90% Infants, pregnant
women, and patients with heart disease are required to maintain an
SO2 of 95% or more Oxygen, compressed air, OR a mixture of helium
and oxygen (heliox) can be used as a delivery mechanism for other
medications (nebulizer) Info Source: Case Files: Emergency
MedicineImage Source: getwellsoon.com
29. 2. Adrenergic Agents 2.55 mg albuterol/levalbuterol every
30 minutes for 1-2 hours (10-20 mg for severe asthmatics) Beta-2
agonists to decrease calcium and promote bronchial relaxation (plus
anti-inflammatory) Albuterol may be combined with a metered-dose
inhaler (MDI) with spacer device Inhalation may be substituted with
epinephrine (0.3 to 0.5 mg) or terbutaline (0.25 mg) May be added
to adrenergic agents to further improve pulmonary function e.g.
Ipratropium bromide given via MDI with spacer device 3.
Anticholinergic Agents Info Source: Case Files: Emergency
Medicine
30. MDI with spacer technique recommended for patients having
difficulty using MDI only Image Source: fastbleep.com
31. 5. Leukotriene Antagonists Zileuton (Zyflo Filmtab),
zafirlukast (Accolate), montelukast (Singulair) improves FEV1
values Mostly used for patients with chronic or aspirin-induced
asthma 4. Corticosteroids Suppresses inflammatory response
Prednisone (40 to 60 mg) PO Methylprednisone (160 mg) IM for severe
patients Beclomethasone, fluticasone, dexamethasone, hydrocortisone
Info Sources: Case Files: Emergency Medicine, First Aid 2014 Image
Source: dermnet.com
32. 6. Positive Pressure Ventilation Bi-level positive airway
pressure (BiPAP) is used for patients with severe asthmatic
exacerbations (FEV1 30) prior to intubation BiPAP machine should be
set to 8-15 cm H2O for inspiratory pressure and 3-5 cm H2O for
expiratory pressure Rapid-sequence endotracheal intubation is given
to patients near-comatose after a bolus of an induction agent
(ketamine) and a paralytic agent (succinylcholine) ABG analysis is
recommended during treatment to monitor patient recovery Info
Source: Case Files: Emergency Medicine Image Sources: nlm.nih.gov,
healthcare.philips.com
33. Other Medications Long-acting 2-agonists for prophylaxis
and patients with low response to short acting 2-agonists
Salmeterol, Formoterol Methylxanthines to inhibit
phosphodiesterase, causing bronchodilation Theophylline Muscarinic
antagonists to prevent bronchoconstriction Ipratropium bromide
Monoclonal anti-IgE antibody to block binding of IgE to FcRI (for
patients with asthma resistant to steroids and beta-agonists)
Omalizumab Info Source: First Aid 2014
34. Info Source: Case Files: Internal Medicine
35. Hospital Admission Criteria Patient should be admitted to a
hospital if they fail to respond to therapy, have new-onset asthma,
have had multiple prior hospitalizations, CAD, have impaired access
to healthcare or intellectual disabilities Patient must be adapted
to room air and moving around ED without complications FEV1 must be
greater than 70% Prescribe albuterol or oral corticosteroids before
discharging Patient education is recommended Patient should be
referred for follow up appointment Info Source: Case Files:
Emergency Medicine Discharge Criteria
36. Patient Education Asthma self-management Peak flow
self-monitoring techniques How to use inhalers Keeping surrounding
environment allergen-free
https://www.youtube.com/watch?v=4GIyZCNICLY Info Source:
Medscape.com Image Source: fairview.org
37. Case-Related Questions
38. Question 1 A 24-year-old man is brought into the ED
complaining of an exacerbation of his asthma. Which of the
following is the most appropriate method of assessing the severity
of his disease? a) Spirometry b) Measurement of the diffusion
capacity of the lungs c) Measurement of the peak expiratory flow d)
Measurement of the alveoli oxygen tension Info Source: Case Files:
Emergency Medicine
39. Answer C. The peak expiratory flow is a reliable and fairly
accurate method of assessing asthma severity. Spirometry, although
providing important information, is rarely available in the ED.
Info Source: Case Files: Emergency Medicine
40. Question 2 Severe asthma is defined as an FEV1 of less
than: a) 10% b) 25% c) 30% d) 42% e) 50%
41. Answer E. Severe asthma is defined as an FEV1 (forced
expiratory volume in 1 second) of less than 50% (