Thomas Kurian

How to manage a wheezing patientThomas Kurian

Thomas Kurian

Approach to a case

Thomas Kurian

Asthma should be considered likely

• episodic wheezing and other symptoms, such as cough and dyspnea

• respond favorably to conventional asthma medications

Thomas Kurian

Historical findings that may suggest that wheezing is NOT due to asthma or COPD

• sore throat• hoarseness• heartburn• sour taste and regurgitation• hemoptysis

Thomas Kurian

History

• ●Onset - foreign body aspiration • goiter compressing the airway or

endobronchial tumor • ●A history of neck or thyroid surgery – ? vocal cord paralysis• ●Prior intubation – • ? vocal fold trauma or paralysis, tracheal

stenosis, or tracheomalacia

Thomas Kurian

History

• ●dyspnea, wheeze, intractable (often barking) cough to the point of syncope, and recurrent pulmonary infections—

• tracheobronchomalacia and hyperdynamic airway collapse.

• ●Cigarette smoking more than 10 pack years • COPD• laryngeal or bronchogenic cancer

Thomas Kurian

History

• Respiratory symptoms in the minutes or hours after a single accidental inhalation of a high concentration of irritant gas, aerosol, or smoke ---

• reactive airways dysfunction syndrome (RADS)●Wheezing associated with a chronic or recurrent cough productive of purulent sputum may suggest bronchiectasis

Thomas Kurian

Physical examination

• oxygen saturation, and evidence of respiratory distress

• Chest and neck auscultation are used to differentiate stridor from wheezing

Thomas Kurian

Acoustic characteristics of wheeze

• •Polyphonic wheeze• •Monophonic wheeze

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Stridor is a type of monophonic wheeze, but its intensity and occurrence during inspiration help distinguish it from lower

airway monophonic wheezing

Thomas Kurian

Timing

• Expiratory wheezing-- neither sensitive nor specific for asthma

• Inspiratory wheezing-- neither a sensitive nor a specific sign of extrathoracic upper airway disease or obstruction

• In some patients with asthma, wheezing may only be heard during inspiration

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Focal wheeze

• persistently located in one area • foreign body in a segmental airway,

endobronchial tumor

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Thomas Kurian

Extrapulmonary findings

• Tonsillar hypertrophy is typically visible on oral exam.

• Neck - lymphadenopathy, thyroid enlargement, or a surgical scar is identified.

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• Spirometry• Flow volume loop

Thomas Kurian

Thomas Kurian

Thomas Kurian

Bronchoprovocation challenge

• A negative methacholine challenge test -strong evidence against asthma or RADS.

Thomas Kurian

Gas transfer

• P(A-a)O2 gradient on arterial blood gases • increased P(A-a)O2 gradient or a reduced

DLCO suggest small airway disease or lung parenchymal involvement

Thomas Kurian

Imaging

• A conventional chest radiograph is appropriate in most adults with new onset or refractory wheezing

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Chest CT

• vascular rings, aneurysms of the major vessels, mediastinal masses, or lymphadenopathy that compress the trachea extrinsically

• Tracheomalacia

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Thomas Kurian

HRCT

• bronchiectasis , mosaic ground glass attenuation

Thomas Kurian

Direct visualization

• At the time of visualization, biopsies can be obtained of intraluminal masses and plaques

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Bronchoscopy

• ●When the flow volume loop suggests extrathoracic obstruction, laryngoscopy is often the next step

• ●Flexible or rigid bronchoscopy

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2 year old child

• acute onset of breathlessness• Temperature, 37.4°C• respiratory rate, 40 breaths per minute• pulse, 110 beats per minute• blood pressure, 92/60 mm Hg• oxygen saturation, 80% on room air. • He had no nasal congestion, rhinorrhea, stridor,

or previous history of difficulty breathing.

Thomas Kurian

• Physical examination - tachypnea and suprasternal and subcostal retractions

• Left sided wheeze

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Thomas Kurian

• What is the probable diagnosis?

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Thomas Kurian

What should be done next?

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Treatment

• Rigid bronchoscopy

Thomas Kurian

What are the DD of wheezing in a child 1) INFECTION 2) ASTHMA:

• i) Transient wheezer • ii) Persistent wheezers • iii) Late onset wheezer

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3) Anatomic abnormalities a) Central airway abnormalities b) Extrinsic airway anomalies c) Intrinsic airway anomalies:

4) Immunodeficiency states

5) Mucociliary clearance disorders

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6) Aspiration Syndromes7) Heart Failure8) Anaphylaxis9) WALRI10) Drugs: Ibuprofen, Aspirin

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Clinical Manifestations

• HISTORY & PHYSICAL EXAMINATION - Birth history - Infection

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RISKS OF FAMILY HISTORY OF ATOPY

Single parent atopy : 22%Maternal Atopy : 32 %

Both parents atopic : 50%

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Diagnostic evaluationInitial evaluation depends on likely etiology 1. Chest Xray 2. Trial of bronchodilators

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Exclude other conditions

3) Structural problems: bronchoscopy 4) Esophageal disease 5) Primary ciliary dyskinesia 6) TB 7) Bronchiectasis 8) CF 9) Systemic immune deficiency10) Cardiovascular disease

Thomas Kurian

Treatment

1. Comfort the child2. Offer frequent liquids 3. Bronchodilators4. Ipratropium bromide5. Oral/ IV steroids6. Inhaled steroids7. Montelukast 8. No role of antibiotics

Thomas Kurian

36 year old obese female , came with history of shortness of breath, cough x 2 monthsHer symptoms were worse in the early morningHer symptoms vary over time and in intensityHer symptoms are triggered by laughter

Thomas Kurian

What is the probable diagnosis?

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These are typical of asthma- True / False

Chest painShortness of breath associated with dizziness, light headedness or peripheral tinglingChronic production of sputumSymptoms triggered by exercise, irritants such as car exhaust fumes, smoke

Thomas Kurian

These are typical of asthma- True / False

Chest painShortness of breath associated with dizziness, light headedness or peripheral tinglingChronic production of sputumSymptoms triggered by exercise, irritants such as car exhaust fumes, smoke

Thomas Kurian

What are the phenotypes of Asthma?

Allergic asthma Non allergic asthma Late onset asthmaAsthma with fixed airflow limitationAsthma with obesity

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How do you confirm the diagnosis?

PFT with reversibility

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For how long should SABA be withheld ?

4 hours

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For how long should LABA be withheld ?

15 hours

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In our patient the PFT revealed

Thomas Kurian

Pre-bronchodilator spirograph shows :FEV1/FVC : 38.39(Very low )FVC : 2.24 (72 % pred.)FET : 6.12 sec.

Diagnosis ?Obstructive airway disease

Post- bronchodilatation spirograph shows:Δ FEV1 : 290 ml (34%)

What is your final diagnosis ?Reversible airway obstruction-Bronchial Asthma

Thomas Kurian

Which is the other way in which Asthma may be diagnosed?

Excessive variability in twice daily PEF over 2 weeksPositive exercise challenge testSignificant increase in lung function after 4 weeks of anti inflammatory treatmentPositive bronchial challenge test

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What is stepwise management in a case of asthma?

Thomas Kurian

Our patient was started onMed to high dose ICS / LABA

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When do you say asthma is well controlled?

Day time symptoms not more than twice/weekNo night time wakingReliever needed not more than twice/week No activity limitation due to asthma

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How to step down treatment?

Once asthma control is achieved and maintained for 3 monthsStepping down ICS doses by 25-50% at 3 month intervals is feasible and safe

Thomas Kurian

What are the non pharmacological interventions?

Thomas Kurian

Non pharmacological interventions

Cessation of smoking and ETSPhysical activityAvoidance of occupational exposuresAvoid Medicines that make asthma worseBreathing techniques

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Non pharmacological interventions

Healthy diet Weight reductionBronchial thermoplastyAllergen immunotherapyAvoidance of outdoor and indoor allergens

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Inhaler techniqueNo 2 devicesChoose CheckCorrect Confirm

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ComorbiditiesObesityGERDRhinitis , Sinusitis , Nasal polyps

Thomas Kurian

Our patient came for follow up and is pregnant

In what percent asthma worsens?

Poor symptom control and exacerbations are associated with worse outcomes for both the baby and the mother

Thomas Kurian

After 6 months of delivery , she had worsening asthma,

and was put on high dose ICS

Thomas Kurian

During this treatment patient had a fracture of femur after

a fall from bikeWhat is the precaution?Why?

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After surgery , she was prescribed regular controller therapy, antibiotics

and analgesicsShe developed nasal congestion , anosmia, conjunctival ingestion

What is the clinical picture resembling?

Thomas Kurian

AERDAspirin challenge test is the gold standardShould avoid NSAIDs.

When NSAIDS are indicated substitute with COX- 2 inhibitorsICS are the mainstayDesensitization

Thomas Kurian

Male 30 year oldcough, breathlessness, wheezing and chest pain Fever , weight loss were also presentSymptoms are mostly nocturnalHe had hepato splenomegaly

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There was eosinophilia 4200 /um

ESR 70

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What is the relevance of place of residence?

Thomas Kurian

Thomas Kurian

What are the investigations to confirm

TPE?High serum levels of IgE filarial-specific IgE and IgG are found

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TPE (i) history suggestive of nocturnal symptoms

mainly cough and dyspnoea(ii) pulmonary infiltrates on chest radiograph(iii) leukocytosis with peripheral eosinophilia >

3000/µm(iv) elevated serum IgE and filarial specific IgG

and IgE(v) clinical improvement with DEC

Thomas Kurian

What is the treatment?DECSteroids

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PreventionAlbendazoleDEC

Thomas Kurian

An 83 year old female presents episode of weakness, breathlessness

orthopnoea

Thomas Kurian

Initial Clinical Findings

Airway – clear & patentBreathing – tachypnoeicCirculation – Pulse present, irregular,

tachycardic; skin colour normal, cap refill normalDisability – No LOC before ambulance arrival,

patient responding to verbal stimuli

Thomas Kurian

What is AMPLE history? AMPLE, Allergies, Medications, Past Medical History, Last

Eaten, Events Leading

AMPLE History A – Allergic to penicillin M – Currently taking Warfarin, Furosemide P – History of CVA x 1 year, CHF L – Last oral intake 7pm the evening previous E – Son stated patient became very weak before going to bed

Thomas Kurian

On examination

Pulse rate 110bpmPulse rhythm IrregularResp rate 24 per minute, regular, shallowWheeze + , basal crackles

Thomas Kurian

Thomas Kurian

SpO2% 89% @ room airCap Refill <2secsBP 178/112RBS normal

Thomas Kurian

Thomas Kurian

What is the treatment to be given?

GTN SL Furosemide 40mg O2CPAP Urinary catheterCPAP Therapy

Thomas Kurian

Investigations

3 Lead ECG 12 Lead ECG CXR Blood tests – to identify any electrolyte

imbalances etc.Urinary catheter

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Assessment Excessive sweatiness/clamminess Tachycardia Hypertension/hypotension in extremis Raised JVP Central cyanosis Tachypnea Basal respiratory crackles Wheeze Pitting ankle oedema ECG changes (old MI, ischaemic changes, indicative of previous

myocardial damage)

Thomas Kurian

15-year-old girl history of ‘poorly controlled asthma’ dyspnoea

on exertion and wheezeHer symptoms started after she was pushed

over while playing footballShe had been treated with inhaled

corticosteroids, short-acting and long-acting β2-agonists and a leukotriene receptor antagonist without improvement.

Thomas Kurian

Inspiratory stridor was noted on clinical examination

Thomas Kurian

Thomas Kurian

Speech and language therapy

Thomas Kurian

A 58-year-old woman was referred with ‘poorly controlled asthma’

She reported prolonged wheeze and chronic cough, was unresponsive to a range of inhaled therapies prescribed by her general practitioner

She worked as a hairdresser and was a non-smoker

She had no history of atopy. She had been treated for asthma for 4 years and had never been intubated.

Thomas Kurian

Inspiratory stridor was noted on clinical examination

Thomas Kurian

Thomas Kurian

The spirometric flow-volume loop showed truncation of inspiratory as well as expiratory flow-volume loops consistent with fixed upper airway obstruction

Bronchoscopy revealed fixed subglottic stenosis She was referred to an otorhinolaryngologist for

endoscopic repair.

Thomas Kurian

A 75-year-old man with a 20 smoking pack-years was referred with a 6-week history of worsening wheeze, cough, green sputum and dyspnoea on exertion.

Inspiratory stridor and expiratory wheeze were noted on clinical examination.

Thomas Kurian

Thomas Kurian

Thomas Kurian

CT of the thorax showed a large retrosternal goitre

Bronchoscopy revealed extrinsic tracheal compression

Thyroidectomy led to resolution of symptoms

Thomas Kurian

Take home message• ●For patients with rapid onset of respiratory distress

associated with wheezing or stridor, the key initial steps are to ensure adequate oxygenation and ventilation based on pulse oximetry and arterial blood gas measurement, followed by a rapid assessment made to determine the most likely cause.If asthma and COPD nebulized bronchodilator treatment

• If there is evidence of anaphylaxis, subcutaneous epinephrine should be given immediately.

Thomas Kurian

• ●For patients with impending respiratory failure and suspicion of central airway obstruction, endotracheal intubation by an experienced clinician should precede a diagnostic evaluation if the initial measures have failed to improve the situation

Thomas Kurian

1. Spirometry2. Flow volume loop3. Imaging of the neck and chest 4. Direct visualization of the airway is often

necessary

Thomas Kurian