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Difficulty in breathing

•Known case of bronchial asthma since September 2009

•via salbutamol challenge test

•Salbutamol nebulization as needed

•No maintenance

•No regular follow up done

• occasional dry cough • night awakenings due to cough ( 2-3 / week)

• give Salbutamol neb every 4 hours

•Improved by having a good sleep after • no consult was done

6 weeks PTA

• Still persistent dry cough

•Night awakenings due to cough (3-4 x/ week)

consulted consulted at local health clinic

> had chest X rayshowed pneumonitis w/ lymphadenopathies

* given with * loratidine ( loraped) once daily * cefaclor 5mL for 7 days

* asked to come back after 3 days

2 weeks PTA

• according to mother after 3 days

• noted decrease frequency of dry cough •Decrease night awakening

• At follow up• Loratidine was replaced with Citirizine 2.5 mL every 4 hours

•Cafaclor was continued for another 4 days

10 days PTA

•Still there was cough •Fever ( highest temp 38.2C) •Watery nasal discharge •Post-tussive vomiting of previously ingested milk

•Mother gave •5mL paracetamol (125mg/5ml)

for every 4 hrs•Salbutamol nebulization

(1/2 nebule + 1cc NSS) every 4 hours

• there was improvement after nebulization however the symptoms re occur after several hours which prompt consult at UST - ERCD

1 day PTA

Gen: no weight loss, no decrease in appetite

HEENT: no headache, no eye discharge, no epistaxis, no sore throat

Cardiovascular: no bruises, no syncope GI: no diarrhea, no melena, no hematocheizaGU: no difficulty in urination Endocrine: no tremors, Musculoskeletal: no bone pain, no muscle pain,

no limitation in range of motionNervous System: no seizure, convulsions, weakness

• Breast fed until 1 week of life and fed after with milk formula • Started complimentary feeding at 6 months • Now, the patient was fed with mixed diet with Nido with 1:1

dilution, 8 ounce 3/day

Feeding history

24 food recallFood CHO (g) CHON (g) FATS (g) Calories

Breakfast 1 cup soy milkPancit Canton 23

22

1.5 21.5100

Lunch Beef nilaga with 2 pc meat½ cup rice

23162

2 82100

Merienda 4 pcs wafer1 juice tetrapack

11.56

1 50

Dinner Beef nilaga with 2 pc meat1/4cup rice 11.5

8

1

1 41

50

Midnight snack French friesMilk 3 ounces

2318

212 15

100253

ACI%

919.5 (86%)

RENI 1070

• Gross Motor: Run well with out support, can jump• Fine Motor: feeds self with spoon • Language: produces 2 words sentences, can point

what he wants • Social: plays with other kids

Developmental History

• Patient completed the EPI program in our OPD-CD however cant

recall the exact dates

• BCG 1 - dose• Hep B – 3 doses• DTP – 3 doses • OPV – 3 doses • Measles – 1 dose

• Hib – 1 dose

Immunization

Admtted last December 2009 for pneumonia

No skin allergies, No surgeries, no blood transfusion

(+) Asthma (father, uncle maternal side)

(+) hypertension (grandfather – maternal side)

(+) heart problem ( grandmother – paternal side)

(-) DM, skin allergy , anemia, leukemia, renal disease, seizures

Name Age Relation Educational Attainment

Occupation Health

AS 46 Grandfather

Graduate Vocational

Technician (+)HPN

LS 52 Grand mother

High School graduate

Housewife Healthy

KR 27 Father College graduate

Technician (+) asthma

CR 25 Mother Graduate Vocational

Housewife Healthy

LS 33 Aunt Graduate vocational

None Healthy

RS 21 Uncle Highschool graduate

None Healthy

lives with his parents, maternal grandparents, uncle and aunt

2 storey building made of cement

Well lit, well ventilated with 2 bedrooms and 1 comfort room

Drinking water is brought from a refill station

Garbage not segregated but collected daily

No nearby factories, no pets in the house, no second hand smoke exposure

There was planted flowers in front of their house which they noted the patient to cough every time he passes by

HR: 120bpm Temp: 37.1 C

RR: 38/minWt: 14kg (Z score O) Ht: 86.6 (Z score 0)HC: 48 cm (above 0)

Awake, good activity and crying

Skin: Warm, moist skin, no active dermatoses, no jaundice, good skin turgor

HEENT: closed fontanels, Pink palpebral conjunctivae, anicteric sclerae, no opacities, normal direct pupillary light reflex, pupils 2-3mm ERTL; nonhyperemic EAC and intact tympanic membrane, AU, no aural discharge; no alar flaring, septum in midline, congested turbinates, (+) whitish nasal discharge; hyperemic posterior pharyngeal wall w/ no exudates, uvula midline, tonsils not enlarged

Neck: Supple neck, (-) palpable cervical lymph node

Lungs: Symmetrical chest expansion, no lagging, (+) suprasternal, intercostal, subcostal retractions, (+) wheezes on both lung fieds, (+) coarse crackles on both lung fields

Heart: Adynamic precordium, apex beat at 4th LICS MCL, no thrills, heaves, lifts, murmurs

Abdomen: globular soft abdomen, NABS, no palpable masses, no tenderness upon palapation

Extremities: Full and equal pulses on all extremities, no edema, no cyanosis, no limitation in movement

Genitourinary: bilaterally descended testes, no discharge, no masses

Alert, awake, crying and irritable

CN I-XII were intact

Motor: all extremities moves spontaneously

Sensory: No sensory deficits

Reflexes: All DTR +2, (-) babinski

(-) nuchal rigidity, kernig’s and brudzinski

* 2years old/ male* (+) family history of asthma* known bronchial asthma * dry cough, noucturnal awakenings* noted coughing when the pastient passes by infront

of the house where there are flowers * good response to salbutamol neb* RR 38/min , (+) suprasternal, intercostal, subcostal

retractions, (+) wheezes on both lung fieds, (+) coarse crackles on both lung fields

Approach to diagnosisApproach to diagnosis

Look for a symptom, sign, or laboratory finding found in the least number of diseases

Shortness of breathCoughWheeze

•Asthma exacerbation•Acute bronchitis•Vocal cord dysfunction•Foreign body aspiration•Gastroesophageal reflux

AsthmaAsthma common chronic inflammatory

disease of the airways characterized by variable and recurring symptoms, airflow obstruction, and bronchospasm.

Asthma is caused by environmental and genetic factors. These factors influence how severe asthma is and how well it responds to medication.

AsthmaAsthma Asthma predominantly occurs in boys in

childhood, with a male-to-female ratio of 2:1 until puberty, when the male-to-female ratio becomes 1:1.

Asthma prevalence is increased in very young persons and very old persons .

Asthma symptoms may include the following: • Cough, worse particularly at night• Wheezing • Shortness of breath • Chest tightness • Sputum production • Decreased exercise tolerance

AsthmaAsthma General asthma physical findings

• Evidence of respiratory distress manifests as increased respiratory rate, increased heart rate, diaphoresis, and use of accessory muscles of respiration.

• Marked weight loss or severe wasting may indicate severe emphysema.

Pulsus paradoxus Depressed sensorium Chest examination

• End-expiratory wheezing or a prolonged expiratory phase is found most commonly, although inspiratory wheezing can be heard.

• Diminished breath sounds and chest hyperinflation

Acute BronchitisAcute Bronchitis clinical syndrome produced by

inflammation of the trachea, bronchi, and bronchioles

usually occurs in association with viral respiratory tract infection

Characteristic symptoms include productive cough, shortness of breath and wheezing.

clinical course of acute bronchitis is self-limited, with complete healing and full return to function typically seen within 10-14 days following symptom onset.

Acute BronchitisAcute Bronchitis The incidence is equal in males and

females occurs most commonly in children

younger than 2 years, with another peak seen in children aged 9-15 years.

begins as a respiratory tract infection that manifests as the common cold.

Acute BronchitisAcute Bronchitis Symptoms often include coryza,

malaise, chills, low grade fever, sore throat, and back and muscle pain.

The cough in these children is usually accompanied by an initial watery nasal discharge.

Crackles, rhonchi, or large airway wheezing, if any, tends to be scattered and bilateral

**There is no specific therapy. The disease is self-limited

Vocal Cord DysfunctionVocal Cord Dysfunction abnormal adduction of the vocal cords

during the respiratory cycle (especially during the inspiratory phase) that produces airflow obstruction at the level of the larynx.

Presents with wheezing, cough, and dyspnea

This condition is predominantly observed in females

This condition predominates in people aged 20-40 years, but it can occur in people aged 6-83 years

Vocal Cord DysfucntionVocal Cord DysfucntionHistory Wheezing Cough A feeling of tightness in the throat Hoarseness and voice change Stridor Shortness of breath Dyspnea on exertion Inspiratory difficulty Unresponsiveness to bronchodilators and corticosteroidsPhysical Exam Laryngeal auscultation may reveal harsh stridulous sounds during

symptoms. Wheezing may be heard in the chest (transmitted from the upper

airway).

Foreign Body AspirationForeign Body Aspiration The male-to-female ratio is 2:1 Children, especially those aged 1-3

years Choking or coughing is present in 95%

of patients Approximately 50% of children have

inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase, and medium-to-coarse rhonchi.

Foreign Body AspirationForeign Body Aspiration Tachypnea; nasal flaring; intercostal,

subcostal, and suprasternal retractions; and differences in percussion between hemithoraces also are common findings

Fever and central cyanosis are less common

consider the possibility of foreign body aspiration, particularly with unilateral wheezing

Gastroesophageal refluxGastroesophageal reflux Immaturity of lower esophageal

sphincter (LES) function, manifested by frequent transient lower esophageal relaxations (tLESRs) that results in retrograde flow of gastric contents into the esophagus.

Gastroesophageal reflux has been associated with significant respiratory symptoms in infants and children

Gastroesophageal refluxGastroesophageal reflux Signs andsymptoms of gastroesophageal reflux in infants and young

children • Typical or atypical crying and/or irritability • Apnea and/or bradycardia • Poor appetite • Vomiting • Wheezing • Abdominal and/or chest pain • Stridor • Weight loss or poor growth (failure to thrive) • Recurrent pneumonitis • Sore throat • Chronic cough • Hoarseness and/or laryngitis

Signs and symptoms in older children - All of the above, plus heartburn and history of vomiting, regurgitation, unhealthy teeth, and halitosis

CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

Bronchial asthma, mildly persistent, in moderate

exacerbation

Course in The Ward (1Course in The Ward (1stst HD)HD)

Please admit the patient under the service of Dr. Moral-Valencia at bed 320G

Diet for age with strict aspiration precaution

Hold feeding of RR > 40cpm Medications given were salbutamol

nebulization, 1 neb every 1 hour, hydrocortisone 60mg/SIVP now then every 6 hours, paracetamol 125 mg/5ml, 6 ml every 4 hrs for fever >38.5C, 0.65% NaCl drip

Patient was given O2/cannula at 1-2 lpm as needed. IVF D5IMB 500ml to run at 37-38 ml/hr

Course in The Ward (2Course in The Ward (2ndnd HD)HD)

Salbutamol + ipratropium bromide was started, alternating with salbutamol nebulization every 6 hours

Course in the Ward (3Course in the Ward (3rdrd HD) HD) Salmeterol + fluticasone propionate

(seretide inhaler) 1 puff BID Prednisolone 20mg/5ml 4.5ml

SANE CriteriaSANE Criteria Safety Affordability Need Efficacy

Problems in the PatientProblems in the Patient Pharmacologic therapy to address

• Bronchial asthma, mildly persistent, in moderate exacerbation

Drugs for Acute AsthmaDrugs for Acute Asthma Bronchodilators

• Anticholinergics• Methylxanthines• Sympathomimetics

Catecholamines – epinephrine B2 agonists

SABA Anti-inflammatory

• Corticosteroids Systemic Inhaled

RelieversRelievers Quickly reverse bronchoconstriction

during acute exacerbation or breakthrough symptoms; taken prn

Bronchodilators• SABA, epinephrine, methylxanthines

Anti-inflammatory agents• Systemic steroids

ControllersControllers Have to be taken continuously on a

maintenance basis to control asthma Bronchodilators

• LABA Anti-inflammatory agents

• Inhaled• Systemic• LT antagonists• Mast cell stabilizers

BronchodilatorsBronchodilators MOA: activation of B receptors ->

activation of Gs coupling proteins -> cAMP -> phosphorylation of target enzymes -> relaxation of bronchial muscles

Epinephrine B2 agonists

EpinephrineEpinephrine For anaphylaxis Not effective in oral intake

Rapidly conjugated and oxidized in GIT and liver a1= a2 ; B1=B2 Triggers sympathetic response, fear,

anxiety, tenseness, restlessness, cardiac arrythmias

Not used in acute asthma, unless not responsive to B2 agonist or asthma is caused by anaphylaxis

SABASABA Terbutaline Salbutamol After oral inhalation, 10% deposited

in bronchial airway where absorption takes place -> systemic circulation.

No substantial effect on inflammation

B2 AgonistsB2 Agonists SABA

• Oral Peak effect 2 hrs Duration of action 4-8 hrs

• Inhaled Peak effect 30-90 mins, 75% of maximum

bronchodilation by 5 mins >4 hrs

Adverse Effects of B2 Adverse Effects of B2 agonistsagonists

Skeletal muscle tremors tachycardia, arrthymias increased bronchial hyperreactivity

and deterioration of disease control

Anticholinergic DrugsAnticholinergic Drugs Ipratropium bromide: treatment for

asthma Binds M2 and M3 receptors with equal

affinity, competitive antagonist to acetylcholine at M3 receptors on smooth muscles -> blocking bronchospasm -> decrease mucus secretion

In combination with SABA, provides quick relief for acute asthma attack

CombiventCombivent contains a microcrystalline suspension of

ipratropium bromide and salbutamol in a pressurized metered-dose aerosol unit for oral inhalation administration.

The 200 inhalation unit has a net weight of 14.7 grams. Anticholinergic bronchodilator

Each actuation meters 21 mcg of ipratropium bromide and 120 mcg of salbutamol from the valve and delivers 18 mcg of ipratropium bromide and 103 mcg of salbutamol from the mouthpiece.

DosageDosage 2 inhalations four times a day. Patients may take additional

inhalations as required; however, the total number of inhalations should not exceed 12 in 24 hours.

Safety and efficacy of additional doses of COMBIVENT Inhalation Aerosol beyond 12 puffs/24 hours have not been studied.

All Adverse Events (in All Adverse Events (in percentages), from percentages), from Two Large Double-Two Large Double-blind, Parallel, 12-blind, Parallel, 12-

Week Studies of Week Studies of Patients with COPDPatients with COPD

MethylxanthinesMethylxanthines Theophylline – both bronchodilator

and anti-inflammatory actions inhibits PDE -> increases cAMP -

>smooth muscle relaxation High level of toxicity; narrow

therapeutic index AE: nausea, vomiting, GIT

disturbances, headache,

CorticosteroidsCorticosteroids Anti-inflammatory effects due to

inhibition of production of pro-inflammatory cytokines -> decreased trafficking of lymphocytes, eosinophils -> decreased bronchial hyperreactivity

Potentiates B2 agonist effect by increasing synthesis of B2 receptors

Decrease mucus production

CorticosteroidsCorticosteroids Systemic steroids

• Oral: prednisone, prednisolone, methylprednisolone

• Parenteral: hydrocortisone, methylprednisolone

Inhaled steroids• Budesonide, fluticasone

Indications of CSIndications of CS Systemic steroids

• For relief of acute asthma exacerbations• Control of severe persistent asthma

Inhaled steroids• As maintenance therapy for all levels of

persistent asthma

Adverse Effects of CSAdverse Effects of CS Inhaled CS adverse effects:

hoarseness/dysphonia, oral candidiasis, throat irritation and cough

Systemic CS adverse effects: truncal obesity, moon facies, buffalo hump, osteoporosis

Anti-Asthma DrugsAnti-Asthma DrugsSafety Affordability Need Efficacy

Combivent nebulizer(salbutamol + ipratropium bromide)

++++ ++++P33.25

++++ ++++

Theophylline 300mg/tab ++ +++++P1.50

++ ++++

Epinephrine HCl 1ml +++ P40.00 ++ ++

Prednisone 20mg/5ml, 3ml ++ P6.25 ++ ++

Methylprednisolone 500mg/IV ++ +P3509.75

++++ ++++

Salmeterol + fluticasone propionate +++ ++++ ++++

Hydrocortisone 100mg/IV +++ +++P40.75

++++ +++

Pre Post Pre Post Pre Post

Time 7:30AM

8AM 815AM 842AM 9AM 920AM

Spot O2 96 96 94 93 96 96

RR 38 34 34 32 32 40

CR 120 128 128 130 148 140

Temp 37.1 37.5 38 38 38.1 37.8

Air entry Fair Fair Fair Fair Fair Fair to good

Retractions

-suprasternal + + + - + +

-intercostal + + + + + +

-subcostal + + + + + +

-supraclavicular

+ + + + + +

Alar flaring - - - - - -

Wheezes + + + + + +

Crackles + + + + + +

Rhonchi + + + + + +