First clinocopathological conferece presentation by Awab Hassan Ammara Mahroof Elishbah Naveed Ali Raza Abila Shakor Bahroz Khan The pathophysiology along with the treatment and drugs used in asthma are briefly covered.

1. 17th Batch
February 26, 2016

2.  Elishbah Naveed
 Abila Shakoor
 Ammmara Mahroof
 Awab Hassan
 Ali Raza
 Bahroz Khan

4. “Parween Bibi”, a 35 year old married female,
from Garhi Habibullah, came to King Abdllah
Teaching Hospital, Mansehra on 22 feb,2016
at 10:00 a.m in OPD. She presented with
complaints of fever for 2 days ,cough for 1
day, breathlessness for 2 hours. She was
conscious and well oriented. Overall health
state was weak

6.  Name: Parveen Bibi
 Sex: Female
 Age: 35 Years
 Marital Status: Married
 Children: 3 (2 sons, 1 daughter)
 Occupation: Housewife
 Address: Garhi Habibullah, Mansehra
 Date of Arrival: 22 Feb 2016
 Time of Arrival: 10am
 Mode of Admission: OPD

7. Fever (last 2 days)
 Cough(1 day)
Breathlessness(2 hours)

8.  Our patient was alright 2 days back, then she
developed fever which was gradual on onset, low
grade (99 F documented). Fever was intermittent with
diurnal variations.
 Fever was associated with cough, palpitations and
breathlessness.
 Upon arrival to hospital patient had an episode of
vomiting. There was no history of unconsciousness.

Fever was relieved by taking anti-pyretics
(Parectomol).

9.  Patient developed a cough one day back
which was gradual in onset, patient had
several episodic attacks of cough which
lasted for 15 minutes.
 Cough was productive, sputum was white in
color, scanty.
 Cough aggravates upon lying down and is
relieved on sitting position.
 Associated with chest discomfort and fever.

10.  Patient developed breathlessness for the last
2 hours which was gradual in onset.
 Breathlessness was also present at rest and
aggravated upon exertion.
It was associated with:
 Cough
 Fever
 Palpitations

11.  Systemic Inquiry:
 1. General
A. Reduced Appetite
B. Disturbed Sleep
C. Weakness & Lethargy

12.  Respiratory System Inquiry:
1. Cough
2. Respiratory wheeze

13.  Alimentary System:
◦ No remarkable findings
 Urinary System:
◦ No significant history
ON SYSTEMIC INQUIRY THERE WERE NO OTHER
REMARKABLE FINDINGS

14.  Past Medical History:
◦ Patient has been asthmatic for last 15 years
◦ No other major illnesses reported
 Past Surgical History
◦ No significant past surgical history

15.  Positive for Asthma.
 Patient’s mother has asthma.
 Patient’s daughter has asthma as well

16.  No history of smoking tobacco
 Leading a healthy & active lifestyle
 With regular bowel habits

17.  Her SES was satisfactory
 She lives in her own house of 4 rooms with
her 6 family members

18.  Patient was prescribed the following drug
regimen for her asthma:
◦ Salbo inhaler (Salbutamol)
◦ Tab Montiget (Montelukast)
◦ Tab Profylline (Doxofylline)
 Patient’s compliance to drug was poor.

19.  According to patient she is not allergic to any
specific allergen but exposure to cold
weather worsens her condition.

20.  Bronchial Asthma
 Emphysema
 COPD
 Bronchiectasis

21.  Patients general
appearance
◦ Pale and anxious

22.  Vitals-
◦ B.P: 110/90 mm/Hg
◦ Pulse: 86 bpm
◦ Temperature: 99 F
◦ Respiration: 26 breaths per minute

23.  No clubbing
 No peripheral / central cyanosis
 Eyes: Anemia not indicated
 Jaundice was not present

24.  Dental hygiene good
 No abnormality seen on thyroid examination
 Lymph nodes not palpable
 Pedal and sacral edema absent
 No other significant findings

25. 1. CVS Systemic Examination
a. Inspection:
• No Chest deformity
• No sternotomy or any other surgical scar
b. Palpation: Apex beat: Normal
c. Auscultation:
S1 + S2 + 0
• No added sounds
• No murmurs

26. b. Respiration:
Inspection
Chest Wall Movement: Regular
Respiratory Rate: Increased (26 breath/min)
No external deformity
No scars
Palpation:
Position of Trachea: No tracheal shift
Local Tenderness: Not present

27. Percussion:
Percussion note: Resonant
Auscultation:
Vesicular breathing with prolonged expiration
Occassional respiratory wheeze
Few Ronchi

28. c. GIT:
INSPECTION:
Shape, contour, movement were normal
Umbilicus central and inverted
Scars, striae and prominent veins absent
PALPATION:
Abdomen is soft and non tender
There is no palpable mass
Liver not palpable
• Spleen not palpable
• Ascites not present

29. c. GIT:
AUSCULTATION:
Bowel Sounds were present
PALPATION:
Abdomen is soft and non tender
There is no palpable mass
Liver not palpable
• Spleen not palpable
• Ascites not present
PERCUSSION:
No significant findings.

30. c. CNS:
Patient was conscious, oriented well with space,
time and place.

31. 1. Following investigations were performed
1. Chest X-Ray (PA view)
2. Complete Blood Picture
3. Urine RE
2. Specialized investigations like spirometry and
PFT were not done due to non availability in the
hospital.

32. Findings:
There were no significant findings on X-Ray Exam

34.  Findings:
 Mild Leucocytosis

35.  CHRONIC ASTHMA EXACERBATED BY MILD
RESPIRATORY INFECTION AND NON
COMPLIANCE TO DRUGS

36. Upon her arrival to the hospital the patient’s
acute symptoms were relieved by:
 O2 inhalation @ 2 lit/min
 Nebulization with Ventoline(Salbutamol) every
4 hourly for 10 mins.
 Nebulization with Atem(Ipratropium bromide)
x B.D
 Nebulization with Clenid (corticosteroid) x
B.D

37.  After the relief of her acute symptoms,
patient was advised to continue this drug
regimen:
◦ Tab Paracetamol- 1Tab x SOS
◦ Tab Moxiget (Moxifloxacin) 400mg x O.D
◦ Tab Myteka (Montelukast) 10 mg 1 x at night
◦ Tab Delracortil (Prednislone) 5mg 3+0+3
For the 1st 3 days then 2+0+2 for 2 days then
1+0+1 for 1 day
(as we have to taper off steroid slowly)
 Tab Hydraline 1 tsp x TDS

38.  Patient was discharged after 4 days and was
asked to come for a follow up after 2 weeks.

39.  Asthma is clinically defined as:
“A chronic inflammatory reversible
disorder with air way hyper reactivity and
variable air obstructions”

41.  Asthma is a global health problem
 Worldwide more than 350 million people are
suffering from asthma.
 Approximately 250,000 people die from
asthma each year

42.  Asthma is more common in women than
men.
 In contrast young boys are affected more
than young girls.
 Hygiene hypotheses is implicated in the
increasing incidence of asthma

43.  This hypothesis has been proposed by
scientists to explain the rise in incidence of
asthma.
 The hypothesis states that the eradication of
infections has altered the immune
homeostasis and promote allergic and other
harmful immune responses
Infections
Allergies

44.  This hypothesis has been proposed by
scientists to explain the rise in incidence of
asthma.
 The hypothesis states that the eradication of
infections has altered the immune
homeostasis and promote allergic and other
harmful immune responses
Infections
Allergies

45.  Asthma has a global distribution with a
relatively higher burden in North America and
Middle East
 Among people aged less than 45 years most
of the burden of disease is due disability.
Infections
Allergies

46.  The burden of asthma measured by disability
and premature death is greatest in children
approaching adolescence and the elderly.
Infections
Allergies

48.  Asthma is clinically defined as:
“A chronic inflammatory reversible
disorder with air way hyper reactivity and
variable air obstructions”

49.  Asthma is associated with
 Palpitations
 Breathlessness
 Wheezing
 Chest tightness
 Cough
 Increased mucus secretion

50.  Indoor and outdoor allergens
 Microbial exposure
 Diet
 Vitamins
 Tobacco smoke
 Air pollution

51.  Asthma is divided into:
◦ Extrinsic Asthma
◦ Intrinsic Asthma
 Less common types include:
◦ Drug-induced asthma (most commonly from Aspirin)
◦ Occupational Asthma

52.  Asthma is clinically divided into 4 categories
for the purposes of treatment:
◦ Intermittent Asthma
◦ Mild Persistent Asthma
◦ Moderate Persistent Asthma
◦ Severe Persistent Asthma

53.  Early Mediators
◦ Histamine
◦ Proteases
◦ Chemotactic Factors
◦ Prostaglandins
◦ Leukotrienes
 Late Mediators
◦ Cytokines
 (IL4, IL5, IL13)

54.  Extrinsic Asthma (Atopic Asthma):
◦ It is the most common type of asthma.
◦ It is a Type 1 Hypersensitivity reaction due to
exposure to extrinsic allergens.

55.  Pathogenesis of Extrinsic Asthma:
 Sensitization of airway to allergens:
 Stimulates production of subset 2 helper T cells (CD4
TH2)
 CD4 TH2 release interleukins IL-4 and IL-5
 IL-4 stimulates isotype switching to IgE production
 IL-5 stimulates production and activation of eosinophills

56.  Re-exposure of airway to allergen:
◦ Exposure stimulates IgE antibodies that illicit two
responses:
 Acute Response:
 1. Antigen cross link IgE antibodies on mast cells.
 2. This results in release of histamine and other
mediators.
 3. Histamine causes bronchoconstriction.
 4. Other mediators cause mucus production and
leucocyte influx

57.  Late Response:
 Occurs 4-8 hours later
 Mediated by leucocytes recruited by chemo tactic
factors and cytokines
 Results in damage to epithelial cells and airway
constriction

58.  After chronic attacks of asthma there is airway
remodeling characterized by:
 Hypertrophy of bronchial smooth muscle
 There is mucous production and
 Increased vascularity
 There is deposition sub epithelial collagen

60.  This is asthma not associated with allergy.
 It is commonly seen in old age group
 It has unknown mechanism but may be
caused by:
 Viral Respiratory Infections
 Stress
 Exercise
 Cold Temperature

61.  Asthma attack that occurs in response to
intake of certain drugs
 Aspirin and NSAIDs are commonly implicated
in sensitive people.

62.  Mechanism:
 Aspirin inhibits cyclooxygenase pathway
of arachidionic acid metabolism. But it does
not effect the lipooxygenase route.
 Thus Aspirin shifts the balance of factors
towards leukotrienes thus causing
bronchospasm

63.  Asthma in response to fumes and chemicals.
 Epoxy resins, chemical dusts, penicillin
products are implicated/

64.  This type of asthma comes in the form of
acute attack following exercise and stops
after 30-40 minutes
 It worsens in cold and dry climate

66.  Clinically defined as
◦ “An acute exacerbation of asthma that remains
unresponsive to initial treatment with
bronchodilators.”
1. It is a medical emergency
2. It has very life threatening complications like
hypercapnia

67.  Wheezing
 Coughing
 Shortness of breath
 Chest tightness/pain

68.  Diagnosis is established when following
criteria is fulfilled
◦ Episodic symptoms of airflow obstruction are
present
◦ Airflow obstruction or symptoms are at least
partially reversible
◦ Exclusion of alternative diagnoses

70.  Investigations that can help in the diagnosis of
Asthma can be broadly divided into 3 categories:
◦ Physical Exam: This includes a “Complete
Physical Examination” as well as patient
interview about S&S.
◦ Pulmonary Function Tests: This includes
Spirometry & Peak Flow studies.
◦ Miscelleaneous:
1. Chest X-Ray
2. Methacholine Challenge Test
3. Allergy Tests
4. Sputum Eosinophills

71.  A physical exam of respiratory system is the
first investigation.
 Physical exam begins with a detailed
interview about the patient’s signs and
symptoms.
 The physician has to note chest wall
movements, any external deformities etc.
 Auscultation can provide very useful clues in
reaching the diagnosis.

72.  Chest X-Ray is the initial investigation for
asthma.
 In most asthmatic patients X-Ray findings are
normal.
 The value of chest radiography is in revealing
complications or alternative causes of
wheezing.

73.  Pulmonary function tests determine how
much air moves in and out as a person
breathes.
 The most common test done in this category
is Spirometry.

74.  In spirometry patient is asked to breath
deeply and then exhale forcefully.
 Patient’s nose is blocked using a nose clip.
 Test is repeated 3 times to ensure accurate
test results.
 Spirometry is not useful for very young
children or comatose adults.

76.  In this test patient breathes nebulized
methacholine or histamine
 Methacholine causes contraction of
bronchioles in asthmatic patients
 This test can help in differentiation between
COPD and Asthma

77.  Sputum eosinophills are a good indicator of
severity of asthma.
 Eosinophilia can indicate active asthma.
 This count is specially elevated in atopic
asthma.
 Blood eosinophilia greater than 4% is
supportive of a diagnosis of asthma.
 Inflammation in asthma is characterized by
influx of eosinophils.

79.  It is said about Asthma that it is a disease in
which with the
◦ right patient
◦ the right clinician
◦ right drug regimen patient can be completely free
of symptoms

81.  Mechanism of Action: These drugs attach to
B2 Receptors and dilate the bronchioles
 Form: Available in inhaler and pill
configuration

82.  Side Effects: Tremors, Palpitations, Dizziness
 Commonly used drugs: Salbutamol, Formetrol

83.  Mechanism of Action: Anticholinergic drugs
inhibit bronchospasm caused by Vagus Nerve
stimulation
 Form: Available in inhaler and pill
configuration

84.  Side Effects: Dry mouth and mouth edema
 Common Drugs: Ipratropium, Tiotropium etc

85.  Mechanism of Action: Methylxanthines are
derivatives of plants. They cause relaxation of
bronchial smooth muscle
 Form: Pills

86. Side Effects: Palpitations, tremors, arrythmias
 Common Drugs: Theophylline, Aminophylline

87.  Mechanism of Action: Corticosteroids reduce
the hyper reactivity of the respiratory tract to
various stimuli. They also reduce
inflammation.
 Form: Pill and Inhaler

88.  Side Effects: Weakness, weight gain, oral
thrush
 Common Drugs: Beclomethasone, Fluticasone

89.  Mechanism of Action: These drugs inhibit the
leukotrienes which are mediators of
inflammation. They are effective in bronchial
asthma.
 Form: Pills

90.  Side Effects: Allergic Reactions, edema,
irritablility and drowsiness
 Common Drugs: Montelukast, Zafirlukast

91.  Mechanism of Action: They inhibit the release
of histamine from mast cells.
 Form: Inhaler and pills

92.  Side Effects: Allergic Reactions, edema,
irritablility and drowsiness
 Common Drugs: Nedocromil, Cromolyn
sodium

93.  Mechanism of Action: It is a new type of
asthma treatment, it is prepared in
genetically modified mice. It inhibits the
binding of IgE on mast cells.
 Form: IV/SC Injections
 Side Effects: Reaction to antibody can occur

94.  Clinically for the purposes of treatment
Asthma is divided into 4 different categories.
 Intermittent Asthma
 Symptoms less than 2 days per week
 Mild Persistent Asthma
 Symptoms more twice a week
 Moderate Persistent Asthma
 Daily Symptoms
 Severe Asthma
 Continual Symptoms

99.  Status Asthmaticus is an acute attack of
asthma that is un responsive to
bronnchodilators.
 It is a medical emergency
 It carries a very high risk of death
 Lets discuss the management of Status
Asthmaticus

100.  Patient is admitted in ICU and put on oxygen
therapy. Oxygen saturation should not come
below 95%
 Patient is given IV or SC Adrenaline to dilate the
bronchioles.
 Patient is then given systemic Salbutamol
infusion.
 If there is stabilization of patient then he is
allowed to go home with prescription of 2 weeks
of:
◦ Systemic Corticosteroids (Prednisone 50mg daily)
◦ Inhaled Corticosteroids
◦ Inhaled B2 Agonists
◦ Inhaled Anticholinergics

101.  Patient must strictly come for follow up every
2nd day until his condition improves.
 If these treatments fail then patient is given
general anesthesia through use of Ketamine
and Succinyl Choline. This relaxes the
muscles and the condition may stabilize.

102.  Many patients do not even require any drug
treatment
 Every case of asthma is unique and has their
own precipitating factors.
 Patients are advised to avoid these
precipitating factors, and avoid allergens etc.

103.  Asthma is a serious health problem that is
increasing in incidence worldwide.
 Although no cure is possible it can be
managed well if the patient strictly adheres to
the treatment regimen.
 A short video summary to summarize
asthma.
 Ending notes.