A case of acute-onset asthma in a young patient and more information regarding asthma and other differential diagnoses.

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 ½ 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

7. Laboratory Investigations
 Pulse Oximetry
 Saturated Oxygen (SpO2): 95%
Image Source: fact-canada.com

8. Current Health Status
 Physician rated patient’s 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
 Curschmann’s 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% (<200 L/minute)
Info Sources: Case Files: Internal Medicine & Emergency MedicineImage Source: img.ehowcdn.com

21. FEV1/FVC Ratio
Image Source: Pulmonary Pathophysiology

22. How To Diagnose Asthma Clinically
 Other Findings:
 SO2 < 90% signifies respiratory distress
 Tachypnea (>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 Hammar’s Pulmonary Pathology

24. Histological Findings in Sputum
 Charcot-Leyden crystals:
eosinophilic breakdown within
mucous plugs
 Curschmann’s 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
 2.5–5 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 <50% and RR >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 β2-agonists for prophylaxis and patients with
low response to short acting β2-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
FcεRI (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% (<200
L/minute).

42. Question 3
 Which of the following possible triggers was most likely
responsible for the acute acceleration of bronchial asthma
in this patient?
a) Allergens (i.e. dust, mold, pollen, dander)
b) Viral Infection
c) Physical Activity
d) Cold weather
e) GERD

43. Answer
B. This 11 year old patient had a recent history of a
cold (viral infection) prior to his asthmatic flare-up. Viral
infections can cause patients with chronic asthma to
undergo excessive bronchoconstriction in response to the
infectious viral agent.

44. Question 4
 This patient experienced a case of extrinsic asthma (based
on the etiology of his flare-up).
a) True
b) False

45. Answer
B. This patient experienced a case of intrinsic asthma
due to his recent viral infection. Extrinsic asthma is a type
1 hypersensitivity in response to an irritant, none of which
the patient’s mother accounted for.

46. Question 5
 During the sensitization phase of extrinsic asthma, which
interleukins are activated?
a) IL-1 & IL-2
b) IL-4 & IL-6
c) IL-4 & IL-5
d) IL-6 & IL-7

47. Answer
C. Extrinsic asthma is classified by a production of
cytokines IL-4 and IL-5 by CD4 Th2 cells when initially
stimulated by an allergen.

48. Question 6
 Which of the following interleukins is responsible for
eosinophilic activation during the sensitization phase of
extrinsic asthma?
a) IL-1
b) IL-2
c) IL-3
d) IL-4
e) IL-5

49. Answer
E. IL-5 is the interleukin responsible for the induction
of eosinophilic activation in extrinsic asthma.

50. Question 7
 Which of the following lab findings can be seen in the
sputum of patients with chronic asthma due to the
breakdown of eosinophils, shaped with characteristic
elongated double pyramids?
a) Curschmann’s spirals
b) Charcot-Leyden crystals
c) Reed-Sternberg cells
d) Creola bodies
e) Kerley B lines

51. Answer
B. Charcot-Leyden crystals are aggregations of broken
down eosinophils found in patients with chronic bronchial
asthma. Curschmann’s spirals are mucous plugs from
shedded epithelium (desquamated) of the bronchioles.
Reed-Sternberg cells are seen in patients with Hodgkin’s
lymphoma. Creola bodies are also found in asthmatic
patients but are ciliated columnar cells shedded from the
epithelium of the bronchial mucosa. Kerley B lines are
seen in chest radiographs and signifies that the patient
has pulmonary edema.
Image Source: medical-labs.net

52. Question 8
 A patient with severe persistent asthma should receive which of the
following daytime medication regimens?
a) High-dose inhaled steroids along with a long acting inhaled β2-agonist;
add oral steroids if needed
b) No daily medications
c) Low-dose inhaled steroids OR cromolyn sodium/LT
antagonist/nedocromil OR sustained-release theophylline
d) Low to medium-dose inhaled steroids plus a long-acting β2-agonist OR
medium-dose inhaled steroids OR low to medium-dose inhaled
steroids plus LT antagonist/theophylline
e) Short-acting inhaled β2-agonist as needed

53. Answer
A. For patients with severe persistent asthma
(continual daytime symptoms and frequent nighttime
symptoms), guidelines for management include high-dose
inhaled steroids along with a long acting inhaled β2-
agonist. Patients may benefit from added oral steroids if
need be.

54. Question 9
 A 19-year-old woman is admitted to the hospital for an
exacerbation of asthma likely precipitated by pollen and
colder weather. Her inpatient regimen includes both
intravenous and inhalant medications. Which of the
following medications is most likely to be used as part of
discharge plan?
a) Theophylline
b) Antibiotics
c) Magnesium
d) Histamines
e) Corticosteroids
Info Source: Case Files: Emergency Medicine

55. Answer
E.Corticosteroids are often used after a hospitalization.
Other standard medications include β2-agonists and oral
leukotriene antagonists. None of the other medications
are used routinely for discharged asthma patients.
Info Source: Case Files: Emergency Medicine

56. Question 10
 A patient with known asthma undergoing therapy with an
inhaled corticosteroid and intermittent (short-acting) β2-
agonist presents with complaints of nocturnal awakenings
secondary to cough and occasional wheezing. This episode
occurs three to four times per week. Pulmonary function
tests in the past have shown mild obstructive lung
disease. Which of the following is the best next step?
a) Oral steroids
b) Leukotriene inhibitors
c) Long-acting β2-agonists
d) Theophylline
e) Antireflux therapy
Info Source: Case Files: Internal Medicine

57. Answer
C. Long-acting β2-agonists are helpful in this situation.
The asthma would be classified as moderate persistent,
and the recommended treatment is long-acting β2-
agonists, such as salmeterol, which are particularly
helpful with nocturnal symptoms.
Info Source: Case Files: Internal Medicine

58. Acknowledgements
 Milton Cato Memorial Hospital
 Dr. Rosmond Adams
 Christine Janke & Luckner Roseme
 Dr. Mohamed Shata
 Dr. Rana Zeine
 Dr. Anwural Siddiqui
 Dr. Fatima Marankan
 Dr. Daphne Santhosh

59. References
1. Toy, E.C., Patlan, J.T. (2013). Case files: internal medicine. United States of
America: McGraw-Hill Companies, Inc.
2. Toy, E.C., Simon, B.C., Takenaka, K.Y., Liu, T.H., Rosh, A.J. (2013). Case files:
emergency medicine. United States of America: McGraw-Hill Companies, Inc.
3. Bickley, L.S. & Szilagyi, P.G. (2013). Bates Pocket Guide to Physical
Examination and History Taking. United States of America: Wolters Kluwer Inc.
4. Wheezing sound: https://www.youtube.com/watch?v=YG0-ukhU1xE
5. Le, T., Bhushan, V., & Sochat, M. (2014). First aid for the usmle step 1.
McGraw-Hill: Chicago.
6. Dail and Hammar's Pulmonary Pathology: Volume I: Nonneoplastic Lung
Disease. (2009). Volume 1 of Dail and Hammar's Pulmonary Pathology.
Springer Science & Business Media
7. Ali, J., Summer, W.R., Levitzky, M.G. (2010). Pulmonary Pathophysiology: a
clinical approach. 3rd ed. McGraw-Hill Lange.

60. Thank You!
Please refer to Case 11 in Case Files: Emergency
Medicine to learn more about this condition.