Asthma oct 2016
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This document summarizes information about two asthma case studies. It includes details about the patients' symptoms, examination findings, lab and imaging results, diagnoses, and treatment plans. The first case involves a 66-year-old man who had an asthma exacerbation after stopping his medications. The second case involves a 16-year-old girl with a history of asthma who presented with shortness of breath. The document also provides background information on asthma including definitions, pathophysiology, clinical assessment findings, diagnostic tests and their results, differential diagnosis, disease classification guidelines, and treatment approaches.
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Asthma oct 2016
- 1. ASTHMA
- 2. CASE No 1 age: 66 • Dan B. Pascaru • HTA from age 45 – Amlodipine – Perindopril
- 3. Case No 1 • Stopped medication in january 2013
- 4. CASE No 1 • Symptoms (2 days) – Coughing – Dyspneea • Signs: – Wheezing – Crackles
- 5. CASE No 1 • Symptoms (2 days) – Coughing – Dyspneea • Signs: –Wheezing – Crackles
- 6. DIAGNOSIS
- 7. DIAGNOSIS • ACUTE EXACERBATION OF ASTHMA ?
- 8. Laboratory Tests ? FIRST LINE SECOND LINE
- 9. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 10. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP = 12.000 SECOND LINE • Sputum examination
- 11. Beta2 mimetics ! prof • Tachycardia • Arrhytmias • Myocardial ischemia
- 12. Case No 2 age: 16 Melinda Pascaru • History of asthma • 2 crisis at age of 14 • 2 crisis/year • No medication
- 13. Case No 2 Symptoms (2 hours) • tachypnea • acute shortness of breath • audible wheezing “I feel like a fish out of water” Signs: Wheezing HR 110, RR 40
- 14. DIAGNOSIS • ACUTE EXACERBATION OF ASTHMA ?
- 15. DIAGNOSIS: ASTHMA • Mild ? • Moderate ? • Severe ?
- 16. Laboratory Tests ? FIRST LINE SECOND LINE
- 17. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 18. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 19. Complete blood count • Hb=12,7 • WBC=7000 • Pl=230.000 • Eosinophil count=15% N=(1-4%) • ESR=14 mm (N=0-9mm) • CRP=N • Fbg=N
- 20. Paraclinical Tests FIRST LINE • EKG • Chest radiograph • Echocardiography SECOND LINE • Spirometry
- 21. Paraclinical Tests FIRST LINE • EKG • Chest radiograph • Echocardiography SECOND LINE • Spirometry
- 23. Laboratory Tests FIRST LINE • EKG • Chest radiograph • Echocardiography SECOND LINE • Spirometry
- 25. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 26. Arterial Blood Gases pH PaCO2 HCO3 - PaO2 (Slightly) pH= 7.5, PaCO2= 27, HCO3- =22 PaO2= 75
- 27. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP=120 SECOND LINE • Sputum examination
- 31. ASTHMA
- 32. DEFINITION Chronic or acute disease ?
- 33. DEFINITION • Common chronic disorder of the airways • Characterized by – Variable and recurring symptoms – Airflow obstruction – Bronchial hyperresponsiveness – And underlying inflamation
- 34. In a class of 30 children, you can expect 2 to 3 students WILL have asthma
- 35. Etiology • Extrinsic asthma – Allergic or atopic asthma • Intrinsic asthma – Nonallergic or nonatopic asthma
- 36. PATOPHYSIOLOGY
- 37. Anatomic Alterations of the Lungs • Smooth muscle constriction of bronchial airways (bronchospasm) • Excessive production of thick, whitish, tenacious bronchial secretions • Hyperinflation of alveoli (air-trapping) • Mucus plugging and, in severe cases, atelectasis
- 38. Figure 13-2. The immunologic mechanisms in asthma.
- 40. Intrinsic Asthma (Nonallergic or Nonatopic Asthma) • Infections • Exercise and cold air • Industrial pollutants or occupational exposure • Drugs, food additives, and food preservatives • Gastroesophageal reflux • Sleep (nocturnal asthma) • Emotional stress • Premenstrual asthma
- 43. Vital signs • Increased respiratory rate • Increased heart rate, cardiac output, blood pressure Clinical Data
- 44. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
- 45. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.
- 46. Chest assessment findings • Expiratory prolongation • Decreased tactile and vocal fremitus • Hyperresonant percussion • Diminished breath sounds • Diminished heart sounds • Wheezing and rhonchi Clinical Data
- 47. • Use of accessory muscles of inspiration • Use of accessory muscles of expiration • Pursed-lip breathing • Substernal intercostal retractions • Increased anteroposterior chest diameter (barrel chest) • Cyanosis • Cough and sputum production • Pulsus paradoxus Clinical Data
- 48. Pulsus paradoxus • Decreased blood pressure during inspiration • Increased blood pressure during expiration Clinical Data
- 49. NONPULMONARY MANIFESTATIONS • Signs of atopy or allergic rhinitis • Skin atopic dermatitis, eczema, or other manifestations of allergic skin conditions.
- 50. LABORATORY TESTS
- 51. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 52. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 53. COMPLETE BLOOD COUNT - Blood eosinophilia greater than 4% or 300-400/µL is consistent with the diagnosis of asthma, but - a normal value is not exclusionary.
- 54. - IgE >100 IU patients with allergic reactions - test for allergic sensitivity : - allergy skin tests (Prick test) - blood radioallergosorbent tests (RAST).
- 55. Paraclinical Tests FIRST LINE • EKG • Chest radiograph • Echocardiography SECOND LINE • Pulmonary Function Study
- 56. Paraclinical Tests FIRST LINE • EKG • Chest radiograph • Echocardiography SECOND LINE • Pulmonary Function Study
- 57. Radiologic Findings Chest radiograph • Normal • Hyperinflation – Increased anteroposterior diameter – Translucent (dark) lung fields – Depressed or flattened diaphragm
- 58. Figure 13-4. Chest X-ray of a 2-year-old patient during an acute asthma attack.
- 60. Laboratory Tests FIRST LINE • Complete blood count • EKG • Chest radiograph • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 61. ABG • pH=7,35-7,45 • paCO2=35-45mmHg • SaO2=93-98% • paO2=80-100mmHg • HCO3=24-26mEq/l
- 62. Time and Progression of Disease 100 50 30 80 0 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors PaO2 Disease OnsetPaO2orPaCO2 Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
- 63. Arterial Blood Gases Mild to Moderate Asthma Episode Acute alveolar hyperventilation with hypoxemia pH PaCO2 HCO3 - PaO2 (Slightly)
- 64. Time and Progression of Disease 100 50 30 80 0 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors Acute Ventilatory FailureDisease Onset Point at which disease becomes severe and patient begins to become fatigued Pa02orPaC02 Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
- 65. Arterial Blood Gases Severe Asthmatic Episode (Status Asthmaticus) Acute ventilatory failure with hypoxemia pH PaCO2 HCO3 - PaO2 (Significantly)
- 66. Laboratory Tests FIRST LINE • Complete blood count • EKG • Chest radiograph • Arterial Blood Gases • BNP SECOND LINE • Pulmonary Function Study • Sputum examination ratio
- 69. NORMAL
- 70. OBSTRUCTION
- 72. Laboratory Tests FIRST LINE • Complete blood count • Biochemistry • Coagulation • Arterial Blood Gases • BNP SECOND LINE • Sputum examination
- 73. Sputum examination • Eosinophils • Charcot-Leyden crystals (see next slide) • Casts of mucus from small airways –called Kirschman spirals • IgE level (elevated in extrinsic asthma)
- 74. Charcot-Leyden Crystals Needle shaped crystals - Represents breakdown products of eosinophils
- 75. DIFFERENTIAL DIAGNOSIS • LEFT HEART FAILURE • COPD
- 76. HEART FAILURE
- 77. COPD
- 78. • Pulmonary Function Testing -the degree of reversibility in FEV1 which indicates a diagnosis of asthma is generally accepted as ≥ 12% and ≥ 200 ml from the pre-bronchodilator value the administration of a short-acting bronchodilator. PARACLINICAL EXAMINATIONS
- 79. ASTHMA-COPD
- 80. Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
- 81. Figure 9-11. Excessive bronchial secretions clinical scenario.
- 86. GINA FEV 1 > 80%
- 87. GINA FEV 1 > 80% FEV 1 > 80%
- 88. GINA FEV 1 =60- 80% FEV 1 > 80% FEV 1 > 80%
- 89. GINA FEV 1 =60- 80% FEV 1<60% FEV 1 > 80% FEV 1 > 80%
- 90. TREATMENT
- 91. 1. Wich of the folowing are clinical findings in asthma ? a) Wheezing b) Retrosternal thoracic Pain c) Diminished breath sounds at auscultation d) Decreased heart rate (bradycardia) e) Hepatomegaly, jugular distension and edema
- 92. 2. In asthma, laboratory tests show: a) Elevated BNP > 12.000 b) Increased anteroposterior diameter in X-ray c) Elevated pH in mild to moderate asthma d) restrictive respiratory disfunction in spirometry e) Thrombus in right pulmonary artery
- 93. 3. What is the treatment for acute asthmatic chrisis ? a) Symbicort 3-4 times a day b) Spiriva 1/day c) Salbutamol d) Oxygen e) Intravenous Amynophiline
- 94. TREATMENT
- 95. Reduce trigers of asthma
- 96. Case No 2 age: 16 Melinda Pascaru • History of asthma • age 12, 14 • No medication
- 97. TREATMENT • 1 • 2 • 3 • 4 • 5 • 6
- 99. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 101. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 102. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 104. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 105. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 107. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 108. Beta2 agonists • Short-acting • FENOTEROL • SALBUTAMOL • TERBUTALINE • Long-acting • FORMOTEROL • SALMETEROL 1 4 hours 12 hours
- 109. Beta2 agonists • Short-acting • FENOTEROL =BEROTEC • SALBUTAMOL =VENTOLIN • TERBUTALINE =BRYCANIL • Long-acting • FORMOTEROL=OXIS TURBUHALER • SALMETEROL=SEREVENT 1 4 hours 3 hoursSELECTIVES 5 min 12 hours
- 110. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 111. Anticholinergics • Short-acting • IPRATROPIUM BROMIDE • OXITROPIUM BROMIDE • Long-acting • TIOTROPIUM 2
- 112. Anticholinergics • Short-acting • IPRATROPIUM BROMIDE=IPRAVENT • OXITROPIUM BROMIDE=ATROVENT • Long-acting • TIOTROPIUM =SPIRIVA 2 24 hours6 hours
- 113. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 114. Methylxantines • Short-acting • Aminophyline • Long-acting • Theophyline (SR) 3
- 115. Methylxantines • Short-acting • Aminophyline =MIOFILIN • Long-acting • Theophyline (SR) 3
- 116. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 117. Glucocorticosteroids • Systemic • Prednisone • Methyl-prednisolone • Inhaled • Beclomethasone=BECOTIDE • Budesonide=PULMICORT • Fluticasone=FLIXOTIDE 4 HHC in acute form Long action
- 118. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 120. Phosphodiesterase-4inhibitors • Cromolyn =INTAL • Nedocromil=TILADE 5
- 121. bronchospasm anticholinergics methylxanthines beta2 simpaticomimetics Inflamation and edema glucocorticosteroids Mastocite degranulation Phosphodiesterase-4 inhibitors 1 2 3 4 5 Leukotriene inhibitors 6
- 122. Leukotriene -inhibitors • Montelukast • Zafirlukast • Zileuton 6
- 123. Leukotriene -inhibitors • Montelukast =SINGULAIR • Zafirlukast=ACCOLATE • Zileuton=ZYFLO 1/day 2/day 4/day 6
- 124. COMBINATIONS – in one inhaler • Short-acting β 2 agonist plus anticholinergic FENOTEROL+IPRATROPIUM SALBUTAMOL+IPRATROPIUM • Long-acting β 2 agonist plusglucocorticosteroids FORMOTEROL+BUDESONIDE SALMETEROL+FLUTICASONE
- 125. COMBINATIONS – in one inhaler • Short-acting β 2 agonist plus anticholinergic FENOTEROL+IPRATROPIUM= BERODUAL SALBUTAMOL+IPRATROPIUM= COMBIVENT • Long-acting β 2 agonist plusglucocorticosteroids FORMOTEROL+BUDESONIDE= SYMBICORT SALMETEROL+FLUTICASONE= SERETIDE 25/50 25/125 25/250
- 126. Others • Mucolitics • Antibiotics • Oxigen • Sodium bicarbonate
- 128. Beta2 mimetics ! • Tachycardia • Arrhytmias • Myocardial ischemia
- 129. OMALIZUMAB • Monoclonal antibody against IgE • Expensive and requires monthly injections • Most effective if allergies trigger asthma • Children with documented allegries • Not for children without allergies
- 131. AN ACUTE EPISODE • Acute episodes can be – mild, – moderately severe, – severe, – or characterized by imminent respiratory arrest.
- 134. ASTHMATIC CRISYS TREATMENT • ? • ? • ? • ? • ?
- 135. ASTHMATIC CRISIS TREATMENT • 1)Beta2 mimetics (VENTOLIN) • 2)ATROVENT (IPRATROPIUM BROMIDE) • 3)AMYNOPHILINE (Miofilin 1-1-1 inj//day) • 4) HHC 100mg (1-0-1 inj/day) • 5)______ • 6)______
- 136. ASTHMATIC CRISIS TREATMENT • Oxygen • Antibiotics : Ampiciline, Cefalosporines, Quinolones • Mucolitics: water, Acetilcisteine 3/day, Bromhexine. • ADRENALINE 0,3-0,5 ml • Prednisone 30-40 mg/day < 5 mg/5 days • Mechanical ventilation
- 137. CHRONICAL TREATMENT • 1)Long acting beta 2 mimetics: Serevent • 2)___________COPD • 3)Teotard • 4) inhaled glucosteroids: Becotide, Pulmocort, Flixotide • 5) Cromolyn, Nedocromil • 6)Leukotriene inhibitors: Singulair, zafirlukast, Zileuton
- 139. cromones R
Editor's Notes
- We will start with 2 case presentations. I would like to see your information about asthma
- Sustain your clinical diagnosis
- Sustain your clinical diagnosis
- I will tell you only the value of BNP and you will tell me if this is CF or Asthma
- Prin efectul beta 1
- His daughtert
- No signs on physical examiation
- What form ? There is a clasification of Asthma
- Hyperpneea elimination of CO2 PaCO2=35-45 HCO#=24-27 PaO2>80 pH 7,35-7,45 RESPIRATORY ALCALOSIS greater than 110 indicates pt is on supplemental oxygen.
- usually, the cough is nonproductive and nonparoxysmal. -children with nocturnal asthma tend to cough after midnight and during the early hours of morning.
- in the mildest form, wheezing is only end expiratory. in a more severe asthmatic episode, wheezing is also present during inspiration.
- Obtained at the Patient’s Bedside Other signs
- Severe asthma
- Total serum immunoglobulin E levels greater than 100 IU are frequently observed in patients with allergic reactions. Two methods are available to …to specific allergens in the environment
- -Gastroesophageal reflux - Obstruction of the upper airways and inhalation of foreign bodies - Dysfunction of the vocal cords - Non-obstructive pulmonary diseases (diffuse interstitial pneumopathy) - Pulmonary thromboembolism - Hyperventilation syndrome and panic attack.
- Being overweight can worsen astma symptoms
- His daughtert
- Neselective: adrenalina alfa=beta, isoprenalina beta1 si beta2 Selective-cele enumerate beta2>> beta1 BEROTEC VENTOLIN BRYCANIL REMINDER: Bronchodilators relieve symptoms but cannot reduce or prevent the swelling of airways that cause the symptoms. Debutul efectului la 5 minute dureaza 4 ore 4 doze/zi. OXIS TURBUHALER SEREVENT Debutul efectului la 3 ore dureaza 12 ore nu in acut ci in tratamentul cronic si profilaxia crizelor de astm ex: astmul indus de effort.
- Neselective: adrenalina alfa=beta, isoprenalina beta1 si beta2 Selective-cele enumerate beta2>> beta1 BEROTEC VENTOLIN BRYCANIL REMINDER: Bronchodilators relieve symptoms but cannot reduce or prevent the swelling of airways that cause the symptoms. Debutul efectului la 5 minute dureaza 4 ore 4 doze/zi. OXIS TURBUHALER SEREVENT Debutul efectului la 3 ore dureaza 12 ore nu in acut ci in tratamentul cronic si profilaxia crizelor de astm ex: astmul indus de effort.
- IPRAVENT=ipatropium bromide ATROVENT Efect in 15 minute, durata 6 ore SPIRIVA 24 ore deci nu se foloseste in urgenta
- IPRAVENT=ipatropium bromide ATROVENT Efect in 15 minute, durata 6 ore SPIRIVA 24 ore deci nu se foloseste in urgenta
- 200 mg de 2 ori/ zi la copii si adolescenti 350 mg Theotard de 2 ori/zi
- 200 mg de 2 ori/ zi la copii si adolescenti 350 mg Theotard de 2 ori/zi
- BECOTIDE PULMICORT FLIXOTIDE Doar pt tratament de intretinere Oral:are used for short-term treatment (3-10 d) to gain prompt control of inadequately controlled acute asthmatic episodes. I.V. corticosteroids are used in the acute phase of asthma.
- INTAL TILADE
- INTAL TILADE
- SINGULAIR 1/zi oraly ACCOLATE 2/zi oraly Zyflo 4/zi oraly
- SINGULAIR 1/zi oraly ACCOLATE 2/zi oraly Zyflo 4/zi oraly
- Nu sunt cu durata lunga beta2 si anticolinergic SERETIDE25/50 microgr 25/125 microgr 25/250 microgr Cele long-acting nu sunt eficiente in acut
- Nu sunt cu durata lunga beta2 si anticolinergic SERETIDE25/50 microgr 25/125 microgr 25/250 microgr Cele long-acting nu sunt eficiente in acut
- Prin efectul beta 1
- You must know that asthmatics can play sports There are many asthmatics players: David Backhamp
- And don’t forget Mark Spitz who won 7 gold medals in swimming in the same Olimpics who was also asthmatic.