The patient presented with generalized wheezing, a history of COPD exacerbation, and partially treated pneumonia. Investigations showed hyperinflated lungs on chest x-ray and bloodwork within normal limits. The patient was admitted and started on IV antibiotics, steroids, bronchodilators, and oxygen. Monitoring of oxygen levels, peak flows and bloodwork was instituted. The treatment plan was to continue bronchodilators and steroids, monitor response, and consider transfer to ICU if symptoms deteriorated.

1. MANAGEMENT A&E

2. 9:30 am BP 140/83, HR 87bpm, spO 2 95%, T 36.4⁰C Generalised rhonchi Plan IV HCT 200mg stat given @ 9:35am. Neb. Combivent PEFR

3. 10:10am Speak in full sentence PEFR 300L/min, RR 30/min, O 2 sat 98% Generalized rhonchi Plan ABG CXR Cont neb

4. 10:26am VBG? pH: 7.377 pCO 2 : 42.0mmHg pO 2: 30.6mmHg Base: -0.4 HCO 3 : 22.9mmol/L WBC: 8.8x10 9 /L Lymph#: 3.2x10 9 /L Gran#: 4.8x10 9 /L Lymph%: 35.8% Gran%: 54.1% Hb: 16.5 g/dL RBC: 5.13x10 12 /L HCT: 47% MCV: 91.8fL MCH: 32.1pg MCHC: 35.1 g/dL Plt: 252x10 9 /L

7. 11:30am BP 140/83; HR 87bpm; T 37⁰C; spO 2 95%↓RA, 98% ↓ NPO 2 3L/min O/E generalized rhochi Plan Admit 7S Cont a/b (h/o admission for similar problem 10 days ago) T azithromycin 500mg od IV claforan 1g tds NPO 2 3L/min Neb combivent 4hourly IV HCT 100mg qid ABG ↓ RA

8. 11:30am ABG pH 7.498 pCO2: 29.4mmHg pO2: 147mmHg HCO3: 25.2mmol/L Base: -0.3mmol/L CXR Hyperinflated lungs Bilateral lung hazziness Coagulation profile PT: 13.2s (11.9 – 13.9) INR: 1.01 (0.86 – 1.14) aPTT: 40.5s (control 37.9) BUSE/creat Na: 139mmo/L K: 4.1mmol/L Creat: 106umol/L Urea: 2.7mmol/L Cl: 108mmol/L

9. MANAGEMENT Medical ward

10. 3:20pm Assessment: infective exarcebation COPD Partially treated pneumonia Haemodynamically stable Not in respiratory failure Investigations: FBC, BUSE/creat, LFT, aPTT/INR, ESR, ECG, sputum C+S, sputum AFB (D/S x3, C+S)

11. Plan Strict I/O, encourage orally IVD 2 Ѳ NS/24hrs Antibiotic IV claforan 2g stat & 1g tds T azithromycin 500mg stat & OD Acute reliever Neb combivent hourly x2 then 2hourly x2 then 6hourly Monitor BUSE/creat on neb combivent PEFR Controller IV HCT 200mg stat & 100mg qid Chest physiotherapy Stop smoking education

12. 11:40pm Plan Refer quit smoking clinic Increase neb combivent 4hourly Continue a/b Continue IV hydrocort Inhaler technique MDI becotide 2puffs bd MDI combivent 2puffs tds

13. PEFR chart L/min Time Day 1 Day 2 day3 day4

14. DIAGNOSING ASTHMA

15. Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors.

16. Symptoms & medical history Lung function Spirometry PEF Additional diagnostic tests Airway responsiveness Skin tests with allergens or measurement of specific IgE in serum

17. MANAGEMENT Exacerbations

22. Prompt tx Inhaled rapid-acting β 2 -agonists in adequate doses are essential. begin with 2 to 4 puffs every 20 minutes for 1 st hour; then mild exacerbations will require 2 to 4 puffs every 3 to 4 hours, and moderate exacerbations 6 to 10 puffs every 1 to 2 hours. Oral glucocorticoids (0.5 to 1 mg of prednisolone/kg or equivalent during a 24 hr period) introduced early in the course of a moderate or severe attack. O 2 is given if patient is hypoxemic (achieve O 2 saturation of 95%).

23. Prompt tx Combination β 2 -agonist/anticholinergic therapy is associated with lower hospitalization rates. Methylxanthines are not recommended if used in addition to high doses on inhaled β 2 -agonists.

24. Monitor response to tx Evaluate symptoms, peak flow, O 2 saturation After exacerbations is resolved Identify precipitating factors Implement avoidance strategies Review pt’s medication

25. MANAGEMENT Ward

26. Continue oxygen > 40% IV HCT 100-200 mg 6 hourly or prednisolone 30-60 mg daily. Neb β 2 -agonist 2-4 hourly preferably in combination with anticholinergic. If patient is still not improving, commence aminophylline infusion (0.5-0.9 mg/kg/hour); monitor blood levels if aminophylline infusion is continued for more than 24 hours. Terbutaline or salbutamol infusion at 3-20 mcg/min after an initial IV bolus dose of 250 mcg over 10 mins can be given as an alternative. In cases where response to the above treatment is inadequate, IV MgSO 4 2 g in 50 ml NS infused over 10-20 mins may be given.

27. Monitoring the response to treatment Repeat measurement of PEF 15-30 minutes after starting treatment. Aim to maintain arterial oxygen saturation above 92%. Repeat arterial blood gas measurements if initial results are abnormal or if patient deteriorate. Monitor PEF at least 4 times daily throughout the hospital stay. Other I(x): BUSE ECG if indicated

28. Transfer pt to ICU or prepare to intubate if there is: Deteriorating PEF Worsening hypoxaemia, or hypercapnia Exhaustion or feeble respiration Confusion or drowsiness Coma or respiratory arrest

29. MANAGEMENT ICU

30. Cont O 2 Cont IV HCT If the patient is mechanically ventilated, administer neb β 2 - agonist with anticholinergic via the ETT. This can be given up to every 15-30 min. IVI aminophylline or terbutaline or salbutamol should be continued IVI MgSO 4 may be added.

31. DISCHARGE PLAN FOR HOSPITALISED PATIENT Before discharge, the patient should be: started on inhaled steroids for at least 48 hours in addition to a short course of oral prednisolone and bronchodilators Stable on the medications he is going to take outside the hospital for at least 24 hours Having PEF of > 75% of predicted or best value and PEF diurnal variability of < 20% Able to use the inhaler correctly and if necessary, alternative inhaler devices could be prescribed Educated on the discharge medication, home peak flow monitoring and self Management plan (for selected, motivated patients), and the importance of regular follow up Given an early follow-up appointment within 2-4 weeks for reassessment of the condition and for adjustment of the medicines

32. MANAGEMENT Chronic asthma

33. Assessing asthma control

34. Mx approach based on control (>5 y/o)

35. Tx steps

36. Monitoring At each visit: Control Technique Compliance & avoiding risk factors Concerns Adjusting medication: Not controlled -> step up, TCA 1/12 Partly controlled -> consider step up Control at least 3 months -> step down

37. CONTROLLERS Medications

41. RELIEVER Medications

45. Per inhalation Ipratropium Br monohydrate 21 mcg, salbutamol sulphate 120 mcg Per UDV Ipratropium Br 0.5 mg, salbutamol sulfate 2.5 mg

46. Seretide 50/100 Accuhaler Salmeterol 50 mcg, fluticasone propionate 100 mcg. Seretide 50/250 Accuhaler . Seretide 50/500 Accuhaler Seretide 25/50 Evohaler Seretide 25/125 Evohaler Seretide 25/250 Evohaler

47. Per 160/4.5 mcg inhalation Budesonide 160 mcg, formoterol 4.5 mcg

48. Identify & reduce exposure to risk factors Tobacco smoke Drugs, foods, and additives Occupational sensitizers House dust mites Animals with fur Cockroaches Outdoor pollens and mold Indoor mold