Wheeze & Stridor CBL 1s d fsefs fddfg f a t year corrected by Prof. Samia.pptx

The Rawalpindi Medical University
1

Respiratory System
CASE BASED LEARNING (CBL)
WHEEZE/STRIDOR
1st year MBBS (BATCH 50)
Dr.Najam-ul-Sehar Date: 28.09.2023
2

Table of Contents
Sr # Content Slide #
1 Motto, Vision 4
2 Professor Umar Model of Integrated Lecture 5
3 Bloom’s Taxonomy(Domains of learning) 6
4 Diagrammatic Representation of Blooms Taxonomy 7
5 Conducting CBL And its Learning Objectives 8,9,10,11,12
6 Horizontal Integration 13,14,15
7 Core Concept 16-19,23-34
8 Vertical Integration 18-21,23-38
9 Biomedical Ethics(lesson of the day) 39,40
10 Suggested Research Article 41,42
11 Brainstorming(SEQ relevant with lecture) 21,211
12 Promoting IT and research culture(Digital Library) 42,43
13 References of this lecture 44

Motto Vision; The Dream/Tomorrow
• To impart evidence
based research oriented
medical education
• To provide best possible
patient care
• To inculcate the values
of mutual respect and
ethical practice of
medicine
4

ProfessorUmarModel of IntegratedLecture
5
60%
CORE SUBJECT
20%
HORIZONTAL
INTEGRATION
Physiology
biochemistry
8%
VERTICAL
INTEGRATION
Pathology
pharmacology
7%
VERTICAL
INTEGRATION
Clinical
integration
5%
VERTICAL
INTEGRATION
Research,
professionalism
Ethics
Digital library

BLOOM'S TAXONOMY : DOMAINS OF LEARNING
Sr. # Domain of
learning
Abbreviation Levels of
the domain
Meaning
1 cognition C C1 Recall / Remembering
2 C2 Understanding
3 C3 Applying / Problem solving
4 Psychomotor P P1 Imitation / copying
5 P2 Manipulation / Follows instructions
6 P3 Precision / Can perform accurately
7 Attitude A A1 Receiving / Learning
8 A2 Respond / Starts responding to the
learned attitude
9 A3 Valuing / starts behaving according to the
learned attitude

BLOOM'S TAXONOMY OF THE
COGNITIVE DOMAIN
7

CBL
• Case-based learning (CBL) is a teaching
method where students learn by analyzing
real-life cases and applying their knowledge to
solve problems or make decisions. CBL is often
used in medical education, where students
analyze patient cases to develop diagnostic
and treatment skills.
8

Conducting CBL
• Identify the learning objectives
• Choose a case: Select a real-life case that is
relevant to the learning objectives you have
identified
• Present the case
• Analyze the case: Have students work in
groups to analyze the case
• Develop hypotheses
9

Conducting CBL (Cont.)
• Test hypotheses: Have students test their
hypotheses by using relevant diagnostic tests or
other methods.
• Discuss the results
• Evaluate learning: Evaluate student learning by
assessing their ability to analyze the case,
develop hypotheses, and apply their knowledge
of medical physiology to diagnose and treat the
patient.
10

LEARNING OBJECTIVES
115
Sr. # Learning Objective Domain of Learning
1 To Discuss gross anatomy of Respiratory tract. C2
2 To Discuss the Case Scenario and Diagnosis. C2
3 To Explain the asthma and causes of Asthma. C3
4 To Describe pathophysiology and treatment of Asthma. C2
5 To Clinically Correlate causes of Wheeze and Stridor. C3

TOPIC: WHEEZE/STRIDOR
• SEQUENCE OF EVENTS:
• Case (shared with students)
• Time given to read.
• Initial discussion.
• Groups formed.
• Detailed discussion.
12

Horizontal Integration
13

14
Horizontal
Integration/Gross
Anatomy
Reference: Textbook of Physiology by Gyton and Hall,14th edition Page No.498

15
Horizontal
Integration/
Gross
Anatomy
Reference: Textbook of Physiology by Gyton and Hall,14th edition Page No.515

Core Concept
16

CORE CONCEPTS
• What is Wheeze/Stridor?
• Discuss and explain Asthma in detail.
• Horizontal integration: Application of
Principles of anatomy regarding mechanism of
breathing.
• Vertical integration: Clinical features of
disease/presentation/diagnosis/complications
& treatment.
17
Vertical
Integration
with Internal
Medicine/Pul
monology

WHEEZE/STRIDOR
• Stridor is a higher-pitched noise that occurs with obstruction in or
just below the voice box.
• Determination of whether stridor occurs during inspiration, expiration,
or both helps to define the level of obstruction.
• Wheezing is a high-pitched noise that occurs during expiration.
• Wheezing typically is due to narrowing, spasm, or obstruction of the
smaller airways in the lungs.
18
CORE
CONCEPT
Core
Concept/Vertical
Integration with
Internal Medicine/
Pulmonology

CAUSES OF WHEEZE/STRIDOR
• Infection-(Viral or bacterial infections)
• Fixed narrowing of the airway at birth
(subglottic stenosis)
• Floppy tissues in the respiratory
tract (laryngomalacia, tracheomalacia)
• Spasm of the airways related to underlying medical
conditions, like asthma, or due to irritants in the
environment.
• Problems with the vocal cords movement
19
CORE
CONCEPT
Vertical Integration
with Internal
Medicine/
Pulmonology

(With Clinical and Para-clinical Sciences)
20

Case Scenario
• A 13 years male presented to emergency department
with complaints of cough, shortness of breath. He had
recurrent episodes of wheezing, cough, dyspnea and
chest tightness for past two years. On general physical
examination, Respiratory rate 25/min, Heart rate
120bpm,SpO2=89%.On auscultation, diffuse whistling
sound is heard all over the lung field. Pulmonary
function test shows reduced FEV1/FVC. Chest Xray
Normal.
• A. What is probable diagnosis of this patient?
• B. What is the pathophysiology in this condition?
• C. Describe the management of this patient.
21
Vertical
Integration
with Internal
Medicine/
Pulmonology/Brain
Storming/Exam
Preparation

ANSWER
• Answer:
Acute Exacerbation of Asthma
22
Vertical
Integration
with Internal
Medicine/
Pulmonology/Brain
Storming/Exam
Preparation

23

24

25

26

27

28

Asthma
• Cause of asthma is Contractile hypersensitivity
of the bronchioles in response to foreign
substances in the air.
• In some cases, the asthma is caused by allergic
hypersensitivity, especially sensitivity to plant
pollens and some irritants in the air, such as
irritants in smog.
29
with Internal
Medicine/
Pulmonology

Pathophysiology of Asthma
• When an asthmatic person breathes in pollen to which he or she is
sensitive (i.e., to which the person has developed IgE antibodies),
the pollen reacts with the mast cell–attached antibodies and causes
the mast cells to release several different substances.
• Among them are the following: (1) histamine; (2) slow-reacting
substance of anaphylaxis (which is a mixture of leukotrienes); (3)
eosinophilic chemotactic factor; and (4) bradykinin.
• The combined effects of all these factors, especially the slow-
reacting substance of anaphylaxis, are to produce the following:
(1) Localized edema in the walls of the small bronchioles, as well as
secretion of thick mucus into the bronchiolar lumens.
• (2) Spasm of the bronchiolar smooth muscle. Therefore, the airway
resistance increases greatly.
30
with Internal
Medicine/
Pulmonology

Contd…
• In asthma, airway obstruction is the result of
(1) thickening of airway walls, brought about by
inflammation and histamine-induced edema.
(2) plugging of the airways by excessive secretion of thick
mucus.
(3) airway hyperresponsiveness, characterized by
profound constriction of the smaller airways (trigger-
induced spasm of the smooth muscle in the walls of these
airways).
In severe asthmatic attacks, pronounced clogging and
narrowing of the airways can cut off all airflow, leading to
death.
31
Core Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

Contd…
32
Reference: Sherwood ,Chapter 13, Page No.456
Core
Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

CLINICAL FEATURES OF ASTHMA
Features that characterize acute severe
asthma are
• Agitation, drowsiness or signs of confusion
• Significant breathlessness at rest
• Tachypnea of more than 30 breaths per
minute
• Use of accessory respiratory muscles
• Tachycardia of >120 beats per minute
• Pulsus paradoxus.
33
Vertical
Integration with
Internal
Medicine/
Pulmonology

CLINICAL FEATURES OF ASTHMA
34
Core
Concept/
Vertical
Integration
Reference: https://emirateshospitals.ae/symptoms-of-asthma-in-children/
Vertical
Integration with
Internal
Medicine/
Pulmonology

EXAMINATION
35
Core
Concept/
Vertical
Integration
Reference: Davidson book of medicine,Page No.409
with Internal
Medicine/
Pulmonology

Diagnosis and Investigations
36
Reference: Davidson Textbook of medicine,Page No.409
Core
Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

Normal Spirogram
37
Reference:Sherwood ,Chapter 13,Page No.461
Core Concept

FEV1/FVC
38
Vertical Integration with
Internal Medicine/
Pulmonology

Contd…
• The functional residual capacity and residual
volume of the lung become especially increased
during an acute asthma attack because of the
difficulty in expiring air from the lungs.
• Also, over a period of years,the chest cage
becomes permanently enlarged,causing a so-
called barrel chest,and both the functional
residual capacity and lung residual volume
become permanently increased.
39
Core Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

Lung Function Tests
Peak flow.
The results of this test are known as peak expiratory flow (PEF). A
peak flow test is done by blowing into a mouthpiece as hard and
as fast as you can with a single breath (expiration).
Spirometry.
A common spirometry measurement is forced expiratory volume,
which measures how much air you can breathe out in one
second.
The results of this test are known as forced expiratory volume
(FEV). Nitric oxide measurement.
This exam measures the amount of nitric oxide gas you have in
your breath when you exhale. High nitric oxide readings indicate
inflammation of the bronchial tubes.
Pulse oximetry.
This test measures the amount of oxygen in your blood. It's
measured through your fingernail and only takes seconds.
40
Core Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

Management/Plan
• Emergency Treatment:
1. Short-acting beta agonists, such as
albuterol. .
2. Oral corticosteroids.
3. Ipratropium (Atrovent HFA).
4. Intubation, mechanical ventilation and
oxygen
41
Core
Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

Management/Plan
42
Core
Concept/
Vertical
Integration
Reference: Google Images
with Internal
Medicine/
Pulmonology

Management/Plan
43
Core
Concept/
Vertical
Integration
with Internal
Medicine/
Pulmonology

Management/Plan
44
with Internal
Medicine/
Pulmonology

Bioethics
(To Promote Biomedical Ethics)
45

MEDICAL ERROR
(lesson of the day)
• Any preventable event that may cause or lead to
inappropriate medication use or patient harm.
• EXAMPLE: A 35years old Known case of Acute
Exacerabation of Asthma was adviced medications
for the emergency treatment. The doctor prescribed
4 grams of corticosteroid injection in place of the
correct dose.How will you proceed?
• ANSWER: High dose corticosteroid can harm the
patient.he should be given the correct dose.
Biomedical
Ethics

Relevance of Topic with
Biomedical Ethics
In the management of asthma, Corticosteroids
are used from low dose to high dose according
to the patient requirement. The doctor adviced
wrong dose of corticosteroids and it is
considered as medical error.High Dose may lead
to life threatening complication.
47
Biomedical
Ethics

Suggested Research Article
(To Promote Research Culture)
48

49
A Meta-Analysis on Predictors of Mortality
Among Patients Hospitalized for Acute
Exacerbation of Asthma. Cureus 15(2): e35225.
Promoting
Research
Culture

Take Home Message/
Crux of the Suggested Research Article
A meta-analysis is a statistical analysis that combines the
results of multiple scientific studies.
• The aim of this meta-analysis is to systematically review
published studies and identify clinically important factors
predicting mortality among patients hospitalized for acute
exacerbation of asthma.
• This study was conducted in accordance with the MOOSE
(Meta-analysis of Observational Studies in Epidemiology)
guidelines.
• A total of six articles met the inclusion criteria and were
included in the present meta-analysis.
• Results are the significant association with shortterm mortality
in patients hospitalized for acute exacerbation of asthma with
diabetes mellitus,pneumonia,and mechanical ventilation.
50
Promoting
Research
Culture

• Steps to Access HEC Digital Library
1. Go to the website of HEC National Digital Library.
2. On Home Page, click on the INSTITUTES.
3. A page will appear showing the universities from Public and
Private Sector and other Institutes which have access to
HEC National Digital Library HNDL.
4. Select your desired Institute.
5. A page will appear showing the resources of the institution
6. Journals and Researches will appear
7. You can find a Journal by clicking on JOURNALS AND
DATABASE and enter a keyword to search for your desired
journal.
How To Access Digital Library
51
Promoting
Research/IT
Culture

References
Books:
• Guyton And Hall textbook of Medical Physiology 14th Edition
• Ganong’s Review of Medical Physiology 25th Edition
• Sherwood, 9th edition.
• Silverthorn Physiology,6th edition
• Vander’s Human Physiology,14th edition
Research:
A Meta-Analysis on Predictors of Mortality Among Patients
Hospitalized for Acute Exacerbation of Asthma.
DOI: 10.7759/cureus.35225
YouTube/videolink:
https://youtu.be/_4XjE10UC3U?si=twizOofhC6SQYWWO

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