Asthma Bronchiale

Coass:Abdi Dzul Ikram H. 0910710020Nydya Parahita 0910710011Oktavinayu Sari L. 0910711011Rosandy Febrianto 0910710117

Supervisor:Dr. Ali Haedar, SpEM

Introduction

DefinitionAsthma bronchiale is a lung disease with characteristics :

(1)Reversible Airway Obstruction (even spontaneously or by medication)

(2)Inflammation of the airway

(3)Increasing of airway response to any stimulation

PAPDI, Alergi Imunologi Klinik, 2012

Epidemiology

PAPDI, Alergi Imunologi Klinik, 2012

In the children age, the prevalence is boy more likely

than girl with ratio 1,5:1

As age increased, the prevalence almost equal

and woman more likely to have asthma compared with

man.

Children more often than adults

In Indonesia, the prevalence about 5-7%

Asthma

Why We Choose This Topic?In 2010, asthma accounted for 3,404 deaths, 439,400

hospitalizations, 1.8 million emergency department visits, and 14.2 million physician office visits (CDC, 2013)

In Indonesia, Asthma is top 10 diseases that causing morbidity and mortality (PDPI, 2003)

Asthma include in 144 diseases that must be treat completely in Primary Helath Care Service Level of Competence 4A

When to refer?1. If often have exacerbation2. In moderate to severe asthma attack3. Asthma with complication

Complication of Asthma: Pneumothorax, Pneumomediastinum, Respiratory Failure, and Asthma Resistant to Steroid

ASTHMA = CHRONIC INFLAMMATION OF AIR WAY

EXCESSIVE CELL :-MAST CELL-EOSINOPHIL-NETROPHIL

-EPITHEL

ReleaseMEDIATORHistaminPDG 2, LTc 4TNF, PAF,Eo chemo F.GM-CSF

EPITHELIALSHEDDING

DIFFUSEOBSTRUCTION

OF THEAIR WAY

INCREASE NEURALMECHANISM

COUGH, DYSPNOEA, WHEEZE

BHR TO ALL STIMULI

RESOLUTION

SPONTAN TREATMENT6

Predisposing Factor• House dust• Flower powder• Animal hair (cat, dog)• Food: milk, egg,fish, tomatto, etc.• Infection: flu, faringitis• Air pollution, i.e. smoking• Spray: perfumery, mosquito drug• Nervous, emotional and exhausted• Change of weather• Etc

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The Goal of Clinical Assessment

Establish the patient’s current treatment and level of asthma control

Identify patients who are at high risk of dying from asthma

Determine the severity of acute asthmatic attack and treat accordingly

Guide to the essentials in Emergency Medicine, 2015

Anamnesis• Presenting symptoms : Triad of asthma

symptoms are dyspnoea, wheezing and cough.

• Precipitating factors, e.g. dust and URI• High risk features• Current medications including compliance

9Guide to the essentials in Emergency Medicine, 2015

Risk Factors for death from asthma Past history of sudden severe exacerbations Prior intubation and mechanical ventilation for asthma Prior admission for asthma to an intensive care unit Two or more hospitalizations for asthma in the past year Three or more emergency care visits for asthma in the past year Hospitalization or an emergency care visit for asthma within the past mounth Use of more than two canisters per month of inhaled short-acting-β2-Agonist Current use of systemic corticosteroids or recent withdrawal from systemic

corticosteroids Difficulty perceiving airflow obstruction or its severity Comorbidity, as from cardiovascular diseases or COPD Serious psychiatric disease or psychosocial problems Low socioeconomic status and urban residence Illicit drug use Not currently using inhaled corticosteroids

Guide to the essentials in Emergency Medicine, 2015

Physical Examination

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General Appearance• Mental state, signs of respiratory distress and

cyanosis

Vital signs• Especially SpO2

Respiratory• Prolonged expiratory phase, rhonchi, crepitations,

and air entry

Guide to the essentials in Emergency Medicine, 2015

LABORATORY FINDING

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Chest X Ray• Indicated in patients not responding to initial therapy.

Look for pneumothorax, pneumonia, or congestive heart failure

Arterial Blood Gas• Usual in severe asthmatic exacerbations to look for

hypercarbia (an ominous sign) and hypoxia

Others• CBC and renal panel (especially for hypokalemia d.t.

nebulized salbutamol)

Guide to the essentials in Emergency Medicine, 2015

Severity of Asthma Exacerbations…..

MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT

Breathless Walking Talking At restInfants – softer Infants- Stopsshorter cry feeding

Can lie flat Prefers sitting *Hunched forward

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated

Respiratory Rate Increased Increased *Often >30/min Bradypnea

GUIDE TO RATES OF BREATHING ASSOCIATED WITHRESPIRATORY DISTRESS IN AWAKE CHILDREN

AGE NORMAL RATE > 2 months < 60/min 2-12 months < 50/min 1-5 years < 40/min 6-8 years < 30/min

GINA 2009

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MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT

Accessory None Present Present Present Muscles & Thoraco-abdominal Suprasternal Movement Retraction

Wheeze Audible with Audible with Audible w/o Absence of wheeze stethoscope stethoscope stethoscope with decreased to

absent breathe sounds

Pulses/min <100 100-120 >120 Bradycardia

GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN Age Normal Limits

Infants 2-12 months <160/minPreschool 1-2 years <120/minSchool Age 2-6 years <110/min

Severity of Asthma Exacerbations…..

GINA 2009

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Severity of Asthma Exacerbations MILD MODERATE SEVERE RESPIRATORY

ARREST IMMINENT

Pulses Paradoxus Absent May be present Often present Absence suggests<10mm Hg 10—20mm Hg 20-40mm Hg respiratory muscle

fatigue

PEF 80% 60-79% <60%%predictedOr%personal best

PaO2 Normal 60mm Hg <60mmHgtest NOT usually Possible Cyanosisnecessary

PaCO2 45 mm Hg 45 mm Hg >45 mm Hg possiblerespiratory failure

SaO2 95% 90-94% <90%

GINA 2009

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PEFR

Flowchart Showing the Management of Asthma(Guide to the essentials in Emergency Medicine, 2015)

Ref. GINA Updated 200817

Patients with asthma

Symptoms of life-threatenning asthma present?

Supportive Measures•Managed in critical care area with high flow supplemental oxygen•Monitoring : ECG, pulse oxymetri, vital signs q 5-10 mnt•IV access 500 ml crystalloid over 3-4 h•Prepare for rapid sequence intubation: Have paralyzing and sedating drugs readily available•Use serial ABGs to detect triad of progressive hypoxaemia, hypercarbia, and acidosis•Indicaions for intubation: Persistent hypercarbia, severe hypoxia with PaO2 <60 mmHg•CXR : Patients not responding to initial therapyDrug therapy• Salbutamol (ventolin) nebulized therapy: 1 ml (5 mg) salbutamol with 2 ml ipatropium bromide & 2 ml NS to make up to 5 ml. (In Child 0,03 ml/Kg diluted in 2 ml of NS; repeat twice)• Oral prednisolone 0,5-1 mg/Kg (max 50 mg)

• Cough• Shortness of Breath• Wheeze

Yes (Present) No (not present)Silent chestCyanosisFeeble respiratory effortExhaustion, confusion, or obtudantionPEFR < 35% of predicted

Improvement

All Other Astmatics• Check patient and PEFR (optional and must also measure height) and after 2 neb doses

• Reassessment: if PEFR ≥ 50% and subjective improvement consider discharge with early follow-up within 48 h (Respiratory Medicine Clinic)

• All patients at discharge should oral prednisolone 0,5-1 mg/Kg/d (40 mg max no tail) for 7-10 d and follow up

• Additional: Inhaled steroids (pulmicort turbohaler 200mcg 2x1)

Non-responders/partial response

• PEFR < 50% predicted with 60 mnt: Repeat neb 2-3 times utilizing salbutamol 5 mg or 7,5 mg with 2 ml Ipatropium, 1,5 ml NS made up to 5 ml

• IV MgSO4 1-2 g slow bolus (20 mnt)

• Adrenaline (use with caution if at all elderly, IHD or severe hypertension) 0,3-0,5 ml 1:1000 solutions SC q 20 mnt in adults > 45 Kg or 0,01 ml/Kg (up to 3 ml) 1:1000 solutions om adults < 45 Kg or children OR

Terbutaline (More β2 selective than adrenaline) 0,25 ml SC q20-30 mnt prn in adults , 0,01 ml/Kg in children (up to 0,25 ml) q 20-30 mnt

Consider admission

• Patient unable to obtain PEFR ≥ 50% despite therapy and observation 1-2 h

• Previous intubation/ ICU admission

• X-ray evidence of pneumothorax. Infection or concomittant CCF

Re-Evaluate

Asthma Observation in Emergency Ward(Singapore General Hospital Policy and Procedure, 2005)

Patients who are observed have to statisfy the following criteria:a) Acceptable vital signs (SBP> 90 mmHg, RR < 25 tpm, and

SaO2 >95% on room air after initial treatment)b) Alert and orientedc) PEFR>50% of predicted valued) PCO2 < 45 mmHg PO2 >70 mmHg in ABG results (if it is

done)e) Absence of pneumoniaf) No past history of ICU admission

The Time Table Of Observation

1 Hour •Prior Nebul 2 doses before transfer to Observation Ward

2 hours •Check vital signs ,PEFR, and SaO2 hourly twice and 2 hourly thereafter

•Administer bronchodilator nebul if indicated

3 hours •if their vital signs are acceptable, there are resolution of breatlessness, bronchospasm and accessory muscle usage, PEFR > 75% predicted and SaO2 > 95% on room air

6 hours •Patients whose PEFR < 75%, RR > 25, or SaO2 < 95% on room air

Discharge with:• prednisolone 30 mg om x 5 days and salbutamol inhaler puffs 6 hourly prn• advised to see family practicioner within 72 h

If No

If Yes

Admitted

Characteristic Controlled(All of the following)

Partly controlled(Any present in any week)

Uncontrolled

Daytime symptoms None (2 or less / week)

More than twice / week

3 or more features of partly controlled asthma present in any week

Limitations of activities None Any

Nocturnal symptoms / awakening

None Any

Need for rescue / “reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Exacerbation None One or more / year 1 in any week

Levels of Asthma Control

Global Initiative for Asthma 200723

Case Report

Patient Identity• Name : Mrs. LS• Sex : Female• Age : 39 years old• Adress : Kedung Kandang -

Malang• Education : Senior High School• Occupation : housewifeAdmitted to ER on November 22nd, 2014

Primary Survey

A : Partial Obstruction (Wheezing sound +)B : symmetrical chest movement, RR 28 x/mnt, Rh(-),

retraction (-), fast and shallow, SaO2 94%C : BP 134/104 mmHg, PR 124x/mnt, warm acral

(Tax : 35,5°C), CRT < 2 sD : round and isochoric pupils, GCS 456

• A : Nebulisation salbutamol + ipatropium bromide (farbivent) 2 amp

• B : O2 4 lpm via Nasal Canule• C : -• D : -

Initial Treatment

AnamnesaChief complain: shortness of breath• Patient suffered from shortness of breath since a day before

admitted. The shortness of breath became more severe since the night before, aggravated by activity and not alleviated by rest. Patient has also been having productive cough since a week before admission, with white sputum and no history of fever. She has been becoming skinnier in last several months, no night sweating.

• Past medical history: diagnosed asthma since 16 years old (exacerbation once a week in the past year, routinely consumes salbutamol and CTM), had lung TB in 2005 and was stated to be recovered.

• Family history: father and uncles have asthma.• Social history: patient lives at home with her husband and

children.

Secondary Survey• General appearance: looked moderately ill• Consciousness : Compos Mentis GCS 456

A : Patent , Rh (-), Wh (+) B : RR= 28x/m, symmetric C : BP= 135/104 mmHg

PR= 124x/m, regular warm acral, CRT < 2 s Tax : 35,5ºC

Head : anemic conjunctiva (-/-), icteric sclera (-/-)Neck : lymph node enlargement (-), mass (-)

JVP : R +3 cmH2O

Thorax :C/ I = ictus invisible

P= ictus palpable ICS V MCL (S) P= RHM ~ SL (D) LHM ~ ictus A= S1 S2 single, m (-)

P/ I = symmetric, retraction (-) P= SF D=S P= S S

S S S S

A= v v Rh - - Wh + + v v - - + + v v - - + +

Abdomen :Rounded, soefl, meteorismus (-), bowel sound (+)H : unpalpableL : troube space tympani

Extremities : an (-), cyan (-), ed (-), ict (-)warm acral, CRT < 2 s

• O2 via Nasal Canule 4 lpm• IV plug• Inj. Methylprednisolone 125 mg (IV)• Nebulisation: Salbutamol +

ipatropium bromide (Farbivent) 2 amp

Management

Laboratory Findings (November 22nd 2014, 11.00)

Lab Value Lab Value

Leukocyte 11720 4700-11300/uL Eo/Ba/Neu/Lim/Mo

22,8/1,0/51,7/18,7/5,8

0-4/0-1/51-67/25-33/2-5

Hemoglobine 14,40 11,4-15,1 g/dL SGOT 19 0-32 U/L

Trombocyte 308000 142000-424000 SGPT 8 0-33 U/L

Hematocrit 44,70% 38-42 RBS 128 <200 g/dL

NatriumKalium

Chloride

1383,83109

136-145 mmol/L3,5-5mmol/L

98-100mmol/L

Ureumcreatinine

14,100,64

16,6-48,52<1,2

Workups

• ECG• Chest X-ray• Lab : CBC, blood chemicals

Conclusion: sinus rhythm 120 bpm

Chest X-Ray AP position, enough KV, enough

inspiration Soft tissue and bone scoliosis Left and right phrenicocostalis

angle blunting Left and right hemidiaphragm

flatten Trachea deviates to the right Hillus normal Cor: normal size, normal aorta,

extracted to the right hemithorax Pulmo: normal vascular pattern,

hyperaerated, fibroinfiltrates and multiple small cavities in upper middle lobe lung dextra and upper area lung sinistra that cause trachea deviates to the right, the heart extracted to the right, and narrow the right ICS.

Conclusion: active lung TB, pulmonary emphysema

Working Diagnosis• SOB dt

moderate asthma attack

Disposition• Pulmonology

department

Discussion

Presenting symptoms : Triad of asthma symptoms are dyspnoea, wheezing and cough.

Precipitating factors, e.g. dust and URI

High risk featuresCurrent medications

including compliance

Presenting symptoms : Dyspnoea 1 days ago, wheezing, and Cough with white sputum 1 weeks ago.

Precipitating factors, susp.URI

Patient have high risk features to death from asthma (see next slide)

Current medications with Salbutamol and CTM, but asthma persist at the level Partially Controlled

Anamnesis

Theory Case

Risk Factors for death from asthma Past history of sudden severe exacerbations Prior intubation and mechanical ventilation for asthma Prior admission for asthma to an intensive care unit Two or more hospitalizations for asthma in the past year Three or more emergency care visits for asthma in the past year Hospitalization or an emergency care visit for asthma within the past mounth Use of more than two canisters per month of inhaled short-acting-β2-Agonist Current use of systemic corticosteroids or recent withdrawal from systemic

corticosteroids Difficulty perceiving airflow obstruction or its severity Comorbidity, as from cardiovascular diseases or COPD Serious psychiatric disease or psychosocial problems Low socioeconomic status and urban residence Illicit drug use Not currently using inhaled corticosteroids

Guide to the essentials in Emergency Medicine, 2015

Physical Examination

General Appearance• Mental state, signs of

respiratory distress and cyanosis

Vital signs• RR, SpO2

Respiratory• Prolonged expiratory

phase, rhonchi, crepitations, and air entry

General Appearance• Compos Mentis, signs of

respiratory distress (+), cyanosis (-)

Vital signs• RR=28x/minute, SpO2 94%

Respiratory• Prolonged expiratory

phase, wheezing (+) all lung area

Theory Case

Laboratory FindingsTheory Case

Chest X Ray• Indicated in patients not

responding to initial therapy. Look for pneumothorax, pneumonia, or congestive heart failure

Arterial Blood Gas

Others• CBC and renal panel

(especially for hypokalemia d.t. nebulized salbutamol)

Chest X Ray• Active Lung TB and

Emphysematous Lung

Others• CBC : Slight

leukositosis with Eosinophilia

Lessons Learnt How to assess patients with SOBDiagnosing asthmaManagement of SOB, especially asthmaCorrelation between asthma and lung TBManagement of asthma with lung TB

Thank You

TB IRIS

• Immune Reconstitution Inflammatory Syndrome (IRIS) refers to : – a phenomenon experienced by people living with

HIV who have recently initiated antiretroviral therapy.

– a paradoxical inflammatory reaction against a foreign antigen (alive or dead) in patients who have started antiretroviral therapy and who have undergone a reconstitution of their immune responses against this antigen. (Colebunders, 2010)

Pathophysiology

• The partial reconstitution of the immune system following initiation of antiretroviral therapy in these patients can result in an exaggerated inflammatory response against any concurrent opportunistic infection. Sometimes the opportunistic infection pathogen against which the inflammatory response is directed remains clinically 'silent' prior to initiation of antiretroviral therapy, such that antiretroviral therapy 'unmasks' a previously undiagnosed disease.

Tuberculosis - Immune Reconstitution Inflammatory Syndrome (TB-IRIS) refers specifically to IRIS that occurs in the context of a patient with active Mycobacterium tuberculosis infection, and is a relatively common complication for HIV-infected persons who initiate antiretroviral therapy in resource-limited settings, particularly in regions that have a high TB prevalence.

Pathogenesis

• Increased lymphoproliferative response to mycobacterium antigens in vitro

• Restoration of cutaneous response to Tuberculin

• Increased [Il-6], activation markers (CD38)• Associated with TNFA-308*1, IL6-174*G

(Colebunders, 2010)

Risk factors for TB/IRIS

• Starting ARV’s within 6 weeks of TB treatment• Disseminated, extra-pulmonary disease• Low base line CD4 count (have a CD4 count <

100 cells/mm3)• have a prompt rise in CD4 count in the initial 3

months of HAART• Fall in viral load• High bacillary burden (?)