history chief complaint history of presenting illness...2. salbutamol 100 mcg/dose mdi 3....
TRANSCRIPT
History
Chief Complaint
My patient, NH, 8 years 2months old malay girl was bought to Hospital AB 2 days ago on 12
am midnight due to unresolved shortness of breath for 20 minutes duration with an
underlying history of bronchial asthma diagnosed at 3 years old however she has defaulted
her medications and follow up for 2 years.
History of Presenting Illness
Patient was previously well until 2 days ago, she developed shortness of breath for 20
minutes duration. During the attack, she was still able to speak in short sentences and she
told that it was not relieved by rest or sitting upright. And also she did not use any inhaler as
she defaulted her follow up and she did not have any inhaler at home. Her mother who was
staying with her claimed that she did not turn cyanosed during the attack. Patient’s mother
claimed that she was still active and does not look drowsy during the attack but noisy
breathing was heard. The shortness of breath is also associated with chesty wet cough
without sputum production for 4 to 5 days. There is no post‐tussive vomitting as well. She
also has fever for 4 days and according to her, the fever is intermittent in nature, low grade
however it was not recorded as she did not seek for medication attention and it was
relieved by paracetamol at home. Her condition is also associated with runny nose and it’s
copious in amount. There is no hemoptysis, night sweat or any recent travel history or sick
contact in the neighbourhood or school. Patient told that her last asthma attack was
approximately 5 months ago and she was brought to the GP Clinic and nebulized to relieve
her asthma attack. She claimed that it was not as severe as this current episode. She has
never been admitted to the hospital for asthma attack or ICU admission or requiring
intubation. Her mother also heard noisy breathing of the patient during the attack. And she
claimed that her breathlessness incident occurs mostly during midnight or early morning
and it happens 2 to 3 times per year. Patient’s mother claimed that she has no known
triggering factors and she has no pet at home but carpets that are frequently cleaned. She is
also sleeping with a teddy bear and it is being washed regularly. Patient also have eczema
and told to be well controlled with corticosteroids cream. Her best peak expiratory flow
during the admission was 100L/min (51% of predicted value) and her best peak expiratory
flow recorded during the clerking was 130L/min (67% of predicted value according to
Malaysian CPG guidelines) after 3 trials. On admission, her mother told that patient
condition was improved by nebulizer.
Review of System:
Systems Symptoms
Cardiovascular system
(No significant findings)
There was no history of chest pain, syncope,
palpitations, night sweats and cyanosis. No
orthopnoea, paroxysmal nocturnal dyspnoea
and no pedal edema.
Gastrointestinal system
(No significant findings)
There was no history of nausea, vomiting,
abdominal pain, abdominal distension,
diarrhea, constipation or change in bowel
habits. No jaundice, no dysphagia, no
haematemesis, no melena, no haematochezia,
no retrosternal burning pain, no tenesmus and
no mass protruding from anal orifice.
Genitourinary system
(No significant findings)
Absence of hematuria, dysuria, frequent
urination, post-void dribbling and flank pain.
No hesitancy, no poor stream of voiding, no
genital ulcers, no rashes and no urethral
discharge.
Central nervous system
(No significant findings)
There were no reports of headaches, fits,
weakness, pain, abnormal movements,
incontinence and tremors. No loss of
consciousness, no slurring of speech and no
clumsiness in performing day to day activities
Musculoskeletal system
(No significant findings)
Absence of joint pain, joint stiffness, no joint
deformities, no low back pain, no joint
swelling, no difficulty in going up or down
stairs and no difficulty in dressing oneself.
Integumentary system
(No significant findings)
No open wounds or rashes, no ulcers. No
fever.
Ophthalmology system
(No significant findings)
No blurring of vision, no red eye, no eye
discharge.
Otorhinolaryngology system
There is runny nose, no ear discharge, no
difficulty in hearing, no running nose, no
nasal block, no post nasal dripping and no
hoarseness of voice.
Endocrine system
(No significant findings)
No polyuria, no polydipsia, no polyphagia, no
weight loss or weight gain, no change in
appetite, no cold or heat intolerance, no
proptosis and no neck swelling. No purpuric
striae over the abdomen, no easy bruising.
Past Medical History
Patient was diagnosed with bronchial asthma since 3 years old in Hospital AB. Patient’s mother told
that she used to take aerochamber inhaler during her asthmatic attack. However, she does not
remember the name of the medication. Patient defaulted her follow up and medications for 2 years
when her parents were divorced at that time. She did not have life‐threatening asthma attack that
requires ICU admission or intubation in her entire life. During these 2 years, she only has asthma
episode once every 3‐4 months and every time she was brought to the GP clinic for nebulizer to
relieve the shortness of breath. This is her second admission to the hospital as her first admission to
the hospital was 4 years ago when she was diagnosed with pneumonia. She was admitted to the
ward, treated with no complications. Otherwise, patient has no genetic disease or any chronic
illness.
Birth History
Antenatal - There were no antenatal complications. The mother was compliant to antenatal
appointments and was compliant to taking supplements given by the doctor. There was no
known gestational diabetes mellitus or hypertension. NH was growing well antenatally. There
was no exposure to drugs, cigarette smoke or alcohol, nor were there any trauma.
Birth - Patient was delivered at 40 weeks of gestation via spontaneous vaginal delivery (SVD)
at Hospital AB. Birth weight was 3.3kg. There were no complications during delivery.
Postnatal - NH’s mother did not suffer from any post natal complications. He was growing well
postnatally, and did not have any admission into the Neonate Intensive Care Unit (NICU).
Immunization History :
According to the mother, she told that her vaccinations are up to date in Klinik Kesihatan PP.
Based on the national immunization schedule for Malaysia by Ministry of Health (MOH), her
last vaccine should be 2nd dose of Mump Measles Rubella vaccine and booster dose of
Diptheria and tetanus vaccine.
Nutrition History:
NH was exclusively breast fed for six months since birth and continued with formula milk. NH
started weaning at around 6 months old. Currently, she takes normal diet 3 times daily
consisting of a mixture of rice, chicken and fish with vegetable at regular time. She is not a
picky eater. She has no history of poor feeding or failure to thrive in the past.
Developmental History:
Gross motor: NH is an active child who loves play around with her friends and badminton.
Fine motor: She is able to read and write well as she is attending to primary school.
Speech, language, hearing and vision: NH has a good command of 3 languages which are
Bahasa Malaysia, Chinese and English. She can speak and communicate well.
Social, emotional and behaviour: NH is currently studying Standard 2 in a chinese Sekolah
Kebangsaan. She is able to cope well in her academic and she has average performance. Her
favourite subject is English and she has many friends and she is able to mix around with them
without any conflicts.
Her mother told that her developments are similar to 2 elder siblings. Patient’s developmental
milestones were appropriate to age.
Drug History
She is currently under the medications listed below:
1. Budesonide 200 mcg/dose Inhalation
2. Salbutamol 100 mcg/dose MDI
3. Prednisolone 3mg/5ml Syrup
Patient does not take any traditional medications and she has no known drug allergies.
Family History
NH’s parents are both alive and well and there is no consanguinity in the marriage. They do
not suffer from any significant medical illnesses such as asthma, epilepsy, thyroid disease,
hypertension, malignancy, or neurological, hematological or cardiovascular problems.
There is a family history of type 2 diabetes mellitus as patient’s paternal grandfather is a
diabetic of 4 years and is on an oral hypoglycemic agent. There is no genetic disease like
G6PD, cystic fibrosis and others.
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Social History
Patient’s mother works as a teacher while her father works as an designer. There is no
consanguinity. NH is the youngest in the family and she has 2 elder siblings who are all
students. Her parents do not smoke or drink alcohol. Since the separation of the parents, NH
has been staying with her father for 2 years along with the paternal grandparents. On further
questioning, it is found that her grandparents will take care of her like preparing meals and
fetching her to school when her father is out for work on the weekdays. She told that she has a
good relationship with her grandparents and her father.
Physical Examination
General Examination:
On inspection, my patient was lying at 45degree angle comfortably on the bed with one
pillow at the back. She was alert, conscious and responsive to the surroundings. She was
orientated to time, place and person. She did not appear to be in pain or respiratory distress.
She appeared to be well hydrated and did not look pale or cyanotic. There were no dysmorphic
features. There was no abnormal movement or posturing. She was of thin build. However, there
were no signs of cachexia. IV cannula was inserted to the dorsum of her right hand and an
identification tag was attached to her left wrist. There is a nebulizer hanging on the bedside but
not connected to the patient. Patient is breathing on room air. Her hydration status was good.
Height: 119 cm (10th centile)
Weight: 19.2 kg (5th centile)
Vital signs on Day 3 of admission:
Body Temperature 37.4 ˚C
Pulse rate 120 beats per minute
Regular rhythm, rate and good volume
No radio-radial delay
No radio-femoral delay
Non collapsing pulse Respiratory rate 30 breathes per minute
Blood pressure 110/64 mmHg
Mean arterial pressure 79 mmHg
Partial pressure of O2 94% on room air
Vital signs of admission (according to the record)
Body Temperature 37.2 ˚C
Pulse rate 150 beats per minute
Regular rhythm, rate and good volume
No radio-radial delay
No radio-femoral delay
Non collapsing pulse Respiratory rate 40 breathes per minute
Blood pressure 122/78 mmHg
Mean arterial pressure 85 mmHg
Partial pressure of O2 92% on room air
Examination of the hands and arm:
Both of the palms are warm, moist and pinkish.
The nail bed is pinkish and capillary refilling time was normal. (< 2 seconds)
No peripheral cyanosis, scars or yellow discoloration.
No evidence of finger clubbing.
No signs of infective endocarditis such as Osler’s nodes, splinter haemorrhages, or
Janeway lesions present.
Koilonychias, leukonychia, Terry’s or Beau’s lines were absent.
No rashes or neurocutaneous stigmata. Skin turgor was normal.
BCG scar is seen on the left deltoid region
Examination of the head and neck:
The conjunctiva on both sides was pink and no yellow discolouration on sclera.
The eyes were not sunken.
She has adequate oral hygiene and good hydration. No chapped lips and his dentition was good.
Her tongue appeared to be symmetrical upon protrusion and no angular stomatitis or glossitis was noted. No signs of central cyanosis.
There were no notable ulcers, gum swellings or bleeding in the buccal mucosa.
Tonsils did not seem enlarged. There was no nasal flaring.
No dysmorphic features, facial asymmetry, ptosis, squint or malar flush.
Both of carotid pulses were palpable with regular character and good pulse volume.
No engorged veins or surgical scars seen.
All the lymph nodes were not palpable and non tender.
Examination of the lower limbs:
Peripheral pulses on the feet were palpable.
No rashes, excoriations, ulcers or gangrene seen.
No varicosities, visible scars or discolouration.
No pitting edema.
No signs of limb ischemia such as cold extremities, loss of hair, shiny skin, pigmentation.
Systemic Examination
Respiratory Examination
Inspection
The chest wall of the patient was found to be barrel in shape which appears to be hyperinflated and
antero‐posterior diameter is increased. It appeared to move symmetrically with respiration. There is
a harrison’s sulcus noted along the lower border of the thorax which is suggestive of chronic asthma.
There is also subcostal recession of the chest. There was no nasal flaring, sternal recession or
intercostal recession. Respiratory rate was counted to be 30 breath per minutes. Patient is in
respiratory distress. Otherwise, there was no other deformities seen in the chest wall such as pectus
excavatum and pectus carinatum. No surgical scars seen. No visible pulsations were observed.
Palpation
There is no deviation of the trachea. Chest wall expansion was symmetrical on both side. Vocal
tactile fremitus was performed and the results tabulated below.
Right Left
Supraclavicular Normal Normal
Infraclavicular Normal Normal
Supramammary Normal Normal
Inframammary Normal Reduced
Axillary Normal Normal
Infra‐axillary Normal Normal
Suprascapular Normal Normal
Interscapular Normal Normal
Infrascapular Normal Normal
Percussion
Resonant sound were heard in all areas of the lung field except for cardiac and liver dullness.
Auscultation
On auscultation, air entry is reduced on the right lung on the middle and lower zone. Expiratory
wheeze is heard in all the lung field.
2. Cardiovascular examination: (no significant findings)
Inspection: No scars or pigmentations were noted on the chest wall. Chest expanded
symmetrically but slightly diminished with respiration. No signs of precordial bulge and
engorged veins seen. There was no surgical scars and visible pulsations noted.
Palpation: Apex beat can be felt on the left 5th intercostal space in the mid clavicular line. No
palpable thrills were and parasternal heaves felt.
Auscultation: S1 and S2 were heard clearly. There were no added heart sounds or murmurs
identified. Intensity of heart sounds was same throughout the examination. No crepitations
heard over the lung bases.
Gastrointestinal System (No significant findings)
Inspection
The patient was in a supine position on the bed. The environment was well lit and conducive for
abdominal examination. The shape of the abdominal wall was flat and symmetrical. All quadrants of
the abdominal wall moved synchronously along with respiration. The umbilicus was centrally placed
and inverted. There was no swelling seen over the abdominal wall. There were no rashes, dilated
veins (caput medusa), surgical scars, visible peristalsis, or visible pulsations observed.
Palpation
On superficial palpation, the abdomen was soft and non‐tender. There was no evidence of guarding,
rebound tenderness and no masses felt. On deep palpation, liver is slightly palpable below the costal
margin and measured to be 6cm in size which is normal and there is no splenomegaly. Kidneys are
not ballotable.
Percussion
All regions of the abdomen were tympanic on percussion.
Auscultation
Shifting dullness was absent which indicates the absence of ascites. Bowel sounds were normal.
Summary
Patient, NH 8 year 2 month malay girl was admitted on 13 December due to shortness of
breath for 20 minutes associated with intermittent fever and chesty cough without sputum
production for 4 days duration. She has an underlying history of Bronchial Asthma
diagnosed at 3 years old and defaulted her treatment for 2 years without follow up or
medications at home. On examination on Day 3 of admission, it was found that her pulse
rate is higher than normal which is 120 beats per minutes with a high respiratory rate of 30
breaths per minute and her oxygen saturation was found to be 94% on room air which is
low. Whereas in respiratory examination, it is found that patient has subcostal recession
and harrison’s sulcus on inspection. In auscultation, patient has expiratory wheeze in all the
lung fields and with reduced air entry on the right side of middle and lower zone. Patient is
alert and conscious and she did not appear to be cyanosed. Her best peak expiratory flow
recorded during the clerking was 130L/min (67% of predicted value)
Provisional Diagnosis
Acute Exacerbation of Bronchial Asthma secondary to Upper respiratory tract
infection
Supporting statement:
Known case of bronchial asthma since 3 year old however she defaulted treatment for 2
years without medications or follow up
NH developed shortness of breath for 20 minutes duration that was associated with
intermittent fever and cough for 4 days duration with runny nose as well
Noisy and rapid breathing noted by the mother
Diurnal variation of the symptoms, usually her shortness of breath is more severe early in
the morning
On admission, her pulse rate was told to be 150 beats per minute, respiratory rate of
40 breath per minute and SpO2 of 92% on room air.
During the admission the peak expiratory flow was 100L/min (51% of predicted
value)
Condition improved by nebulizer and bronchodilator.
On examination on Day 3 of admission, patient is found to have subcostal recession,
harrison’s sulcus and barrel chest
Expiratory wheeze is heard in all the lung fields.
Patient has also eczema
Differential Diagnosis
1. Pneumonia
Supporting statement:
Fever
Shortness of breath
Tachypnoea
Chesty cough
Opposing statement:
No sputum production
No pleuritic chest pain
On percussion, lung is resonance bilaterally
There is no crepitation heard on auscultation
2. Laryngotracheobronchitis ( Croup )
Supporting statement:
Patient present with shortness of breath
Fever
Coryza symptoms like runny nose and sneezing
Opposing statement:
More common in children within 6months to 3 years old
No barking cough
No stridor
No hoarseness of voice
3. Acute bronchiolitis
Supporting statement:
Low grade fever
Cough and wheeze
Coryza symptoms
Chest wall recession
Opposing statement:
Usually in children younger than 2 years with peak incidents at 3‐6 months
Investigations :
1. Full Blood Count
Analyse the white blood cell count to rule out presence of any infections.
To particularly look at eosinophil levels.
Check for the haemoglobin level and red blood cell count to ensure anaemia is
absent.
13/12/2017 (day 1) Significance
White Blood Cell 8.5 x 10^9/L Normal
Red Blood Cell 4.92 x 10^12/L Normal
Haemoglobin 11.5 g/dL Normal
Haematocrit 34.2 % Normal
Mean Cell Volume 78.6 fl Normal
Mean Cell Hemoglobin 26.2 pg Normal
Mean Cell Hemoglobin
conc.
33.0 g/dL Normal
Red Cell Distribution
Width
13.8 % Normal
Platelet 196 x 10^9/L Normal
Absolute Neutrophil 3.2 x 10^9/L Normal
Absolute Lymphocyte 1.9 x 10^9/L Normal
Absolute Monocyte 0.70 x 10^9/L Normal
Absolute Eosinophil 1.80 x 10^9/L Normal
Absolute Basophil 0.00 x 10^9/L Normal
2. Spirometry (suggestive investigation)
Spirometry is used in many lung conditions to provide information such as the lung disease is
obstructive or restrictive in nature. There are 3 main components from spirometry.
FEV1: The amount of air you can forcefully exhale in one second. FEV1 stands for forced
expiratory volume in one second.
FVC: The maximum amount of air you can forcefully exhale. FVC stands for forced vital
capacity.
FEV1/FVC: The percentage your total air capacity that you can forcefully exhale in one
second.
Spirometry can be used to see how lung function changes over time. A decline in lung function
increases the risk of an asthma attack. Spirometry should be done after treatment has started
and symptoms have stabilized. It should be repeated anytime symptoms start to worsen, and at
least once every one to two years to monitor the progression of the disease.
3. Chest X‐Ray
A simple chest X‐Ray could be helpful to evaluate if the patient has signs of consolidations or
hyperinflation and may be used to rule out some of the differential diagnosis.
An important tool in the examination of patients with an exacerbation of asthma, but
patients should not be left waiting in the treatment room for a radiograph before treatment
Interpretation:
This is a Chest X Ray of NH taken in erect position on 13/12/2017. The trachea is in the
midline, lung fields are clear. However, there is a hyperinflation of the chest as more than 6
anterior ribs above diaphragm on the midclavicular is noted.
4. Pulse Oximetry Important to exclude hypoxemia and to assess the requirement of oxygen administration
Usually oxygen saturation of 97% above constitute of mild asthma, 92‐97% constitutes
moderate asthma, and less than 92% signifies severe asthma
Results:
‐On admission, NH has a oxygen saturation of 92% and her oxygen saturation raised to 97% with
2L flow of oxygen per minute with simple face mask.
5. Arterial Blood Gas (suggestive investigation)
ABG may be taken in patient with asthma but it is not mandatory or may not be required in
all patients admitted with asthma.
It can reveal dangerous level of hypoxemia or hypercapnia secondary to hyperventilation.
Usually it is only taken in patient whose oxygenation is not restored to normal level with
oxygen therapy
Hypercarbia is of concern in that it reflects inadequate ventilation and may indicate the need
for mechanical ventilation if the PCO2 is elevated as a result of patient exhaustion; however,
the decision to proceed with endotracheal intubation and mechanical ventilation is a clinical
assessment.
6. Allergy Skin Testing (suggestive investigation)
Allergy skin testing is a useful adjunct in individuals with atopy. Results help guide indoor allergen
mitigation or help diagnose allergic rhinitis symptoms. The allergens that most commonly cause
asthma are aeroallergens such as house dust mites, animal danders, pollens, and mold spores. Two
methods are available to test for allergic sensitivity to specific allergens in the environment, allergy
skin tests and blood radioallergosorbent tests (RASTs). Allergy immunotherapy may be beneficial in
controlling allergic rhinitis and asthma symptoms for some patients.
Principle of Management
First before going into the management of the patient, we should know the aim or goals of
treatment of acute asthma. These includes preventing death, relieving bronchospasm, correcting
hypoxaemia, restoring lung function, preventing relapse and developing an asthma action plan with
long term management.
For patient with Acute Exacerbation of Bronchial Asthma, it is crucial to first assess the
severity. In this patient, her severity of acute asthma falls under moderate severity as she can only
speak in phrases or short sentences on admission and on examination, there are several findings like
increased respiratory rate of 40 breath per minute, pulse rate of 150 beats per minute and SpO2 of
92% on room air. There is also use of accessory muscle and subcostal recession seen. Her peak
expiratory flow is 67% of predicted value.
Patient should be admitted to the ward with close monitoring of pulse, PEFR and Oxygen
Saturation. For the initial approach, patient should be treated with nebulized Salbutamol 8‐12 puffs
for quick relief. MDI SABA via spacer is also shown to be as effective as nebulized SABA as well.
Systemic corticosteroid is also essential to hasten the recovery and it should be given early. Oral
prednisolone 1mg/kg/day of maximum 60mg for 3 to 5 days should be advised. On the other hand,
oxygen therapy via face mask is also required as her SpO2 level falls under the normal value and
should be maintained above 95%. Other therapies include Ipratroprium Bromide may be added if
patient do not respond to Salbutamol alone. Parenteral Aminophylline may be considered as well in
severe asthma if patient is not responsive to maximum dose of bronchodilators and steroids.
For long term management of asthma and follow up, when asthma control is achieved,
patient should be maintained at the lowest dose of maintenance therapies possible. However before
any therapy is reduced, asthma must be under control for at least 3‐6 months depending on the
severity of underlying asthma prior to therapy. In each follow up, 3 aspects are required to be
addressed.
1. Degree of asthma control (refer to Table 1)
2. Compliance to medication and technique
3. Asthma Education
Table 1‐ Assessment of degree of asthma control by GINA guidelines.
Asthma education include explanation of the nature of the disease and treatment,
recognition of the symptoms of asthma, avoiding the triggering factors, information about the
medication and technique and education on exercise. Identifying the triggering factors like
environment allergen, smoke, infection, food allergy, exercise, cold air, dust are important in the
prevention of acute asthma. Management of the chronic asthma based on level of control is a step
up or step down approach as shown below:
Patient should commerce treatment as the step most appropriate to the initial severity. For
stepping up, patient should be reassessed 1 month after the initiation of the treatment and if control
is not adequate, step up after looking at the factors above. For stepping down, review the patient
after 3‐6 months if the control is good and consider gradual reduction.
Asthma action plan is a written plan, customised for every asthmatic patient. The action plan is
developed and designed by the doctor to help asthmatic patients to control their asthma. Action
plans may differ from patient to patient depending on severity. The asthma action plan may need to
be reviewed and updated from time to time so that any changes in asthma medication is recorded
according to the asthma control.
Step 1 : when patient is well?
Patient has good breathing, no cough, no wheezing and can play or do daily activities without
restriction.
Your action is:
Give preventer medicine as prescribed by doctor and ensure Peak flow reading more than 80% of
personal best.
Step 2 : When your child is not well?
Your child is not well when he/she has increasing symptoms of cough, wheeze, chest tightness.
Waking‐up at night due to coughing and peak flow reading is 50% – 80% of personal best.
Your action is:
Continue preventer medication as prescribed and take reliever medication once and as required.
Your child may need up to 4 hourly medication depending on the improvement of symptoms.
If symptoms improve, continue with step 1.
Step 3 : When your child gets worse?
The symptoms are not relieved with the treatment in step 2.
The cough and wheeze get worse with difficulty in breathing with flaring around the nostrils. The
reliever medications are needed more frequently than every 4 hours and peak flow reading is less
than 50% of personal best.
Your action is:
To continue preventer medication as prescribed and reliever medication 4 hourly. Also to take a
dose of oral prednisalone as prescribed and visit doctor immediately.
Asthma action plan also include what to do during emergency.
In the asthma action plan, it is told that patient should be given 4‐6 puffs of reliever medication
during emergency. The child may require 4‐6 puffs of reliever medication every 20 minutes to a
maximum dose of 12 puffs before bringing the child to the nearest clinic or emergency department.
Regarding follow up and social issue :
Other than that, in this patient, we will also have to address the social and family issues. We
have to make sure patient is under proper supervision and care. Not only that, her father has to be
informed about the disease and the necessities for medications and follow up. Complications of
uncontrolled asthma should be clearly informed to the parents to reinforce their knowledge about
the importance of appropriate treatment for the patient. Patient should also be referred to the
nutritionist to improve her weight gain as her weight falls in the 5th percentile for her age. She
should be advised about her dietary intake requirement and her growth chart should be plotted in
order to monitor her growth. This is to ensure patient has adequate nutrition to support her growth.
Discussion including Evidence based medicine (EBM)
Effect of Nebulized 3% Hypertonic Saline with Salbutamol on Management of
Acute Asthma
Nebulized 3% hypertonic saline is widely used in children with acute bronchiolitis to
rehydrate the airway surface liquid and improving mucociliary clearance. Therefore, it is
also interesting to find out if 3% hypertonic saline nebulizer can actually helps patient in the
management of acute asthma.
In a clinical triad found, they compared the effects of 3% Hypertonic saline with
salbutamol and salbutamol alone based on peak flow meter findings in adult patients with
acute asthma. 3% HS plus salbutamol led to a significant increase in PEFR and FEV1 in 40th
min (11% and 5% respectively) and 60th min (15% and 11% respectively) in the intervention
group compared to the control group that only nebulized salbutamol. The results also
showed that PEFR and FEV1 in both groups were significantly increased as the treatment
processed and the time passed. The percent changes in PEFR compared to the baseline
valued showed a significant difference between two groups in 40th min (24% and 15%
respectively) and 60th min (34% and 23% respectively), while regarding to FEV1 only in 60th
min (25% and 18% respectively) significant difference was observed between groups.
In a recent study Koskela et al demonstrated that inhalation of HS solution (with
osmolalities of 600, 900, 1200, 1500, 1800, and 2100 mOsm/kg) for 2 min period improves
percentage increase in FEV1 (6.1 ± 5.5 vs 2.8 ± 3.5; p = 0.02) and variation of PEFR (14.9 ±
9.0 vs 9.29 ± 4.74; p = 0.01) after nebulization of 0.4 mg of salbutamol in asthmatic patients
with chronic cough compared to non‐asthmatic patients with chronic cough during the
incremental saline challenge with salbutamol pretreatment.
The postulated mechanisms of benefit of 3% HS in asthmatic patients are as follows:
1) HS induces an osmotic flow of water into the mucus layer, rehydrating the airway
surface liquid and improving mucus clearance.
2) HS breaks the ionic bonds within the mucus gel, thereby reducing the degree of
cross‐linking and entanglements and lowering the viscosity and elasticity of the mucus
secretion.
3) HS stimulates cilial beat via the release of prostaglandin E2.
4) HS can theoretically reduce edema of the airway wall by absorbing water from the
mucosa and submucosa,
5) HS inhalation can also cause sputum induction and cough, which can help to clear
the sputum outside of the bronchi and thus improve airway obstruction.
Treatment of Asthma‐COPD overlap syndrome (ACOS)
Patients with features of both asthma and COPD have been recognized. They
experience frequent exacerbations and have poor quality of life, a more decline in lung
function and high mortality than asthma or COPD alone. However, there was no generally
agreed term or defining features for this category of chronic airway obstruction. In 2014,
asthma‐COPD overlap syndrome (ACOS) was defined by a joint project of Global Initiative
for Asthma (GINA) committee and the Global Initiative for Chronic Obstructive Lung
Disease (GOLD) committee.
Smoking cessation is the first step of management for smokers. It decreases the
symptoms of wheezing, cough, sputum, and dyspnea and disease severity and improves the
patient's quality of life. It also improves airway inflammation and airway obstruction, which
leads to prevent a rapid decrease in FEV1.0. Smoking cessation improves the efficacy of ICS
and theophylline clearance.
Active asthma without COPD decreased pulmonary function compared with inactive
asthma. To obtain good control of asthma is very important to maintain lung function;
therefore, the use of ICS is strongly recommended for patients with asthma to obtain better
control. Pulmonary function shows a more rapid decrease in ACOS patients than in patients
with COPD. Therefore, ICS are recommended for ACOS patients by the Japanese COPD
guidelines, irrespective of the severity of COPD or Global initiative chronic Obstructive
Lung Disease (GOLD) stage of airway obstruction.
A combination of ICS and bronchodilators, LAMA, or LABA is the recommended
pharmacological therapy for ACOS.The daily activities of ACOS patients are decreased
because of dyspnea on exertion. This results in deconditioning and decreased cardiac function
and skeletal muscle wasting, which, in turn, leads to less exercise and deterioration of
dyspnea, thus creating a vicious circle. To resolve this issue, pulmonary rehabilitation and
appropriate respiration techniques and drug administration are recommended; short‐acting
bronchodilators administered before exercise are also effective.
In summary, ACOS patients should receive a combination of ICS and long‐acting
bronchodilators LABAs and/or LAMAs after considering the risks and benefits. Depending
on the symptoms or severity of disease, other medications or early pulmonary rehabilitation
should be additionally considered.
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