pharma conference. difficulty in breathing known case of bronchial asthma since september 2009 via...
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Pharma ConferencePharma Conference
Difficulty in breathing
•Known case of bronchial asthma since September 2009
•via salbutamol challenge test
•Salbutamol nebulization as needed
•No maintenance
•No regular follow up done
• occasional dry cough • night awakenings due to cough ( 2-3 / week)
• give Salbutamol neb every 4 hours
•Improved by having a good sleep after • no consult was done
6 weeks PTA
• Still persistent dry cough
•Night awakenings due to cough (3-4 x/ week)
consulted consulted at local health clinic
> had chest X rayshowed pneumonitis w/ lymphadenopathies
* given with * loratidine ( loraped) once daily * cefaclor 5mL for 7 days
* asked to come back after 3 days
2 weeks PTA
• according to mother after 3 days
• noted decrease frequency of dry cough •Decrease night awakening
• At follow up• Loratidine was replaced with Citirizine 2.5 mL every 4 hours
•Cafaclor was continued for another 4 days
10 days PTA
•Still there was cough •Fever ( highest temp 38.2C) •Watery nasal discharge •Post-tussive vomiting of previously ingested milk
•Mother gave •5mL paracetamol (125mg/5ml)
for every 4 hrs•Salbutamol nebulization
(1/2 nebule + 1cc NSS) every 4 hours
• there was improvement after nebulization however the symptoms re occur after several hours which prompt consult at UST - ERCD
1 day PTA
Gen: no weight loss, no decrease in appetite
HEENT: no headache, no eye discharge, no epistaxis, no sore throat
Cardiovascular: no bruises, no syncope GI: no diarrhea, no melena, no hematocheizaGU: no difficulty in urination Endocrine: no tremors, Musculoskeletal: no bone pain, no muscle pain,
no limitation in range of motionNervous System: no seizure, convulsions, weakness
• Breast fed until 1 week of life and fed after with milk formula • Started complimentary feeding at 6 months • Now, the patient was fed with mixed diet with Nido with 1:1
dilution, 8 ounce 3/day
Feeding history
24 food recallFood CHO (g) CHON (g) FATS (g) Calories
Breakfast 1 cup soy milkPancit Canton 23
22
1.5 21.5100
Lunch Beef nilaga with 2 pc meat½ cup rice
23162
2 82100
Merienda 4 pcs wafer1 juice tetrapack
11.56
1 50
Dinner Beef nilaga with 2 pc meat1/4cup rice 11.5
8
1
1 41
50
Midnight snack French friesMilk 3 ounces
2318
212 15
100253
ACI%
919.5 (86%)
RENI 1070
• Gross Motor: Run well with out support, can jump• Fine Motor: feeds self with spoon • Language: produces 2 words sentences, can point
what he wants • Social: plays with other kids
Developmental History
• Patient completed the EPI program in our OPD-CD however cant
recall the exact dates
• BCG 1 - dose• Hep B – 3 doses• DTP – 3 doses • OPV – 3 doses • Measles – 1 dose
• Hib – 1 dose
Immunization
Admtted last December 2009 for pneumonia
No skin allergies, No surgeries, no blood transfusion
(+) Asthma (father, uncle maternal side)
(+) hypertension (grandfather – maternal side)
(+) heart problem ( grandmother – paternal side)
(-) DM, skin allergy , anemia, leukemia, renal disease, seizures
Name Age Relation Educational Attainment
Occupation Health
AS 46 Grandfather
Graduate Vocational
Technician (+)HPN
LS 52 Grand mother
High School graduate
Housewife Healthy
KR 27 Father College graduate
Technician (+) asthma
CR 25 Mother Graduate Vocational
Housewife Healthy
LS 33 Aunt Graduate vocational
None Healthy
RS 21 Uncle Highschool graduate
None Healthy
lives with his parents, maternal grandparents, uncle and aunt
2 storey building made of cement
Well lit, well ventilated with 2 bedrooms and 1 comfort room
Drinking water is brought from a refill station
Garbage not segregated but collected daily
No nearby factories, no pets in the house, no second hand smoke exposure
There was planted flowers in front of their house which they noted the patient to cough every time he passes by
HR: 120bpm Temp: 37.1 C
RR: 38/minWt: 14kg (Z score O) Ht: 86.6 (Z score 0)HC: 48 cm (above 0)
Awake, good activity and crying
Skin: Warm, moist skin, no active dermatoses, no jaundice, good skin turgor
HEENT: closed fontanels, Pink palpebral conjunctivae, anicteric sclerae, no opacities, normal direct pupillary light reflex, pupils 2-3mm ERTL; nonhyperemic EAC and intact tympanic membrane, AU, no aural discharge; no alar flaring, septum in midline, congested turbinates, (+) whitish nasal discharge; hyperemic posterior pharyngeal wall w/ no exudates, uvula midline, tonsils not enlarged
Neck: Supple neck, (-) palpable cervical lymph node
Lungs: Symmetrical chest expansion, no lagging, (+) suprasternal, intercostal, subcostal retractions, (+) wheezes on both lung fieds, (+) coarse crackles on both lung fields
Heart: Adynamic precordium, apex beat at 4th LICS MCL, no thrills, heaves, lifts, murmurs
Abdomen: globular soft abdomen, NABS, no palpable masses, no tenderness upon palapation
Extremities: Full and equal pulses on all extremities, no edema, no cyanosis, no limitation in movement
Genitourinary: bilaterally descended testes, no discharge, no masses
Alert, awake, crying and irritable
CN I-XII were intact
Motor: all extremities moves spontaneously
Sensory: No sensory deficits
Reflexes: All DTR +2, (-) babinski
(-) nuchal rigidity, kernig’s and brudzinski
* 2years old/ male* (+) family history of asthma* known bronchial asthma * dry cough, noucturnal awakenings* noted coughing when the pastient passes by infront
of the house where there are flowers * good response to salbutamol neb* RR 38/min , (+) suprasternal, intercostal, subcostal
retractions, (+) wheezes on both lung fieds, (+) coarse crackles on both lung fields
Approach to diagnosisApproach to diagnosis
Look for a symptom, sign, or laboratory finding found in the least number of diseases
Shortness of breathCoughWheeze
•Asthma exacerbation•Acute bronchitis•Vocal cord dysfunction•Foreign body aspiration•Gastroesophageal reflux
AsthmaAsthma common chronic inflammatory
disease of the airways characterized by variable and recurring symptoms, airflow obstruction, and bronchospasm.
Asthma is caused by environmental and genetic factors. These factors influence how severe asthma is and how well it responds to medication.
AsthmaAsthma Asthma predominantly occurs in boys in
childhood, with a male-to-female ratio of 2:1 until puberty, when the male-to-female ratio becomes 1:1.
Asthma prevalence is increased in very young persons and very old persons .
Asthma symptoms may include the following: • Cough, worse particularly at night• Wheezing • Shortness of breath • Chest tightness • Sputum production • Decreased exercise tolerance
AsthmaAsthma General asthma physical findings
• Evidence of respiratory distress manifests as increased respiratory rate, increased heart rate, diaphoresis, and use of accessory muscles of respiration.
• Marked weight loss or severe wasting may indicate severe emphysema.
Pulsus paradoxus Depressed sensorium Chest examination
• End-expiratory wheezing or a prolonged expiratory phase is found most commonly, although inspiratory wheezing can be heard.
• Diminished breath sounds and chest hyperinflation
Acute BronchitisAcute Bronchitis clinical syndrome produced by
inflammation of the trachea, bronchi, and bronchioles
usually occurs in association with viral respiratory tract infection
Characteristic symptoms include productive cough, shortness of breath and wheezing.
clinical course of acute bronchitis is self-limited, with complete healing and full return to function typically seen within 10-14 days following symptom onset.
Acute BronchitisAcute Bronchitis The incidence is equal in males and
females occurs most commonly in children
younger than 2 years, with another peak seen in children aged 9-15 years.
begins as a respiratory tract infection that manifests as the common cold.
Acute BronchitisAcute Bronchitis Symptoms often include coryza,
malaise, chills, low grade fever, sore throat, and back and muscle pain.
The cough in these children is usually accompanied by an initial watery nasal discharge.
Crackles, rhonchi, or large airway wheezing, if any, tends to be scattered and bilateral
**There is no specific therapy. The disease is self-limited
Vocal Cord DysfunctionVocal Cord Dysfunction abnormal adduction of the vocal cords
during the respiratory cycle (especially during the inspiratory phase) that produces airflow obstruction at the level of the larynx.
Presents with wheezing, cough, and dyspnea
This condition is predominantly observed in females
This condition predominates in people aged 20-40 years, but it can occur in people aged 6-83 years
Vocal Cord DysfucntionVocal Cord DysfucntionHistory Wheezing Cough A feeling of tightness in the throat Hoarseness and voice change Stridor Shortness of breath Dyspnea on exertion Inspiratory difficulty Unresponsiveness to bronchodilators and corticosteroidsPhysical Exam Laryngeal auscultation may reveal harsh stridulous sounds during
symptoms. Wheezing may be heard in the chest (transmitted from the upper
airway).
Foreign Body AspirationForeign Body Aspiration The male-to-female ratio is 2:1 Children, especially those aged 1-3
years Choking or coughing is present in 95%
of patients Approximately 50% of children have
inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase, and medium-to-coarse rhonchi.
Foreign Body AspirationForeign Body Aspiration Tachypnea; nasal flaring; intercostal,
subcostal, and suprasternal retractions; and differences in percussion between hemithoraces also are common findings
Fever and central cyanosis are less common
consider the possibility of foreign body aspiration, particularly with unilateral wheezing
Gastroesophageal refluxGastroesophageal reflux Immaturity of lower esophageal
sphincter (LES) function, manifested by frequent transient lower esophageal relaxations (tLESRs) that results in retrograde flow of gastric contents into the esophagus.
Gastroesophageal reflux has been associated with significant respiratory symptoms in infants and children
Gastroesophageal refluxGastroesophageal reflux Signs andsymptoms of gastroesophageal reflux in infants and young
children • Typical or atypical crying and/or irritability • Apnea and/or bradycardia • Poor appetite • Vomiting • Wheezing • Abdominal and/or chest pain • Stridor • Weight loss or poor growth (failure to thrive) • Recurrent pneumonitis • Sore throat • Chronic cough • Hoarseness and/or laryngitis
Signs and symptoms in older children - All of the above, plus heartburn and history of vomiting, regurgitation, unhealthy teeth, and halitosis
CLINICAL DIAGNOSISCLINICAL DIAGNOSIS
Bronchial asthma, mildly persistent, in moderate
exacerbation
Course in The Ward (1Course in The Ward (1stst HD)HD)
Please admit the patient under the service of Dr. Moral-Valencia at bed 320G
Diet for age with strict aspiration precaution
Hold feeding of RR > 40cpm Medications given were salbutamol
nebulization, 1 neb every 1 hour, hydrocortisone 60mg/SIVP now then every 6 hours, paracetamol 125 mg/5ml, 6 ml every 4 hrs for fever >38.5C, 0.65% NaCl drip
Patient was given O2/cannula at 1-2 lpm as needed. IVF D5IMB 500ml to run at 37-38 ml/hr
Course in The Ward (2Course in The Ward (2ndnd HD)HD)
Salbutamol + ipratropium bromide was started, alternating with salbutamol nebulization every 6 hours
Course in the Ward (3Course in the Ward (3rdrd HD) HD) Salmeterol + fluticasone propionate
(seretide inhaler) 1 puff BID Prednisolone 20mg/5ml 4.5ml
SANE CriteriaSANE Criteria Safety Affordability Need Efficacy
Problems in the PatientProblems in the Patient Pharmacologic therapy to address
• Bronchial asthma, mildly persistent, in moderate exacerbation
Drugs for Acute AsthmaDrugs for Acute Asthma Bronchodilators
• Anticholinergics• Methylxanthines• Sympathomimetics
Catecholamines – epinephrine B2 agonists
SABA Anti-inflammatory
• Corticosteroids Systemic Inhaled
RelieversRelievers Quickly reverse bronchoconstriction
during acute exacerbation or breakthrough symptoms; taken prn
Bronchodilators• SABA, epinephrine, methylxanthines
Anti-inflammatory agents• Systemic steroids
ControllersControllers Have to be taken continuously on a
maintenance basis to control asthma Bronchodilators
• LABA Anti-inflammatory agents
• Inhaled• Systemic• LT antagonists• Mast cell stabilizers
BronchodilatorsBronchodilators MOA: activation of B receptors ->
activation of Gs coupling proteins -> cAMP -> phosphorylation of target enzymes -> relaxation of bronchial muscles
Epinephrine B2 agonists
EpinephrineEpinephrine For anaphylaxis Not effective in oral intake
Rapidly conjugated and oxidized in GIT and liver a1= a2 ; B1=B2 Triggers sympathetic response, fear,
anxiety, tenseness, restlessness, cardiac arrythmias
Not used in acute asthma, unless not responsive to B2 agonist or asthma is caused by anaphylaxis
SABASABA Terbutaline Salbutamol After oral inhalation, 10% deposited
in bronchial airway where absorption takes place -> systemic circulation.
No substantial effect on inflammation
B2 AgonistsB2 Agonists SABA
• Oral Peak effect 2 hrs Duration of action 4-8 hrs
• Inhaled Peak effect 30-90 mins, 75% of maximum
bronchodilation by 5 mins >4 hrs
Adverse Effects of B2 Adverse Effects of B2 agonistsagonists
Skeletal muscle tremors tachycardia, arrthymias increased bronchial hyperreactivity
and deterioration of disease control
Anticholinergic DrugsAnticholinergic Drugs Ipratropium bromide: treatment for
asthma Binds M2 and M3 receptors with equal
affinity, competitive antagonist to acetylcholine at M3 receptors on smooth muscles -> blocking bronchospasm -> decrease mucus secretion
In combination with SABA, provides quick relief for acute asthma attack
CombiventCombivent contains a microcrystalline suspension of
ipratropium bromide and salbutamol in a pressurized metered-dose aerosol unit for oral inhalation administration.
The 200 inhalation unit has a net weight of 14.7 grams. Anticholinergic bronchodilator
Each actuation meters 21 mcg of ipratropium bromide and 120 mcg of salbutamol from the valve and delivers 18 mcg of ipratropium bromide and 103 mcg of salbutamol from the mouthpiece.
DosageDosage 2 inhalations four times a day. Patients may take additional
inhalations as required; however, the total number of inhalations should not exceed 12 in 24 hours.
Safety and efficacy of additional doses of COMBIVENT Inhalation Aerosol beyond 12 puffs/24 hours have not been studied.
All Adverse Events (in All Adverse Events (in percentages), from percentages), from Two Large Double-Two Large Double-blind, Parallel, 12-blind, Parallel, 12-
Week Studies of Week Studies of Patients with COPDPatients with COPD
MethylxanthinesMethylxanthines Theophylline – both bronchodilator
and anti-inflammatory actions inhibits PDE -> increases cAMP -
>smooth muscle relaxation High level of toxicity; narrow
therapeutic index AE: nausea, vomiting, GIT
disturbances, headache,
CorticosteroidsCorticosteroids Anti-inflammatory effects due to
inhibition of production of pro-inflammatory cytokines -> decreased trafficking of lymphocytes, eosinophils -> decreased bronchial hyperreactivity
Potentiates B2 agonist effect by increasing synthesis of B2 receptors
Decrease mucus production
CorticosteroidsCorticosteroids Systemic steroids
• Oral: prednisone, prednisolone, methylprednisolone
• Parenteral: hydrocortisone, methylprednisolone
Inhaled steroids• Budesonide, fluticasone
Indications of CSIndications of CS Systemic steroids
• For relief of acute asthma exacerbations• Control of severe persistent asthma
Inhaled steroids• As maintenance therapy for all levels of
persistent asthma
Adverse Effects of CSAdverse Effects of CS Inhaled CS adverse effects:
hoarseness/dysphonia, oral candidiasis, throat irritation and cough
Systemic CS adverse effects: truncal obesity, moon facies, buffalo hump, osteoporosis
Anti-Asthma DrugsAnti-Asthma DrugsSafety Affordability Need Efficacy
Combivent nebulizer(salbutamol + ipratropium bromide)
++++ ++++P33.25
++++ ++++
Theophylline 300mg/tab ++ +++++P1.50
++ ++++
Epinephrine HCl 1ml +++ P40.00 ++ ++
Prednisone 20mg/5ml, 3ml ++ P6.25 ++ ++
Methylprednisolone 500mg/IV ++ +P3509.75
++++ ++++
Salmeterol + fluticasone propionate +++ ++++ ++++
Hydrocortisone 100mg/IV +++ +++P40.75
++++ +++
Pre Post Pre Post Pre Post
Time 7:30AM
8AM 815AM 842AM 9AM 920AM
Spot O2 96 96 94 93 96 96
RR 38 34 34 32 32 40
CR 120 128 128 130 148 140
Temp 37.1 37.5 38 38 38.1 37.8
Air entry Fair Fair Fair Fair Fair Fair to good
Retractions
-suprasternal + + + - + +
-intercostal + + + + + +
-subcostal + + + + + +
-supraclavicular
+ + + + + +
Alar flaring - - - - - -
Wheezes + + + + + +
Crackles + + + + + +
Rhonchi + + + + + +