CASE PRESENTATION

FAMILY CASE PRESENTATION:

ABAT FAMILY
YOUTH A By: COMMITTEE
RED,ROXAS,Sergielyn
ROSETE, PAUL DARYL
APRIL ANNE
RUANTO, MA. ALYZA
SALAMATIN, Ethel Kate
RUNGBOON, NATTAPONG
SABLAN, SHARMAINE
SALVO, SALAMATIN,
Geraldine ETHEL KATE Marie
SANTIAGO, CHASTINE LEI
PGI –IN-CHARGE: DR. NURBEN HAMID
CONSULTANT IN CHARGE: DR. RONWALDO SAN DIEGO
General Objective:
• To present and discuss a case of Bronchial Asthma.
Specific objectives:
• To discuss the process of acquiring bronchial asthma.
• To discuss the causes and risk factors of developing
bronchial asthma in relation to the patient.
• To briefly describe the different pathophysiologic
mechanisms that lead to the development of Bronchial
Asthma.
• To discuss the key areas of Bronchial Asthma
management.
• To provide recommendations on our clinical practice in
the management of bronchial asthma.
• Name: M.B.
• Age: 55 year old
• Gender: Male
• Date of Birth: May 13, 1964
• Place of Birth: Bulacan
• Religion: Roman Catholic
• Address: Catacte, Bustos, Bulacan
• Informant: M.B.
• Reliability: 90%
• Date of Admission: Consulted for the second time at our
institution last May 13, 2019.
DIFFICULTY
OF
BREATHING
chief complaint
History of Present Illness
2 WEEKS PTA:
• Noted to have easy fatigability described as
difficulty of breathing associated with loss of
appetite.
• Consulted at a health center.
• Provided with Hypertensive meds only.
• Patient self-medicated with Salmeterol +
Fluticasone inhaler which provided minimal relief.
History of Present Illness
 DURING INTERIM:
• Still with difficulty of breathing now
associated with occasional cough, non-
productive.
• No consultation done
• No medications taken
History of Present Illness
 2 DAYS PTA:
• Still with on and off cough and difficulty of breathing,
now with shortness of breath and chest tightness.
• Sought consult with the same health center
• Provided with hypertensive meds only
for 7 days.
History of Present Illness
 Two hours PTC, due to the persistence of on and off
episodes of cough, difficulty of breathing and
shortness of breath, the patient then decided to seek
consult at our institution, hence admission.
 Past Medical History
• (+) Asthma (March 2019) – claimed by the
patient.
*Maintenance Meds: Salmeterol + Fluticasone
inhaler
• (+) Hypertension – 2 years now (usual: 130/100,
Max: 170/110)
*Maintenance Meds: Amlodipine 10mg OD
(+) Pulmonary Tuberculosis – (2008) Completed 9
months of treatment ordered by MD
(+) History of previous hospitalizations – BA
(March 2, 2019) at BMC
 Past Medical History

(-) Diabetes Mellitus

(-) CVD
(-) Malignancies
(-) Thyroid Disease
(-) Allergies to Food and Medications
(-) Surgery
(-) Blood Transfusion
Family History
• (+) Bronchial Asthma – Paternal side
• (+) PTB – Paternal side
• (-) Hypertension
• (-) Diabetes Mellitus
• (-) Stroke
• (-) Kidney Disease
• (-) Thyroid Disorders
• (-) Cancer
 Personal and
Social History
• Previously worked as a welder for 15 years.
• Lives with his wife and their 3
children at Catacte, Bustos, Bulacan
• Drinking water: purified water from
refilling stations
• Garbage is collected regularly
• Previous smoker for 66 pack years
• Non-alcoholic beverage drinker
• No history of any illicit drug use
Review of Systems
• General
(-)fever
(-)chills
(-)weakness
(-)sleep disturbance
(-)weight loss
Review of Systems
• Integumentary
(-) pruritus
(-) rashes
(-) pallor
(-) hyperpigmentation
(-) jaundice
Review of Systems
• HEENT
(-) head injury/trauma (-) hoarseness
(-) eye redness
(-) eye discharge
(-) blurring of vision
(-) ear ache and ear discharge
(-) epistaxis
(-) sore throat
Review of Systems
• Respiratory
(-) Hemoptysis
Review of Systems
• Cardiovascular
(-) palpitations
(-) fainting spells
(-) pedal edema
Review of Systems
• Gastrointestinal
(-) abdominal pain
(-) vomiting
(-) constipation
(-) melena
(-) hematochezia
(-) hematemesis
Review of Systems
• Genitourinary
(-) dysuria
(-) frequency
(-) nocturia
(-) frothy urine
(-) penile discharge
Review of Systems
• Neurologic
(-) headache
(-) loss of consciousness
(-) numbness
(-) unsteady gait
(-) seizures
(-) change in behavior
Review of Systems
• Musculoskeletal
(-) muscle pain
(-) joint pain
(-) swelling, bipedal
(-) trauma or fall
General Survey
• Awake, conscious, coherent and in
mild distress

Vital Signs
BP: 100/70 mmHg
PR: 111 bpm
RR: 24 cpm
Temp: 37.1 ˚C
O2 Sat: 97%
Head–– normocephalic, with evenly distributed
black hair. No lumps, no lesions, no
deformities.
Eyes­
––
­ anicteric sclera, pink palpebral
conjunctiva. No pain, no discharges. No
dysconjugate gaze, no lid lag, no nystagmus.
Ears–– no discharges, no lumps or lesions.
Good hearing acuity to whispered voice.
Nose–– no nasoaural discharge, pink mucosa. No
alar flaring. No sinus tenderness.
Throat–– oral mucosa is pink. No erosions,
ulcerations.
Neck–– No cervical lymphadenopathies. Thyroid
gland elevates upon swallowing.
• Capillary refill <2 seconds
• Radial pulses 2+ bilaterally, with
regular rate and rhythm
• PMI at 5th ICS MCL
• Normal rate and regular rhythm
upon auscultation, S1 and S2 are
distinct.
• (-) murmurs.
• Muscles are well developed
• (-) mass, lesion, nor deformities
• (-) tenderness upon palpation
• AP diameter is approximately 1/3 of
the transverse diameter
• Symmetrical chest expansion
• No subcostal retractions, no lagging
• (+) Wheezes on both lung fields but
louder on the right lung
• umbilicus midline
• Globular and soft abdomen
• (-) tenderness on palpation
• Grossly normal extremities
• No deformities, no external signs of cyanosis,
no pallor, no edema
• Full and equal pulses on brachial, radial and
dorsalis pedis
• Awake
• Ambulatory
• Oriented to time, place and
person
 SALIENT FEATURES:
● 40 years old
● Difficulty of breathing
● Occasional cough more worse at night
● Chest tightness
● Wheeze
● Smoker consuming 40 sticks a day for 33 years = 66
pack years
● Previous worker at koprahan x 4 months and also
worked as a welder for 15 years
● Recurrent asthma episodes
 DIFFERENTIAL DIAGNOSIS:
COPD
Rule In Rule Out
(+) cough Irreversible
(+) risk for smokers (-) PND
(+) DOB (-) barrel chest
(+) tachypnea
(+) chest tightness
 Upper airway Obstruction

Rule In Rule Out

(+) dyspnea (-) cough
(-) foreign body aspiration
(-) response to
bronchodilators
(-)Stridor
 Bronchiectasis
Rule In Rule out
(+) cough (-) blood streaked
(+) dyspnea sputum
(+) chest tightness (-) weight loss
(+)wheeze (-) night sweats
 Tension Pneumothorax
Rule In Rule Out
(+) DOB (-) neck vein distention
(+) chest tightness (-)Decrease breath
(+) tachypnea sounds
(-) hypotension
(-) tracheal deviation on
affected side
 CLINICAL IMPRESSION:

BRONCHIAL ASTHMA IN
ACUTE EXACERBATION
 Signs and Symptoms of asthma
 Clinical presentations of asthma can go differently from patient to
patient.

 The typical main symptoms are:

Paroxysmal shortness of breath
Expiratory stridor (differential diagnosis: inspiratory stridor in the
event of obstruction of the upper airways)
Chronic cough, mostly dry and in spasms (“cough-variant asthma)
Thoracic tightness
• Because of low sympathetic, that is, the high vagal tone
in the second half of the night, most patients describe a
peak of their symptoms. If symptoms occur seasonally,
(e.g, during pollination), this might be a sign of allergic
asthma.
• In most cases, the asthma appears only episodically in
the beginning, and patients remain symptom-free most
of the time.
 CONTENTS
:
❶ DEFINITION.
❷ EPIDEMIOLOGY.
❸ ETIOLOGY.
❹ PATHOPHYSIOLOGY.
❺ CHEST EXAMINATION.
❻ BRONCHIAL ASTHMA
MANAGEMENT.
 ❶DEFINITION
 Bronchial Asthma as inflammatory disease of the airways.
 Bronchial Asthma describes a chronic inflammatory disease of
the airways. During the course of the inflammation, a bronchial
hyperreactivity occurs.
 In comparison to healthy people, the airways of patients with
asthma react more sensitive to various stimuli. The consequence
is a paroxysmal and recurring obstruction of the airways.
 However, this obstruction occurs spontaneously, and with drug
treatment, it is completely or partially reversible.
 ❷EPIDEMIOLOGY
• Bronchial Asthma in the population
• Bronchial Asthma is one of the most common chronic diseases in
humans. Around 5% of adults and even 10% of children and young
people are affected.
• With regard to gender distribution, different statements can be
found in the literature. According to a study by the Robert Koch
Institute (Germany), slightly more women than men were affected
between 2003 and 2008. Other sources state an approximately
equal distribution.
• Regardless, it is an undisputed fact that the initial onset of the
allergic type of asthma occurs mostly during childhood.
 ❸ETIOLOGY
Causes and triggering factors:
Generally, two types of asthma can be distinguished.
1. Allergic, extrinsic asthma
Patients with allergic, extrinsic asthma develop asthma symptoms when coming into
contact with environmental allergens (e.g pollen, pet hair, house dust mites, mildews,
occupational allergens such as flour dust)
The allergic type of asthma often exists in combination with other diseases pertaining to
the atopic syndrome, such as allergic rhinitis or neurodermatitis. They all have in common a
polygenic predisposition for excessive production of IgE. If both parents are affected by
allergic asthma, their children will have a risk of disease around 60-80%. On the island
Tristan da Cunha, 50% of the population suffer from asthma due to hereditary transmission.
2. Non-allergic, intrinsic asthma
For non-allergic, intrinsic asthma, the following trigger factors
may play a role: respiratory infection (infectious asthma),
acetylsalcylic acid/NSAIDs (analgesic asthma syndrome), noxious
inhaled agents, gastroesophageal reflux, as well as cold air and
physical or mental stress.
Often, the two types can not be rigorously distinguished
especially when they occur in adult asthmatics. Only 30% of patients
suffer from a purely extrinsic or intrinsic asthma; the rest display
hybrid forms of both types.
 ❹ PATHOPHYSIOLOGY
 The origin of bronchial asthma:
In the case of allergic asthma, only a few minutes after coming into contact with a
corresponding allergen, the production of IgE antibodies begins. These antibodies
activate mast cells, which release mediators such as leukotriene, prostaglandin and
histamine (Type 1 hypersensitivity reaction). These mediators cause bronchospasms,
on one hand, and attract inflammatory cells, on the other. The latter eventually cause
a long term full picture of chronic inflammation.
In the case of non-allergic asthma, the immunological process is similar but
without a triggering allergen. Here, it is for instance substitute infectious
agents(especially viruses) that are suspected to act as triggering factors.
  All different types of Asthma have the resulting pathologic
consequences in common:
1. Constriction of the airways due to bronchospasm, but also due to an
edematous mucosal swelling;
2. Hypersecretion of thick mucus; hyperplasia of smooth
muscles(remodeling); in addition,
3. Bronchial hyperreactivity and (chronic) bronchial inflammation.
 ❺BRONCHIAL ASTHMA
EXAMINATION
Who is at risk of developing bronchial
asthma?
 Having a blood relative (such as a parent or sibling) with asthma
 Having another allergic condition, such as allergic rhinitis and atopic dermatitis
 Being overweight
 Being a smoker
 Exposure to secondhand smoke
 Exposure to exhaust fumes or other types of pollution
 Exposure to occupational triggers, such as chemicals used in farming, hairdressing
and manufacturing
STEPS OF EXAMINATION:
• Full history & examination.
• Chest examination:
- Inspection.
- Palpation.
- Percussion.
- Auscultation.
CHEST AND LUNGS EXAMINATION
VISUAL INSPECTION

Level of distress
Chest shape
 Asymmetry of chest expansion
 Retractions
 Lagging
 CHEST AND LUNGS EXAMINATION
PALPATION
 Tenderness
 Asymmetry
 Diaphragmatic excursion
 Crepitus
 Vocal Fremitus
 CHEST AND LUNGS EXAMINATION
PERCUSSION

 Resonance or dullness of the lungs

 CHEST AND LUNGS EXAMINATION
AUSCULTATION
 Place the patient in sitting position or if patient is to remain
recumbent, roll the patient from one side to the other to examine the
back.
 Patient should inhale and exhale through the mouth, deeper than
their usual breaths.
 Identify the sounds heard classified as breath sounds.
Diagnosis
Diagnosis
• Asthma is usually characterized by chronic airway inflammation and
has two key defining features:
• A history of respiratory symptom such as wheeze, shortness of breath, chest
tightness, and cough that vary overtime and in intensity
• Variable expiratory airflow limitation
Respiratory symptoms that are characteristic
of asthma
• Features that increase the probability of asthma
• More than one symptom (wheeze, shortness of breath, cough, chest
tightness) especially in adults
• Symptoms often worse at night or in the early morning
• Symptoms vary over time and in intensity
• Symptoms are triggered by viral infections, exercise, allergen exposure,
changes in weather, laughter or irritants such as car exhaust fumes
• Features that decrease the probability of asthma
• Isolated cough with no other respiratory symptoms
• Chronic production of sputum
• Shortness of breath associated with dizziness, light-headedness or
paresthesia
• Chest pain
• Exercise-induced dyspnea with noisy inspiration
Diagnosis
• The diagnosis of asthma is usually apparent from the symptoms of
variable and intermittent airways obstruction, but must be confirmed
by objective measurements of lung function.
Lung Function Tests
• Spirometry
• Simple spirometry confirms airflow limitation with a reduced FEV1, FEV1/FVC
ratio, and PEF
• Reversibility of >12% and 200mL increase in FEV1 15min after an inhaled
SABA or in some patients by a2- to 4-week trial of oral corticosteroids
• PEF
• Measurements of PEF twice daily may confirm the diurnal variations in airflow
obstruction.
• Important aid in diagnosis and monitoring of asthma
• Improvement of 60L/min or ≥20% of prebronchodilator PEF after inhalation of
a bronchodilator; or diurnal variation in PEF >20%
Lung Function Tests
• Flow Volume Loop
• Flow-volume loops show reduced peak flow and reduced maximum
expiratory flow.
• Whole Body Plethysmography
• Increased airway resistance
• Increased total lung capacity and residual volume
• Gas Diffusion
• Gas diffusion is usually normal, but there may be a small increase in gas
transfer in some patients.
Airway Responsiveness
• Methacholine or Histamine Provocative Challenge
• Reduced FEV1 by 20%
• Used in the DDx of chronic cough
• Occasionally exercise testing is 0done to demonstrate the post
exercise bronchoconstriction if there is a predominant history of EIA.
• Allergen challenge is rarely necessary and should only be undertaken
by a specialist if specific occupational agents are to be identified.
Hematologic Test
• Blood tests are not usually helpful. Total serum IgE and specific IgE to
inhaled allergens (radioallergosorbent test [RAST]) may be measured
in some patients.
Imaging
• Chest X-ray
• Usually Normal
• Hyperinflated lungs in severe cases
• Pneumothorax in exacerbations

• High Resolution CT
• Areas of bronchiectasis in severe asthma
• Thickening of the bronchial walls
CHEST X-RAY
Skin Tests
• Skin prick tests to common inhalant allergens (house dust mite, cat
fur, grass pollen) are positive in allergic asthma and negative in
intrinsic asthma, but are not helpful in diagnosis.
• Positive skin responses may be useful in persuading patients to
undertake allergen avoidance measures.
Exhaled Nitric Oxide
• Noninvasive test to measure airway inflammation
• test of compliance with therapy
• Elevated in Asthma
• Reduced by ICS
• Useful in demonstrating insufficient anti-inflammatory therapy and
may be useful in down-titrating ICS.
GOAL

• The long term goals are symptom control and risk reduction
• Aim is to reduce the burden to the patient and to reduce their risk of
exacerbations, airway damage, and medication side effects.
CONTROL-BASED MANAGEMENT CYCLE
MEDICATIONS:
• classified as controllers or relievers.

Controllers:
• taken daily on a long-term basis to keep asthma under clinical control chiefly
through their anti-inflammatory effects.

Relievers:
• used on as needed basis that act quickly to reverse bronchoconstriction and
relieve its symptoms.
Asthma Triggers
• Airborne substances, such as pollen, dust mites, mold spores, pet dander or particles
of cockroach waste
• Respiratory infections, such as the common cold
• Physical activity (exercise-induced asthma)
• Cold air
• Air pollutants and irritants, such as smoke
• Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB,
others) and naproxen (Aleve)
• Strong emotions and stress
• Sulfites and preservatives added to some types of foods and beverages, including
shrimp, dried fruit, processed potatoes, beer and wine
• Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up
into your throat
PATIENT’S EDUCATION

DO NOT SMOKE
THANK YOU!