Post on 23-Jan-2018
A “ DIFFERENT ” CASE
OF BRONCHIAL
ASTHMA
Prof. RAMASAMY.S
Prof. CHITRAMBALAM.P
Dr. PRASANNA KARTHIK( ASST.)
Dr. SARAVANAN.S (2nd YEAR M.D)
HIS(S)TORY
29 year old male , Manager by profession from
Avadi , Chennai
Breathlessness since 1 month
Cough with sputum production since a week
HIS(S)TORY
Patient was apparently normal a month back
Breathlessness on exertion( MMRC GRADE 1)
since 1 month , insidious in onset , gradually
progressive
Productive cough since 1 week with scanty
whitish non foul smelling sputum
Had wheezing predominantly at night
All the above symptoms increased in severity for
the past 1 week and not adequately relieved by
medications
HIS(S)TORY
No h/o hemoptysis and chest pain
No h/o loss of weight, loss of appetite , night
sweats
No h/o Halitosis, pedal edema, puffiness of face
PAST HISTORY
Known case of Bronchial asthma since 3 years of age – had occasional episodes of wheezing relieved by SOS medications.
Not on any regular prophylactic drugs.
Not a known case of T2DM, SHT, EPILEPSY, JAUNDICE,
PERSONAL HISTORY
Mixed diet
Normal Bowel and Bladder habits
Non Alcoholic , Non Smoker , no social
addictions
FAMILY HSTORY
No history of similar complaints in the family
members
GENERAL EXAMINATION
Well built and Well nourished
Not Anemic , Jaundiced , Clubbing or Cyanosed.
Dyspnoeic at rest.
VITALS
PULSE: 116 bpm, regular in rhythm and normal
volume
BP :100/80 mm Hg RUL, Supine
No orthostatic hypotension
Respiratory rate 24/min
Oxygen saturations: 93% at room air
SYSTEMIC EXAMINATION
INSPECTION:
Upper respiratory tract : Normal
Trachea appears to be in mid line
Apical impulse seen at 5th ICS
Normal chest wall symmetry
PALPATION:
Position of trachea: Midline
Position of apical impulse : ½ inch medial to M.C.L
in the 5th I.C.S
Normal chest wall movements
No intercostal tenderness
PERCUSSION:
Resonant in all the areas of the chest
AUSCULTATION:
Normal vesicular breath sounds with bi-lateral
rhonchi
OTHER SYSTEMS
CVS: S1 , S2 heard in all areas, no murmurs
ABDOMEN: Soft, no organomegaly
CNS: NFND
INVESTIGATIONS
HEMATOLOGY:
C.B.C: 15,500/MM3
D.C : N 80% L 16% E 4%
HB: 12 g/dl
PLATELETS: 3.2 lakhs/mm3
BIO-CHEMISTRY:
RBS: 112 mg%
Urea: 56 mg%
Creat: 0.8 mg%
CHEST X-RAY
CHEST XRAY
Trachea: Mid line
C:T Ratio: 40%
Angles : Free
Lung Fields : Clear
Right Lower Lobe Bronchus seemed to be
Clogged – giving rise to a suspicion of
“GLOVED FINGER” appearance
Hence, proceeded to estimate Serum Ig-E ,
HRCT CHEST and Sputum for Fungal spores.
Urine routines: Unremarkable
ECHOCARDIOGRAPHY : NORMAL
SERUM IG-E: 680 IU/ML , RAISED ( 0.5 – 290
IU/ML)
Sputum culture: No organisms isolated
Sputum for Fungal Spores : Negative
HRCT THORAX
HRCT REPORT
MODERATE PNEUMO-MEDIASTINUM( no
cause is visualised , probably spontaneous
pneumo-mediastinum due to asthma)
Minimal surgical Emphysema of neck
No bullae or Pneumothorax
MANAGEMENT
Tab. Levofloxacin 500 mg OD
Tab. Levocitrizine 5 mg h/s
Tab. Montelukast 10 mg h/s
Nebulise : Duolin bd
O2 therapy and Rest
HRCT after 2 weeks
REPEAT CT THORAX REPORT
Thin Linear streak of air seen in the prevascular
space involving the para-aortic and sub-aortic
region
Rest of the mediastinum shows no features of
pneumomediastinum
No subcutaneous emphysema seen in the deep
cervical spaces of neck
PNEUMO MEDIASTINUM
MEDIASTINAL CONNECTIONS
The mediastinum communicates with the sub-
mandibular space, retropharyngeal space and
vascular sheaths within the neck
It can also communicate with Retro peritoneum
via sternocostal attachments to the Diaphragm, as
well as the periaortic and perioesophageal fascial
planes
PULMONARY CAUSES
1. Rupture of alveolus with air dissection along
peribronchial vascular sheaths into the hilum
and mediastinum
2. Ruptured bleb with peripheral extensions
3. Sudden rise in intra pulmonary pressure:
a) Asthma
b) Forceful coughing
c) Artificial ventilation
d) Vomiting, Crying( in children)
TRAUMA
Rupture of trachea or main bronchus , usually via
accidental trauma
Trauma to the neck
BOERHAAVE’S syndrome
BAROTRAUMA
PRESENTATION
May complain of retro sternal chest pain radiating down
the both arms that is exacerbated by respiration and
swallowing
DYSPNOEA- in association with Asthma, Tension
Pneumothorax
FEVER- due to cytokine release with air leak
Dysphagia, Dysphonia, Neck swelling and Torticollis
PHYSICAL EXAMINATION
Sub cutaneous air
Oxygen saturations
Associated Pneumothorax
HAMMAN’S SIGN:
“CRUNCHING” sound heard over the apex of the heart
with every cardiac cycle in left lateral decubitus position
DIAGNOSTIC PROCEDURES
X-RAY CHEST
CT CHEST
Chest tube ( pneumothorax)
Bronchoscopy if Tracheo-bronchial perforation is suspected
Oesophagoscopy if an oesophageal perforation is suspected
MANAGEMENT
Usually no treatment is required , but the
mediastinal air will be absorbed faster if the patient
inspires high concentrations of oxygen
Percutaneous placement of mediastinal drains:
If the Mediastinal structures are compressed
MECHANICAL VENTLATION with low pressure or
Tidal volumes
FOLLOW UP
Patients should avoid strenuous physical activity
like weight lifting , scuba diving until resolution of
symptoms , for upto 6 months
MESSAGE……
Bronchial asthma not responding to conventional
therapy
Revise your diagnosis
Suspect ABPA
Rule out other Endo Bronchial Obstructive
pathologies
Remember the possibility of
“PNEUMO-MEDIASTINUM”