1. 1. Breathing Complications CCBS MD4 Clinical Case Camille Renee Dr. Mohamed Shata Dr. Rana Zeine May 26 2015
2. 2. Setting Clinic: Milton Cato Memorial Hospital - Accident & Emergency Department Supervising Physician: Dr. Rosmond Adams Date of Examination: May 10 2015 Image Source: iwnsvg.com
3. 3. Identification Data Male 11 years of age Onset of Condition: 12 hours prior to examination Image Source: nrls.npsa.nhs.uk
4. 4. History of Present Illness Recent cold and cough Family history of asthma Feelings of Malaise CC: Wheezing Image Source: ligorilaw.com
5. 5. History of Exposure and Treatment Medications taken in the last 4 weeks: Salbutamol Prednisone Nebulizer (Ventolin/Salbutamol) up to 3 times in hr. No recent contact with animals Home free of dander No history of injections
6. 6. Physical Examination Blood Pressure: 90/40 mmHg Temperature: 98.8 F Weight: 105 lbs Respiratory Rate: 28 Inspection, Palpation, Percussion, Auscultation HEENT: normal CNS function, EOM/TM intact, throat WNL, NC/AT Cardiac: chest pain, no wheezing, normal heart sounds Info Source: Bates Pocket Guide to Physical Examination
7. 7. Laboratory Investigations Pulse Oximetry Saturated Oxygen (SpO2): 95% Image Source: fact-canada.com
8. 8. Current Health Status Physician rated patients health status at 3/5 (Good). Image Source: analytics-toolkit.com
9. 9. Differential Diagnoses 1. Emphysema/COPD: Obstructive lung disease with poor airflow and the inability to expire properly 2. URTI: acute illness characterized by pharyngitis, rhinitis, whooping cough, sneezing, and sore throat. There is invasion of the mucosa by bacteria and/or viruses 3. Asthma: Obstructive and reversible condition with infiltration of airway walls. Coughing, wheezing, shortness of breath exacerbated by exercise, irritants, and viral infections. Info Source: Medscape.com
10. 10. 1. Emphysema Pink puffer, barrel-shaped chest Alevolar wall destruction and enlarged air spaces 1. Centriacinar: associated with smoking 2. Panacinar: associated with alpha1-antitrypsin deficiency Increased elastase causes increased lung compliance Patient will exhale through pursed lips to increase airway pressure Source: First Aid 2014
11. 11. 2. Upper Respiratory Tract Infection Most common acute illness Infections: nasopharyngitis, GAS, rhinosinusitis, epiglottitis, pertussis, laryngotracheitis, influenza, HSV, gonococcal pharyngitis, mononucleosis Invasion of upper mucosa: IgA- mediated and cellular immunity with inflammatory cytokines to initiate immune response Can lead to asthmatic exacerbations Info Source: Emedicine.Medscape.com Image Source: ificanucan.files.wordpress.com
12. 12. 3. Asthma Bronchial hyperresponsiveness causing reversible bronchoconstriction Smooth muscle hypertrophy Curschmanns spirals Charcot-Leyden crystals Can be triggered by viral URIs, allergens, and stress Info Source: First Aid 2014Image Source: HuffingtonPost.com
13. 13. Patient Diagnosis Acute Acceleration of Bronchial Asthma supported by patient history and current signs and symptoms. Tx: Patient to be nebulized with prednisone and Ventolin
14. 14. What is Asthma? Condition of bronchial hyperactivity and smooth muscle hypertrophy Leads to chronic inflammation condition of the airways associated with widespread reversible bronchospasm Between 4-8% of all adults are asthmatic. The prevalence is higher in children, elderly, and Hispanics/African Americans It is responsible for 10 million+ lost school/work days and $30 billion dollars spent on medical expenses per year https://www.youtube.com/watch?v=S04dci7NTPk Info Sources: Case Files: Internal Medicine & Emergency Medicine Image Source: wallstreetotc.com
15. 15. Two Phases, Two Types Early (immediate) Temporary and reversible bronchoconstriction after 10 minute exposure to irritant Peak bronchoconstriction occurs at 30 minutes and resolves within hours Tx: beta-agonists Late (delayed) Continued exposure to the irritant for 3-4 hours or refractory bronchoconstriction Presence of inflammatory cells, bronchial edema, and mucosecretion Tx: corticosteroids Info Source: Case Files: Emergency Medicine
16. 16. Extrinsic Asthma Type 1 Hypersensitivity in response to irritant 1. Sensitization: CD4 Th2 produces IL-4 and IL-5 cytokines IL-4 allows class-switching to IgE antibody IL-5 will initiate activation of eosinophils 2. Early Activation: Mast cells are activated and release histamine, leukotrienes, and acetylcholine Histamine causes bronchoconstriction, mucosecretion, and chemotaxis Leukotrienes further induce bronchoconstriction (LTC4, LTD4, LTE4) Acetylcholine causes parasympathetic-mediated bronchoconstriction 3. Late Activation: Eosinophils are activated Mediated by eotaxin and produces major basic protein aka proteoglycan 2 to cause bronchospasm and epithelial damage Source: MedBullets.com
17. 17. Intrinsic Asthma Non-allergen mediated Induced by: Viral infections: RSV, Rhinovirus, Parainfluenza, etc. Stress or Exercise Chemical Sensitivities: NSAIDs, ASA, oozone-produced free radicals May lead to Status asthmaticus Life-threatening asthma that does not respond to standard treatments Source: MedBullets.com
18. 18. Coughing is Usually the Only Symptom! Although wheezing is considered a classic sign of reactive airway disease, cough is often the only symptom (including during an asthmatic attack). During an asthmatic attack, look for these symptoms: Anxiety or fatigue Unable to speak in full sentences Use of accessory muscles Tripod position Info Sources: Case Files: Internal Medicine & Emergency Medicine Image Source: paramedicine.com
19. 19. Other Asthmatic Manifestations People with asthma eventually develop heightened sensitivity of their airways https://www.youtube.com/watch?v=v-qr78Wj4xM
20. 20. How To Diagnose Asthma Clinically Peak Expiratory Flow Spirometry can confirm airflow obstruction (reduced FEV1 and FEV1/FVC) Methacholine Challenge Used to diagnose bronchial hyperreactivity (positive: reversible with increase in FEV1 of 12% or more after administering bronchodilator) Severe asthma is defined as an FEV1 of less than 50% (30 breaths/minute) because of low I/E ratio Hypoxemia Pulsus paradoxus (decreased blood flow to the left heart due to lung hyperinflation) Mucous plugging Remember to assess: nature and duration of symptoms, medication and family history, and possible triggers. Info Source: Case Files: Emergency Medicine
21. 23. Gross Examination Postmortem Info Source: Dail and Hammars Pulmonary Pathology
22. 24. Histological Findings in Sputum Charcot-Leyden crystals: eosinophilic breakdown within mucous plugs Curschmanns spirals: mucous plugs from shedded epithelium Source: First Aid 2014, MedBullets.com
23. 25. Making the Right Diagnosis DDx Vocal cord dysfunction (exclude using laryngoscopy) Tracheal and Bronchial lesions or tumours (exclude using CT scan) Foreign bodies Pulmonary migraine Congestive heart failure (exclude by checking ECG and EF) Severe Sinus Disease (exclude using CT scan) Aortic Arch anomalies (check flow-volume) GERD (exclude by using scintigraph, PET, etc.) Patients with a smoking history of 20-pack years or more should be considered for COPD Info Source: Medscape.com Image Source: ishareimage.com
24. 26. What Can Trigger Asthma? Allergens (i.e. dust, mold, pollen, dander) Viral Infections Physical Activity Cold weather Stress GERD Changes in hormone levels Info Source: Case Files: Emergency Medicine Image Source: healthclips.com
25. 27. Managing Asthmatic Patients 1. Oxygen, Compressed Air, or Heliox 2. Adrenergic Agents 3. Anticholinergic Agents 4. Corticosteroids 5. LT Antagonists 6. Positive Pressure Ventilation Info Source: Case Files: Emergency Medicine
26. 28. 1. Oxygen Used to maintain SO2 of >90% Infants, pregnant women, and patients with heart disease are required to maintain an SO2 of 95% or more Oxygen, compressed air, OR a mixture of helium and oxygen (heliox) can be used as a delivery mechanism for other medications (nebulizer) Info Source: Case Files: Emergency MedicineImage Source: getwellsoon.com
27. 29. 2. Adrenergic Agents 2.55 mg albuterol/levalbuterol every 30 minutes for 1-2 hours (10-20 mg for severe asthmatics) Beta-2 agonists to decrease calcium and promote bronchial relaxation (plus anti-inflammatory) Albuterol may be combined with a metered-dose inhaler (MDI) with spacer device Inhalation may be substituted with epinephrine (0.3 to 0.5 mg) or terbutaline (0.25 mg) May be added to adrenergic agents to further improve pulmonary function e.g. Ipratropium bromide given via MDI with spacer device 3. Anticholinergic Agents Info Source: Case Files: Emergency Medicine
28. 30. MDI with spacer technique recommended for patients having difficulty using MDI only Image Source: fastbleep.com
29. 31. 5. Leukotriene Antagonists Zileuton (Zyflo Filmtab), zafirlukast (Accolate), montelukast (Singulair) improves FEV1 values Mostly used for patients with chronic or aspirin-induced asthma 4. Corticosteroids Suppresses inflammatory response Prednisone (40 to 60 mg) PO Methylprednisone (160 mg) IM for severe patients Beclomethasone, fluticasone, dexamethasone, hydrocortisone Info Sources: Case Files: Emergency Medicine, First Aid 2014 Image Source: dermnet.com
30. 32. 6. Positive Pressure Ventilation Bi-level positive airway pressure (BiPAP) is used for patients with severe asthmatic exacerbations (FEV1 30) prior to intubation BiPAP machine should be set to 8-15 cm H2O for inspiratory pressure and 3-5 cm H2O for expiratory pressure Rapid-sequence endotracheal intubation is given to patients near-comatose after a bolus of an induction agent (ketamine) and a paralytic agent (succinylcholine) ABG analysis is recommended during treatment to monitor patient recovery Info Source: Case Files: Emergency Medicine Image Sources: nlm.nih.gov, healthcare.philips.com
31. 33. Other Medications Long-acting 2-agonists for prophylaxis and patients with low response to short acting 2-agonists Salmeterol, Formoterol Methylxanthines to inhibit phosphodiesterase, causing bronchodilation Theophylline Muscarinic antagonists to prevent bronchoconstriction Ipratropium bromide Monoclonal anti-IgE antibody to block binding of IgE to FcRI (for patients with asthma resistant to steroids and beta-agonists) Omalizumab Info Source: First Aid 2014
32. 34. Info Source: Case Files: Internal Medicine
33. 35. Hospital Admission Criteria Patient should be admitted to a hospital if they fail to respond to therapy, have new-onset asthma, have had multiple prior hospitalizations, CAD, have impaired access to healthcare or intellectual disabilities Patient must be adapted to room air and moving around ED without complications FEV1 must be greater than 70% Prescribe albuterol or oral corticosteroids before discharging Patient education is recommended Patient should be referred for follow up appointment Info Source: Case Files: Emergency Medicine Discharge Criteria
34. 36. Patient Education Asthma self-management Peak flow self-monitoring techniques How to use inhalers Keeping surrounding environment allergen-free https://www.youtube.com/watch?v=4GIyZCNICLY Info Source: Medscape.com Image Source: fairview.org
35. 37. Case-Related Questions
36. 38. Question 1 A 24-year-old man is brought into the ED complaining of an exacerbation of his asthma. Which of the following is the most appropriate method of assessing the severity of his disease? a) Spirometry b) Measurement of the diffusion capacity of the lungs c) Measurement of the peak expiratory flow d) Measurement of the alveoli oxygen tension Info Source: Case Files: Emergency Medicine
37. 39. Answer C. The peak expiratory flow is a reliable and fairly accurate method of assessing asthma severity. Spirometry, although providing important information, is rarely available in the ED. Info Source: Case Files: Emergency Medicine
38. 40. Question 2 Severe asthma is defined as an FEV1 of less than: a) 10% b) 25% c) 30% d) 42% e) 50%
39. 41. Answer E. Severe asthma is defined as an FEV1 (forced expiratory volume in 1 second) of less than 50% (