ORAL CASE PRESENTATION

sayu

HSM/ 6.2 yrs/ Malay girl◦ Past medical history of bronchial asthma

Presented to A&E with cough and shortness of breath of 1/7◦ Cough preceded SOB by a few hours

no sputum production, no haemoptysis◦ Symptoms worse during the night therefore

transported to ED◦ Admitted to B3

Patient particulars

Other associated features:+Fever : low grade without chills and rigors+Runny nose +Sore throat +Wheeze

Negative findings◦ Haemoptysis◦ Facial pain◦ Post-tussive vomiting◦ Chest pain, Palpitations◦ Gastrointestinal symptoms (nausea, vomiting, diarhhoea)◦ Neurological manifestations (headache, syncope,

dizziness)◦ Genitourinary symptoms ◦ No LOW or LOA

PMH◦ Bronchial asthma since the age of 2◦ Frequency of exacerbations: 1 in 3 months◦ Last exacerbation: one month ago where the GP provided

nebuliser◦ Not on medication◦ First time requiring hospitalization◦ Triggers :

Cold air Respiratory infection Smoke, dust , pollution NOT exercise

◦ Symptoms: No day time or night time symptoms No hindrance to daily activity (plays as normal)

◦ History of atopy Has allergic rhinitis no eczema

PSH: none Drugs and allergies: none Family history:

◦ Mother, 34, secretary. No known medical illnesses◦ Father, 38, sales executive

History of childhood asthma Perinatal history:

◦ Uncomplicated SVD, to term, 3.1kg. Immunisation: up to date Development:

◦ Attending school◦ Alert. Good relationship with mother

Social history:◦ Adult diet◦ Father smokes in the house◦ Lives in an apartment with her parents and

elder sister (8 years, healthy)◦ No pets or carpets in the house◦ Her neighbor (cousin) had the “flu” few days

ago◦ Close quarters.

BP: 100/60 RR: 45 bpm HR : 140 bpm spO2: 98% Temp: 37.3C

Nebuliser administered 3X but no resolution Admitted to B3

Vital statistics at A&E

General appearance:◦ Patient propped in bed.◦ Patient looks tired and using accessory muscles to breathe. Can

talk few words at a time. ◦ Good nutritional status◦ On nasal prong O2◦ Tachypnoeic ◦ Branula inserted in left hand

Hands:◦ No peripheral cyanosis or clubbing◦ Warm peripheries◦ Tachycardia (120bpm)

Good volume◦ CRT<2s

Physical Examination

Face ◦ No conjunctival pallor◦ No engorged turbinates

Mouth◦ Mildly injected pharynx◦ No tonsillar hypertrophy◦ Tongue: mild dehydration, no cyanosis

Lymph node enlargement◦ bilateral; anterior cervical chain

Chest ◦ Lungs:

No chest wall deformities No tracheal deviation Air entry equal into both lungs Widespread rhonchi Occasional crepitations (more on R side)

◦ Cardiac: S1&S2 – no murmurs

Abdomen ◦ Soft and non-tender◦ No organomegaly

No skin lesions Other systems examination unremarkable

Relevant Investigations:◦ Pulse oxymetry: 98%◦ FBC

WBC 24.8 Neutrophils 91.9%

◦ BUSE ◦ CXR : hyperinflated lungs

PVD: acute exacerbation of asthma secondary to a upper respiratory tract infection

Monitor vital stats◦ to maintain sPO2 >95%

Nasal prong O2

Nebulised salbutamol every 4 hrs Prednisolone (15mg) Sy Penicillin 225mg QID

No signs of improvement! Repeat pulse oximetry showed sPO2: 91%

◦ IV hydrocortisone (QID)◦ Neb ipratropium (atrovent) 4hrly◦ Neb salbutamol 2hrly

Treatment

Can the addition of Montelukast help reduce the dosage of oral corticosteroid required for maintenance?

QUESTION 1

Anti-inflammatory properties◦ Less adverse side effects compared to

corticosteroids Relieves symptoms of seasonal allergies

Benefits of Montelukast

Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial

J Pediatr2009;155:795-800

Sept 2005- Feb 2008 Randomized double blind double dummy trial 130 children (ages 2-17 yrs) Mild to moderate acute asthma Subjects: stabilised in the ED and discharged by

the 8th hour Randomized into 2 groups

Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial

J Pediatr2009;155:795-800

Each patient receiving 2 tablets per dosage.◦ 63 patients: Oral Prednisolone + placebo◦ 67 patients: Oral Montelukast + placebo

Drugs to be taken at days 1,2,3,4, and 5 after randomization

Inhaled 500mcg albuterol every 4 hourly for 5 days

Inhaled 100mcg of fluticasone twice a day from day 7

Home visit at 48 hours to assess respiratory status

Home visit on the 8th day to assess primary outcome

PRIMARY OUTCOME:Treatment failure within 8 days Hospitalization Unscheduled visit related to asthma The need for additional corticosteroid

therapy

Proportion of patients remaining without additional therapy over time

Conclusion from study:◦ No comparable outcome for Montelukast◦ Montelukast has a higher rate of treatment failure

when compared to oral prednisolone

Children with mild-moderate asthma should continue oral corticosteroid after ssdischarge

Anti-Leukotriene Rc Antagonist has a milder anti-inflammatory effect.◦ Prednisolone exerts effect on T cell, eosonophils

and other inflammatory cells

Synergistic effect with LABA for optimum efficacy.

Discussion

Would the influenza vaccine benefit my patient in reducing future exacerbations of asthma?

QUESTION 2

Influenza is a common cause of hospitalization in asthmatic children.

The inactivated vaccine is 80% effective in preventing influenza in the general population.

However it is used only in approximately 10% of asthma patients

Influenza and asthma

-American Journal of Respiratory and Critical Care Medicine. 2004;169:488–493

Objective : to determine whether parenteral influenza vaccination is more effective than placebo in 6–18-year-old children with asthma.

DESIGN: randomized, double-blind, placebo-controlled trial◦ 347 children: vaccine, 349: placebo◦ Airway symptoms recorded in a diary and

according to a pre-defined severity score. At the score of 4, a throat swab was taken

Influenza Vaccination in Children with AsthmaRandomized Double-Blind Placebo-Controlled Trial

Primary outcome:◦ Number of asthma exacerbations associated with

virologically proven influenza infection. Throat swab

Secondary outcome :◦ Duration and the severity of each exacerbation◦ Adverse reactions to vaccine◦ Any upper respiratory tract symptoms◦ Unscheduled visit to family doctor

Results◦ Primary outcome:

It was 31% less in the placebo group (95% CI: -34% to 161% increase)

◦ Secondary outcome: Similar severity in both groups. 3.1 days shorter duration in the vaccine group.

(95% CI: -6.2 to 0.002 days) Adverse reactions seen significantly more in the vaccine

group (injection site erythema, stiffness of arm, myalgia)

Influenza vaccination did not result in asignificant reduction of the number, severity,

or duration of asthma exacerbations caused by influenza

For my patient: It is beneficial in preventing influenza

infection However, if my patient does get the

infection and thus the exacerbation, the course will be similar to the population who has not been vaccinated.

Ethical issue: Painful placebo injection administered Consent from parent for child