| ID | 389 |
|---|---|
| Name | BRONCHIAL ASTHMA |
| Cause | Smoking and secondhand smoke. Infections such as colds, flu, or pneumonia. Allergens such as food, pollen, mold, dust mites, and pet dander. Exercise. Air pollution and toxins. Weather, especially extreme changes in temperature. Drugs (such as aspirin, NSAIDs, and beta-blockers) |
| Signs Symptoms | Shortness of breath. Chest tightness or pain. Wheezing when exhaling, which is a common sign of asthma in children. Trouble sleeping caused by shortness of breath, coughing or wheezing. Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu. |
| Diagnosis | Differential diagnosis Pulmonary tuberculosis, bronchiolitis, recurrent pneumonia, congestive heart failure tropical eosinophilia, gastroesophageal reflux, bronchienctasis, cystic fibrosis. |
| Investigations | Investigation: 1. CBC and total circulating eosinophil count to exclude tropical pulmonary eosinophilia (eosinophil count >20%, circulating eosinophil count >2000/cmm); blood eosinophilia (>250-400 cells/cmm) is usual in asthma. 2. Sputum for AFB and eosinophil- to exclude pulmonary tuberculosis, pulmonary eosinophilia/asthma. 3. Chest X-ray P/A view- to exclude pulmonary tuberculosis, consolidation, pneumothorax, pulmonary edema, foreign body in the airways. Hyperinflation and atelactasis is usual in asthma. 4. Pulmonary function tests (PFT): i. Spirometry (used in > 5 years old children): Airflow obstruction is indicated by reduced FEVi/FVC (< 80%). ii. PEFR: The PEFR value < 80% indicates airflow obstruction. This value is calculated considering the height of the child from peak flow chart (predicted or from personal best). iii. Reversibility test: It is done to differentiate obstructive defect from restrictive defect and to differentiate asthma. Reversibility can be found out by recording PEFR or FEVi before and 30 minutes after administration of Pa-agonist aerosol. An increase of 10% in PEFR or FEVi after aerosol therapy is strongly suggestive of asthma. Failure to respond, however, does not exclude asthma. iv. Variability tests: The PEFR is usually lowest in the morning (6.00 AM) and highest in the afternoon (6.00 PM) in asthmatic patients. PEFR measurements on morning & afternoon (for -1 wk) before treatment can establish diurnal variability. Increases in variability of > 30% on an average, indicate increased bronchial responsiveness & worsening asthma. 5. ECG/Echocardiography to exclude cardiac diseases. 6. Arterial blood gas analysis (PC>2, PCCh) and pH. |
| Management | Treatmant Management of bronchial asthma includes - A. Treatment of acute attack. B. Treatment of chronic bronchial asthma. C. Treatment of special variant asthma. A. Treatment of acute asthma exacerbation: Treatment of mild acute asthma: Clear the airway (secretion, if any). Inhaled salbutamol: 1 puff stat, another one after 5 min, then 1-2 puffs 3-4 hourly for the next 12-24 hours. Spacer is preferable. If inhaled salbutamol is unavailable, give oral salbutamol 0.2-0.4mg/kg/day 6-8 hourly divided doses for the next 12-24 hours. If no improvement after 24 hours, advice for hospitalization for further management. 2. Treatment of moderate acute asthma: Inhaled salbutamol with spacer 2 puffs stat and then every 20 mins. for 3 times. If improvement occurs continue salbutamol inhaler 2 puffs 2-4 hourly for 24-36 hours. If salbutamol inhaler is not available or no improvement with inhaler, give nebulized salbutamol 0.15-0.30mg/kg/dose (at home or health centre). If improvement occurs continue salbutamol inhaler 2 puffs 2-4 hourly for 24-36 hours. If improvement continues with the above measure, but wheeze still persists after 24-36 hours, add oral prednisolone l-2mg/kg/day in 3 divided doses for 3 days. If improvement continues and no wheeze following salbutamol inhaler alone or with prednisolone (for 3 days), discontinue inhaler but maintain other advices, such as- avoid allergens, cold, exercise and other inducing agents etc. If no improvement with nebulized salbutamol or following prednisolone treatment (for 3 days) in addition to inhaler, advice hospitalization for further management. 2. Treatment of Severe Acute Asthma: i. Immediate hospitalization. ii. Propped up position, iii. Humidified 0)2 inhalation 4-6 1/min by nasal prongs or mask. iv. Nebulized Salbutamol 0.15-0.30mg/kg/dose (max. 5mg) in 3-4ml normal saline every 20 minutes or continuously at 0.5mg/kg/hour. v. Inj. Hydrocortisone 3-4mg/kg/dose 4-6 hourly; Or, Inj. Methylprednisolone Img/kg/dose every 6 hour for 48 hours followed by l-2mg/kg/day in 2 divided doses until PEFR 70% of personal best or predicted; Or, Prenisolone 2mg/kg startig dose orally and then Img/kg 6-12 hourly orally for 3-10 days. If adequate response, then inhaled salbutamol 2 puffs 2-4 hourly for 3-5 days and oral prednisolone l-2(mg/kg/day fo;r 3-10 days. If response in inadequate, then add ipratropium bromide every 20 mins. 3 daoses & then 2-4 hourly (dose < 2 years: 250ug, > 2 years: 250-500ug). If no improvement occurs then add- Inj. Aminophylline 5mg/kg bolus dosage over 20 mins. and then 0.5-0.7mg/kg/hour; Or, Inj. Salbutamol 15mg/kg bolus and then 0. lug/kg/min. If no improvement occurs by above measures, then referred to ICU care. If ICU care is available give ICU care and ventilatory support. If ICU care is not available, then use Inj. Epinephrine (1:1000) 0.1 ml/kg (max 0.3ml) s.c every 15 min for 3 doses. vi. Inj. MgSO4 (50%) 50mg/kg/dose (max. 2gm) in 30ml normal saline slowly in 30 mins. General management: 1. Dehydration (if any), must be corrected by dextrose saline. Potassium may be given if hypokalemia develops. Usually more than 1-1.5 times maintenance level of fluid should be given. Care should be taken not to overhydrated the patient. 2. Routine administration of antibiotics are not needed. But, if there is consolidation on chest X-ray, blood neutrophilia, or presence of coarse crepitations or bronchial breath sounds give antibiotics, such as erythromycin or amoxycillin. 3. Chest X-ray should be obtained in all severe cases or when mediastinal emphysema, pneumothorax or pneumonia are suspected. 4. Sedation is hazardous. Tranquillizers, morphine & other opiates are contraindicated because of their depressant effect on respiratory centre. 5. Rarely, respiratory failure may require intermittent positive pressure respiration, bronchial lavage, bronchoscopic aspiration, etc. Sings of respiratory failure: Barely audible wheezing and breath sound; minimal thoracic movement with hyperinflation; depressed level of consciousness and response to pain. Cyanosis in 40% ambient 02 or Pa02 < 50 mm Hg in 100% inhaled O2. PaCO2 > 60mm Hg. C. Treatment of special variant asthma.17 1 Exercise induced asthma (EIA): To prevent EIA, normal dose of salbutamol inhaler or cromolyn inhaler should be taken immediately before starting exercise. This will give 2-3 symptom free hour. If any attack occurs, 2-4 puffs should be taken immediately. 2 Seasonal asthma: Seasonal asthma should be treated according to stepwise approach. Anti-inflammatory therapy (inhaled corticosteroids, cromones) should be initiated daily prior of the anticipated onset of symptoms and continued through the season. 3 Drug induced asthma: Avoidance of triggering drug (e.g aspirin, (3-blocker etc.) is mandatory. Leukotriene antagonists (e.g Montelukast) may be used. (Montelukast: Dose: Children 2-5 year of age, 4mg chewable tablet at bed time; 6-14 year of age, 5mg tablet; > 15 year of age, lOmg chewable tablet at bed time). |
| Introduction | Bronchial asthma is a chronic inflammatory disorder causing hyperresponsiveness of airways to certain stimuli resulting in recurrent airflow obstruction, presenting as wheezing, breathlessness, chest tightness & coughing. |
| History | |
| Etiology | refer under cause |
| Clinical Features | Clinical features: Clinical Mild Mild Moderate Severe features Intermittent Persistent Persistent Persistent Days with symptoms < 2/week 3-6/week Daily Continual Nights with symptoms < 2/month 3-4/month > 5/month Frequent PEFRorFEV1 > 80% > 80% > 60% - < 80% <60% PEFR variability <20% 20-30% > 30% > 30% |
| Preventions | Follow asthma action plan. ... Get vaccinated for influenza and pneumonia. ... Identify and avoid asthma triggers. ... Monitor Patients breathing. ... Identify and treat attacks early. ... Take your medication as prescribed. ... Pay attention to increasing quick-relief inhaler use. |
| Treatment | Fluticasone propionate , budesonide, ciclesonide , beclomethasone, mometasone and fluticasone furoate Bronchodilators |
| Complications | Insomnia, fatigue, physical inactivity and weight gain, the flu, mental health conditions, pneumonia, obstructive sleep apnea, and side effects from medication. In some cases, untreated asthma can lead to hospitalization, respiratory failure, and death. |
| Prognosis | |
| Types | Allergic asthma. Aspirin-induced asthma. Cough-variant asthma. Exercise-induced asthma. Nighttime asthma. Steroid-resistant asthma. Occupational asthma. |
| Classification | Classification: According to frequency of symptoms, severity of attack and pulmonary function test (PFT) abnormalities, asthma is classified into four groups: 1. Intermittent asthma: In between the attacks patient is symptom free and PFT is normal. 2. Persistent asthma: Frequent attacks (> 2/month), in between the attack, patient may or may not be symptom free. PFT is abnormal except in mild persistent variety. 3. Acute asthma exacerbation: Loss of control of any class or variant of asthma which may cause mild to life threatening attack. This is further classified as-i. Mild acute asthma, ii. Moderate acute asthma, iii. Severe acute asthma (status asthmaticus). Severe acute asthma (Status asthmaticus): This term has replaced ‘status asthmaticus’ as the description of life-threatening attacks of asthma, characterised by respiratory distress and arterial hypoxemia which does not respond to usual bronchodilators. When an acute attack of asthma becomes severe & life-threatening, the patient will have ceased to show any response to bronchodilator aerosols. It is a potentially fatal condition that demand agressive treatment & careful monitoring. Death may occur from respiratory arrest. Hospitalization is the must. A careful analysis of arterial blood is necessary for pO2, pCOz & PH. 4. Special variant asthma: 4.1 Exercise induced astnma (EIA): EIA usually occurs during or few minutes after vigorous activity. Reaches its peak 5-10 minutes after stopping the activity, and usually resolves in another 20-30 minutes. An exercise challenge test can be used to establish the diagnosis. 4.2 Drug induced asthma: Some drugs e.g Aspirin may cause asthma symptom to appear by blocking cyclo-oxygenase pathway of arachidonic acid metabolism, leading to enhancing lipooxygenase pathway to produce enough leukotriens to aggravate asthma. b-blocker e.g atenolol, propranolol may also cause bronchospasm. 4.3 Seasonal asthma: Some patients experience asthma symptoms only in relation to certain pollens and molds appearing in the environment during a specific season. 4.4 Cough variant asthma or eosinophilic bronchitis: Common in young children, presents with chronic cough and sputum eosinophilia, but PFT is normal. Monitoring of morning and afternoon PEF variability and/or therapeutic trial with anti-inflammatory drug or bronchodilator may be helpful in the diagnosis. |
| Observation | |
| Pathology |
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