Download - Acute Management of Bronchial Asthma 2
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Acute Exacerbation of Bronchial
AsthmaBy Tengku Abdul Kadir B Tengku
Zainal Abidin.
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A&E HSNZ at 7:30pm
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CASE STUDY
Elisya, a 5 year old girl with underlying bronchialasthma since 1 yo on MDI Budesonide 200 mcg BDand MDI Salbutamol 2 puffs PRN came with c/o
rapid breathing since 3 pm today
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The parents brought the patient to KK
Seberang Takir at 5 pm after the symptoms
were not relieved after taking 4 puffs of MDI
salbutamol. At KK Seberang Takir, she was
given neb Ventolin x 2, but still had rapid
breathing thus was referred to HSNZ
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What further questions do you want to ask ?
What are the differential diagnoses? What are you going to do next?
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From the hx, there is no URTI sx, no
fever, patient was still active andtolerating orally well before the
episode of rapid breathing
Patient had hx of visiting her uncle
today at 2pm and was exposed to
cigarette smoke from her uncle. She
developed rapid breathing after
that.
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Interval symptoms
Last exacerbation was in November last year
No nocturnal cough
No daytime symptoms No need for reliever since last exacerbation
Patient was active, no exercise induced sx
Symptoms usually precipitated by URTI, coldweather or exposure to cigarette smoke
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From the physical examination, patient was alert, goodcry, mildly tachypnoeic with mild subcostal recession,pulse volume good and capillary refill immediate
Vital signs:
BP 98/50 HR 110
RR 40
spO2 97% under NPO2 2L/min
Lungs: A/E equal, PEP, no crepts, bilateral rhonchi CVS: S1S2 No murmur
PA: Soft, not distended, non tender
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This patient was given neb Ventolin x 1. 1 hour
post neb, patient still had rapid breathing but
she was less tachypnoeic and was able to talk
to her mother
i i i
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Do you want to a mit t is c i
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Criteria for admission
failure to respond to standard home treatment
failure of those with mild or moderate acute
asthma to respond to nebulised -agonists
relapse within 4 hours of nebulised -agonists
severe acute asthma
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In 6EF, patient was put under NPO2, was
given neb Ventolin 2 hourly, neb Combivent
4hourly, IV Hydrocortisone 4mg/kg stat then
qid for one day
Patients condition improved after 4hours, was
less tachypnoeic, able to tolerate orally and
able to sleep comfortably. The lungs hadminimal rhonchi with no crepitations.
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Initial steps for assessment
Diagnosis
- symptoms e.g. cough, wheezing, breathlessness,pneumonia
Triggering factors- food, weather, exercise, infection, emotion, drugs,aeroallergens
Severity- respiratory rate, colour, respiratory effort,conscious level
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Ref: Paediatric Protocol 2nd Edition Page:95
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Management Consideration
monitor pulse, colour, PEFR, ABG and SpO:
close monitoring for at least 4 hours
hydration - give maintenance fluids
antibiotics indicated only if bacterial infection
suspected
avoid sedatives and mucolytics
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Ref: Paediatric Protocol 2nd
Edition Page:96
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Medication given
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On discharge, patients must be provided with
an Asthma Action Plan to assist parents or
patients to prevent/terminate asthma attacks.
The plan must include:
- how to recognize worsening asthma
- how to treat worsening asthma
- how & when to seek medical attention
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Take home message
Good initial assessment based on diagnosis,
triggering factors and severity
Initial treatment with oxygen and medication
Discharge patient with Asthma Action Plan
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References
Paediatric Protocol For Malaysian Hospitals 2ndedition
GINA guidelines of Bronchial Asthma
Classifying Asthma Severity and TreatmentDeterminants : National Guidelines Revisitedby R Khajotia MBBS (Bom), MD (Bom), MD
(Vienna), FAMA (Vienna), FAMS (Vienna).International Medical University, Seremban,Malaysia
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THANK YOU!
ANY QUESTIONS? NO? GOOD!