how to manage a wheezing patient
TRANSCRIPT
Thomas Kurian
How to manage a wheezing patientThomas Kurian
Thomas Kurian
Approach to a case
Thomas Kurian
Asthma should be considered likely
• episodic wheezing and other symptoms, such as cough and dyspnea
• respond favorably to conventional asthma medications
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Historical findings that may suggest that wheezing is NOT due to asthma or COPD
• sore throat• hoarseness• heartburn• sour taste and regurgitation• hemoptysis
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History
• ●Onset - foreign body aspiration • goiter compressing the airway or
endobronchial tumor • ●A history of neck or thyroid surgery – ? vocal cord paralysis• ●Prior intubation – • ? vocal fold trauma or paralysis, tracheal
stenosis, or tracheomalacia
Thomas Kurian
History
• ●dyspnea, wheeze, intractable (often barking) cough to the point of syncope, and recurrent pulmonary infections—
• tracheobronchomalacia and hyperdynamic airway collapse.
• ●Cigarette smoking more than 10 pack years • COPD• laryngeal or bronchogenic cancer
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History
• Respiratory symptoms in the minutes or hours after a single accidental inhalation of a high concentration of irritant gas, aerosol, or smoke ---
• reactive airways dysfunction syndrome (RADS)●Wheezing associated with a chronic or recurrent cough productive of purulent sputum may suggest bronchiectasis
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Physical examination
• oxygen saturation, and evidence of respiratory distress
• Chest and neck auscultation are used to differentiate stridor from wheezing
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Acoustic characteristics of wheeze
• •Polyphonic wheeze• •Monophonic wheeze
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Stridor is a type of monophonic wheeze, but its intensity and occurrence during inspiration help distinguish it from lower
airway monophonic wheezing
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Timing
• Expiratory wheezing-- neither sensitive nor specific for asthma
• Inspiratory wheezing-- neither a sensitive nor a specific sign of extrathoracic upper airway disease or obstruction
• In some patients with asthma, wheezing may only be heard during inspiration
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Focal wheeze
• persistently located in one area • foreign body in a segmental airway,
endobronchial tumor
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Thomas Kurian
Extrapulmonary findings
• Tonsillar hypertrophy is typically visible on oral exam.
• Neck - lymphadenopathy, thyroid enlargement, or a surgical scar is identified.
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• Spirometry• Flow volume loop
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Thomas Kurian
Thomas Kurian
Bronchoprovocation challenge
• A negative methacholine challenge test -strong evidence against asthma or RADS.
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Gas transfer
• P(A-a)O2 gradient on arterial blood gases • increased P(A-a)O2 gradient or a reduced
DLCO suggest small airway disease or lung parenchymal involvement
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Imaging
• A conventional chest radiograph is appropriate in most adults with new onset or refractory wheezing
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Chest CT
• vascular rings, aneurysms of the major vessels, mediastinal masses, or lymphadenopathy that compress the trachea extrinsically
• Tracheomalacia
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Thomas Kurian
HRCT
• bronchiectasis , mosaic ground glass attenuation
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Direct visualization
• At the time of visualization, biopsies can be obtained of intraluminal masses and plaques
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Bronchoscopy
• ●When the flow volume loop suggests extrathoracic obstruction, laryngoscopy is often the next step
• ●Flexible or rigid bronchoscopy
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2 year old child
• acute onset of breathlessness• Temperature, 37.4°C• respiratory rate, 40 breaths per minute• pulse, 110 beats per minute• blood pressure, 92/60 mm Hg• oxygen saturation, 80% on room air. • He had no nasal congestion, rhinorrhea, stridor,
or previous history of difficulty breathing.
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• Physical examination - tachypnea and suprasternal and subcostal retractions
• Left sided wheeze
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Thomas Kurian
• What is the probable diagnosis?
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Thomas Kurian
What should be done next?
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Treatment
• Rigid bronchoscopy
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What are the DD of wheezing in a child 1) INFECTION 2) ASTHMA:
• i) Transient wheezer • ii) Persistent wheezers • iii) Late onset wheezer
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3) Anatomic abnormalities a) Central airway abnormalities b) Extrinsic airway anomalies c) Intrinsic airway anomalies:
4) Immunodeficiency states
5) Mucociliary clearance disorders
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6) Aspiration Syndromes7) Heart Failure8) Anaphylaxis9) WALRI10) Drugs: Ibuprofen, Aspirin
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Clinical Manifestations
• HISTORY & PHYSICAL EXAMINATION - Birth history - Infection
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RISKS OF FAMILY HISTORY OF ATOPY
Single parent atopy : 22%Maternal Atopy : 32 %
Both parents atopic : 50%
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Diagnostic evaluationInitial evaluation depends on likely etiology 1. Chest Xray 2. Trial of bronchodilators
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Exclude other conditions
3) Structural problems: bronchoscopy 4) Esophageal disease 5) Primary ciliary dyskinesia 6) TB 7) Bronchiectasis 8) CF 9) Systemic immune deficiency10) Cardiovascular disease
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Treatment
1. Comfort the child2. Offer frequent liquids 3. Bronchodilators4. Ipratropium bromide5. Oral/ IV steroids6. Inhaled steroids7. Montelukast 8. No role of antibiotics
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36 year old obese female , came with history of shortness of breath, cough x 2 monthsHer symptoms were worse in the early morningHer symptoms vary over time and in intensityHer symptoms are triggered by laughter
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What is the probable diagnosis?
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These are typical of asthma- True / False
Chest painShortness of breath associated with dizziness, light headedness or peripheral tinglingChronic production of sputumSymptoms triggered by exercise, irritants such as car exhaust fumes, smoke
Thomas Kurian
These are typical of asthma- True / False
Chest painShortness of breath associated with dizziness, light headedness or peripheral tinglingChronic production of sputumSymptoms triggered by exercise, irritants such as car exhaust fumes, smoke
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What are the phenotypes of Asthma?
Allergic asthma Non allergic asthma Late onset asthmaAsthma with fixed airflow limitationAsthma with obesity
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How do you confirm the diagnosis?
PFT with reversibility
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For how long should SABA be withheld ?
4 hours
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For how long should LABA be withheld ?
15 hours
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In our patient the PFT revealed
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Pre-bronchodilator spirograph shows :FEV1/FVC : 38.39(Very low )FVC : 2.24 (72 % pred.)FET : 6.12 sec.
Diagnosis ?Obstructive airway disease
Post- bronchodilatation spirograph shows:Δ FEV1 : 290 ml (34%)
What is your final diagnosis ?Reversible airway obstruction-Bronchial Asthma
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Which is the other way in which Asthma may be diagnosed?
Excessive variability in twice daily PEF over 2 weeksPositive exercise challenge testSignificant increase in lung function after 4 weeks of anti inflammatory treatmentPositive bronchial challenge test
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What is stepwise management in a case of asthma?
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Our patient was started onMed to high dose ICS / LABA
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When do you say asthma is well controlled?
Day time symptoms not more than twice/weekNo night time wakingReliever needed not more than twice/week No activity limitation due to asthma
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How to step down treatment?
Once asthma control is achieved and maintained for 3 monthsStepping down ICS doses by 25-50% at 3 month intervals is feasible and safe
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What are the non pharmacological interventions?
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Non pharmacological interventions
Cessation of smoking and ETSPhysical activityAvoidance of occupational exposuresAvoid Medicines that make asthma worseBreathing techniques
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Non pharmacological interventions
Healthy diet Weight reductionBronchial thermoplastyAllergen immunotherapyAvoidance of outdoor and indoor allergens
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Inhaler techniqueNo 2 devicesChoose CheckCorrect Confirm
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ComorbiditiesObesityGERDRhinitis , Sinusitis , Nasal polyps
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Our patient came for follow up and is pregnant
In what percent asthma worsens?
Poor symptom control and exacerbations are associated with worse outcomes for both the baby and the mother
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After 6 months of delivery , she had worsening asthma,
and was put on high dose ICS
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During this treatment patient had a fracture of femur after
a fall from bikeWhat is the precaution?Why?
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After surgery , she was prescribed regular controller therapy, antibiotics
and analgesicsShe developed nasal congestion , anosmia, conjunctival ingestion
What is the clinical picture resembling?
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AERDAspirin challenge test is the gold standardShould avoid NSAIDs.
When NSAIDS are indicated substitute with COX- 2 inhibitorsICS are the mainstayDesensitization
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Male 30 year oldcough, breathlessness, wheezing and chest pain Fever , weight loss were also presentSymptoms are mostly nocturnalHe had hepato splenomegaly
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There was eosinophilia 4200 /um
ESR 70
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What is the relevance of place of residence?
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Thomas Kurian
What are the investigations to confirm
TPE?High serum levels of IgE filarial-specific IgE and IgG are found
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TPE (i) history suggestive of nocturnal symptoms
mainly cough and dyspnoea(ii) pulmonary infiltrates on chest radiograph(iii) leukocytosis with peripheral eosinophilia >
3000/µm(iv) elevated serum IgE and filarial specific IgG
and IgE(v) clinical improvement with DEC
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What is the treatment?DECSteroids
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PreventionAlbendazoleDEC
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An 83 year old female presents episode of weakness, breathlessness
orthopnoea
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Initial Clinical Findings
Airway – clear & patentBreathing – tachypnoeicCirculation – Pulse present, irregular,
tachycardic; skin colour normal, cap refill normalDisability – No LOC before ambulance arrival,
patient responding to verbal stimuli
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What is AMPLE history? AMPLE, Allergies, Medications, Past Medical History, Last
Eaten, Events Leading
AMPLE History A – Allergic to penicillin M – Currently taking Warfarin, Furosemide P – History of CVA x 1 year, CHF L – Last oral intake 7pm the evening previous E – Son stated patient became very weak before going to bed
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On examination
Pulse rate 110bpmPulse rhythm IrregularResp rate 24 per minute, regular, shallowWheeze + , basal crackles
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Thomas Kurian
SpO2% 89% @ room airCap Refill <2secsBP 178/112RBS normal
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Thomas Kurian
What is the treatment to be given?
GTN SL Furosemide 40mg O2CPAP Urinary catheterCPAP Therapy
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Investigations
3 Lead ECG 12 Lead ECG CXR Blood tests – to identify any electrolyte
imbalances etc.Urinary catheter
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Assessment Excessive sweatiness/clamminess Tachycardia Hypertension/hypotension in extremis Raised JVP Central cyanosis Tachypnea Basal respiratory crackles Wheeze Pitting ankle oedema ECG changes (old MI, ischaemic changes, indicative of previous
myocardial damage)
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15-year-old girl history of ‘poorly controlled asthma’ dyspnoea
on exertion and wheezeHer symptoms started after she was pushed
over while playing footballShe had been treated with inhaled
corticosteroids, short-acting and long-acting β2-agonists and a leukotriene receptor antagonist without improvement.
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Inspiratory stridor was noted on clinical examination
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Thomas Kurian
Speech and language therapy
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A 58-year-old woman was referred with ‘poorly controlled asthma’
She reported prolonged wheeze and chronic cough, was unresponsive to a range of inhaled therapies prescribed by her general practitioner
She worked as a hairdresser and was a non-smoker
She had no history of atopy. She had been treated for asthma for 4 years and had never been intubated.
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Inspiratory stridor was noted on clinical examination
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Thomas Kurian
The spirometric flow-volume loop showed truncation of inspiratory as well as expiratory flow-volume loops consistent with fixed upper airway obstruction
Bronchoscopy revealed fixed subglottic stenosis She was referred to an otorhinolaryngologist for
endoscopic repair.
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A 75-year-old man with a 20 smoking pack-years was referred with a 6-week history of worsening wheeze, cough, green sputum and dyspnoea on exertion.
Inspiratory stridor and expiratory wheeze were noted on clinical examination.
Thomas Kurian
Thomas Kurian
Thomas Kurian
CT of the thorax showed a large retrosternal goitre
Bronchoscopy revealed extrinsic tracheal compression
Thyroidectomy led to resolution of symptoms
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Take home message• ●For patients with rapid onset of respiratory distress
associated with wheezing or stridor, the key initial steps are to ensure adequate oxygenation and ventilation based on pulse oximetry and arterial blood gas measurement, followed by a rapid assessment made to determine the most likely cause.If asthma and COPD nebulized bronchodilator treatment
• If there is evidence of anaphylaxis, subcutaneous epinephrine should be given immediately.
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• ●For patients with impending respiratory failure and suspicion of central airway obstruction, endotracheal intubation by an experienced clinician should precede a diagnostic evaluation if the initial measures have failed to improve the situation
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1. Spirometry2. Flow volume loop3. Imaging of the neck and chest 4. Direct visualization of the airway is often
necessary
Thomas Kurian