pathology conference on asthma
TRANSCRIPT
FIRST CLINCOPATHOLOGICAL
CONFERENCE17th Batch
February 26, 2016
Elishbah Naveed Abila Shakoor Ammmara Mahroof Awab Hassan Ali Raza Bahroz Khan
PRESENTERS
Case Presentation
“Parween Bibi”, a 35 year old married female, from Garhi Habibullah, came to King
Abdllah Teaching Hospital, Mansehra on 22 feb,2016 at 10:00 a.m in OPD. She
presented with complaints of fever for 2 days ,cough for 1 day, breathlessness
for 2 hours. She was conscious and well oriented. Overall health state was
weak
HISTORY
Parveen Bibi
Name: Parveen Bibi Sex: Female Age: 35 Years Marital Status: Married Children: 3 (2 sons, 1 daughter) Occupation: Housewife Address: Garhi Habibullah, Mansehra Date of Arrival: 22 Feb 2016 Time of Arrival: 10am Mode of Admission: OPD
History of Patient
Fever (last 2 days) Cough(1 day)Breathlessness(2 hours)
Chief Complaints
Our patient was alright 2 days back, then she developed fever which was gradual on onset, low grade (99 F documented). Fever was intermittent with diurnal variations.
Fever was associated with cough, palpitations and breathlessness.
Upon arrival to hospital patient had an episode of vomiting. There was no history of unconsciousness.
Fever was relieved by taking anti-pyretics (Parectomol).
History of Present Illness
Patient developed a cough one day back which was gradual in onset, patient had several episodic attacks of cough which lasted for 15 minutes.
Cough was productive, sputum was white in color, scanty.
Cough aggravates upon lying down and is relieved on sitting position.
Associated with chest discomfort and fever.
History of Present Illness
Patient developed breathlessness for the last 2 hours which was gradual in onset.
Breathlessness was also present at rest and aggravated upon exertion.
It was associated with: Cough Fever Palpitations
History of Present Illness
Systemic Inquiry:
1. General A. Reduced AppetiteB. Disturbed SleepC. Weakness & Lethargy
History of Present Illness
Respiratory System Inquiry:1. Cough 2. Respiratory wheeze
History of Present Illness
Alimentary System:◦ No remarkable findings
Urinary System:◦ No significant history
ON SYSTEMIC INQUIRY THERE WERE NO OTHER REMARKABLE FINDINGS
History of Present Illness
Past Medical History:◦ Patient has been asthmatic for last 15 years◦ No other major illnesses reported
Past Surgical History◦ No significant past surgical history
History of Past Illness
Positive for Asthma.
Patient’s mother has asthma.
Patient’s daughter has asthma as well
Family History
No history of smoking tobacco
Leading a healthy & active lifestyle
With regular bowel habits
Personal History
Her SES was satisfactory
She lives in her own house of 4 rooms with her 6 family members
Socioeconomic History
Patient was prescribed the following drug regimen for her asthma:◦ Salbo inhaler (Salbutamol)◦ Tab Montiget (Montelukast)◦ Tab Profylline (Doxofylline)
Patient’s compliance to drug was poor.
Drug and Treatment History
According to patient she is not allergic to any specific allergen but exposure to cold weather worsens her condition.
Allergic History
Bronchial Asthma
Emphysema
COPD
Bronchiectasis
History based Diffrential Diagnosis
Patients general appearance◦Pale and anxious
General Physical Examination
Vitals-
◦B.P: 110/90 mm/Hg ◦Pulse: 86 bpm◦Temperature: 99 F◦Respiration: 26 breaths per minute
General Physical Examination
No clubbing
No peripheral / central cyanosis
Eyes: Anemia not indicated
Jaundice was not present
General Physical Examination
Dental hygiene good
No abnormality seen on thyroid examination
Lymph nodes not palpable
Pedal and sacral edema absent
No other significant findings
General Physical Examination
1. CVS Systemic Examinationa. Inspection:
• No Chest deformity• No sternotomy or any other surgical scar
b. Palpation: Apex beat: Normal
c. Auscultation:S1 + S2 + 0
• No added sounds• No murmurs
Systemic Examination
b. Respiration:Inspection
Chest Wall Movement: RegularRespiratory Rate: Increased (26 breath/min)No external deformityNo scars
Palpation:Position of Trachea: No tracheal shift
Local Tenderness: Not present
Systemic Examination
Percussion: Percussion note: Resonant
Auscultation:Vesicular breathing with prolonged
expirationOccassional respiratory wheeze
Few Ronchi
Systemic Examination
c. GIT: INSPECTION:
Shape, contour, movement were normalUmbilicus central and invertedScars, striae and prominent veins absent
PALPATION: Abdomen is soft and non tender
There is no palpable mass Liver not palpable
• Spleen not palpable• Ascites not present
Systemic Examination
c. GIT: AUSCULTATION:
Bowel Sounds were presentPALPATION:
Abdomen is soft and non tenderThere is no palpable mass
Liver not palpable• Spleen not palpable• Ascites not present PERCUSSION: No significant findings.
Systemic Examination
c. CNS: Patient was conscious, oriented well with space, time and place.
Systemic Examination
1. Following investigations were performed1. Chest X-Ray (PA view)2. Complete Blood Picture3. Urine RE
2. Specialized investigations like spirometry and PFT were not done due to non availability in the hospital.
Investigations
Findings:
There were no significant findings on X-Ray Exam
Chest X Ray
Complete Blood Picture
Complete Blood Picture Findings:
Mild Leucocytosis
CHRONIC ASTHMA EXACERBATED BY MILD RESPIRATORY INFECTION AND NON COMPLIANCE TO DRUGS
Investigations based diagnosis
Upon her arrival to the hospital the patient’s acute symptoms were relieved by:
O2 inhalation @ 2 lit/min Nebulization with Ventoline(Salbutamol)
every 4 hourly for 10 mins. Nebulization with Atem(Ipratropium
bromide) x B.D Nebulization with Clenid (corticosteroid) x
B.D
Management
After the relief of her acute symptoms, patient was advised to continue this drug regimen:◦ Tab Paracetamol- 1Tab x SOS◦ Tab Moxiget (Moxifloxacin) 400mg x O.D◦ Tab Myteka (Montelukast) 10 mg 1 x at night◦ Tab Delracortil (Prednislone) 5mg 3+0+3
For the 1st 3 days then 2+0+2 for 2 days then 1+0+1 for 1 day (as we have to taper off steroid slowly) Tab Hydraline 1 tsp x TDS
Management
Patient was discharged after 4 days and was asked to come for a follow up after 2 weeks.
Management
Asthma is clinically defined as:
“A chronic inflammatory reversible disorder with air way hyper reactivity and variable air obstructions”
Definition
Epidemiology of Asthma
Asthma is a global health problem Worldwide more than 350 million people are
suffering from asthma. Approximately 250,000 people die from
asthma each year
Epidemiology
Asthma is more common in women than men.
In contrast young boys are affected more than young girls.
Hygiene hypotheses is implicated in the increasing incidence of asthma
Epidemiology
This hypothesis has been proposed by scientists to explain the rise in incidence of asthma.
The hypothesis states that the eradication of infections has altered the immune homeostasis and promote allergic and other harmful immune responses
Hygiene Hypothesis
Infections Allergies
This hypothesis has been proposed by scientists to explain the rise in incidence of asthma.
The hypothesis states that the eradication of infections has altered the immune homeostasis and promote allergic and other harmful immune responses
Hygiene Hypothesis
Infections Allergies
Asthma has a global distribution with a relatively higher burden in North America and Middle East
Among people aged less than 45 years most of the burden of disease is due disability.
Burden of Asthma
Infections Allergies
The burden of asthma measured by disability and premature death is greatest in children approaching adolescence and the elderly.
Burden of Asthma
Infections Allergies
Pathophysiology of Asthma
Asthma is clinically defined as:
“A chronic inflammatory reversible disorder with air way hyper reactivity and variable air obstructions”
Definition
Asthma is associated with
Palpitations Breathlessness Wheezing Chest tightness Cough Increased mucus secretion
Pathophysiology of Asthma
Indoor and outdoor allergens Microbial exposure Diet Vitamins Tobacco smoke Air pollution
Environmental Factors Triggering Asthma
Asthma is divided into:◦ Extrinsic Asthma ◦ Intrinsic Asthma
Less common types include:◦ Drug-induced asthma (most commonly from Aspirin)◦ Occupational Asthma
Classification
Asthma is clinically divided into 4 categories for the purposes of treatment:
◦ Intermittent Asthma◦ Mild Persistent Asthma◦ Moderate Persistent Asthma◦ Severe Persistent Asthma
Clinical Classification
Early and Late Mediators of Asthma Early Mediators
◦ Histamine◦ Proteases◦ Chemotactic Factors◦ Prostaglandins ◦ Leukotrienes
Late Mediators◦ Cytokines
(IL4, IL5, IL13)
Extrinsic Asthma (Atopic Asthma):◦ It is the most common type of asthma.◦ It is a Type 1 Hypersensitivity reaction due to
exposure to extrinsic allergens.
Pathophysiology of Asthma
Pathogenesis of Extrinsic Asthma:
Sensitization of airway to allergens: Stimulates production of subset 2 helper T cells
(CD4 TH2) CD4 TH2 release interleukins IL-4 and IL-5 IL-4 stimulates isotype switching to IgE production IL-5 stimulates production and activation of eosinophills
Extrinsic (Atopic) Asthma
Re-exposure of airway to allergen:◦ Exposure stimulates IgE antibodies that illicit
two responses: Acute Response:
1. Antigen cross link IgE antibodies on mast cells. 2. This results in release of histamine and other
mediators. 3. Histamine causes bronchoconstriction. 4. Other mediators cause mucus production and
leucocyte influx
Extrinsic (Atopic) Asthma
Late Response: Occurs 4-8 hours later
Mediated by leucocytes recruited by chemo tactic factors and cytokines
Results in damage to epithelial cells and airway constriction
Extrinsic (Atopic) Asthma
After chronic attacks of asthma there is airway remodeling characterized by: Hypertrophy of bronchial smooth muscle There is mucous production and Increased vascularity There is deposition sub epithelial
collagen
Airway Remodelling
This is asthma not associated with allergy. It is commonly seen in old age group It has unknown mechanism but may be
caused by: Viral Respiratory Infections Stress Exercise Cold Temperature
Intrinsic Asthma
Asthma attack that occurs in response to intake of certain drugs
Aspirin and NSAIDs are commonly implicated in sensitive people.
Drug Induced Asthma
Mechanism: Aspirin inhibits cyclooxygenase
pathway of arachidionic acid metabolism. But it does not effect the lipooxygenase route.
Thus Aspirin shifts the balance of factors towards leukotrienes thus causing bronchospasm
Drug Induced Asthma
Asthma in response to fumes and chemicals.
Epoxy resins, chemical dusts, penicillin products are implicated/
Occupational Asthma
This type of asthma comes in the form of acute attack following exercise and stops after 30-40 minutes
It worsens in cold and dry climate
Exercise Induced Asthma
IgE Mediated Type 1 HS
Clinically defined as◦ “An acute exacerbation of asthma that remains
unresponsive to initial treatment with bronchodilators.”
1. It is a medical emergency2. It has very life threatening complications like
hypercapnia
Status Asthmaticus
Wheezing Coughing Shortness of breath Chest tightness/pain
Clinical Features of Asthma
Diagnosis is established when following criteria is fulfilled◦ Episodic symptoms of airflow obstruction are
present◦ Airflow obstruction or symptoms are at least
partially reversible◦ Exclusion of alternative diagnoses
Diagnosis
Investigations Of Asthma
Investigations that can help in the diagnosis of Asthma can be broadly divided into 3 categories:◦Physical Exam: This includes a “Complete Physical
Examination” as well as patient interview about S&S.
◦Pulmonary Function Tests: This includes Spirometry & Peak Flow studies.
◦Miscelleaneous: 1. Chest X-Ray2. Methacholine Challenge Test3. Allergy Tests4. Sputum Eosinophills
Investigations Useful For Asthma
A physical exam of respiratory system is the first investigation.
Physical exam begins with a detailed interview about the patient’s signs and symptoms.
The physician has to note chest wall movements, any external deformities etc.
Auscultation can provide very useful clues in reaching the diagnosis.
Physical Exam
Chest X-Ray is the initial investigation for asthma.
In most asthmatic patients X-Ray findings are normal.
The value of chest radiography is in revealing complications or alternative causes of wheezing.
Chest X-Ray
Pulmonary function tests determine how much air moves in and out as a person breathes.
The most common test done in this category is Spirometry.
Pulmonary Function Tests
In spirometry patient is asked to breath deeply and then exhale forcefully.
Patient’s nose is blocked using a nose clip. Test is repeated 3 times to ensure accurate
test results. Spirometry is not useful for very young
children or comatose adults.
Spirometry
Video Demonstration of Spirometry
In this test patient breathes nebulized methacholine or histamine
Methacholine causes contraction of bronchioles in asthmatic patients
This test can help in differentiation between COPD and Asthma
Methacholine Challenge Test
Sputum eosinophills are a good indicator of severity of asthma.
Eosinophilia can indicate active asthma. This count is specially elevated in atopic
asthma. Blood eosinophilia greater than 4% is
supportive of a diagnosis of asthma. Inflammation in asthma is characterized by
influx of eosinophils.
Sputum/Blood Eosinophills
Anti-Asthma Drugs
It is said about Asthma that it is a disease in which with the ◦ right patient ◦ the right clinician◦ right drug regimen patient can be completely free
of symptoms
DRUGS USED IN TREATMENT OF ASTHMA
Mechanism of Action: These drugs attach to B2 Receptors and dilate the bronchioles
Form: Available in inhaler and pill configuration
Sympathomimetics
Side Effects: Tremors, Palpitations, Dizziness
Commonly used drugs: Salbutamol, Formetrol
Sympathomimetics
Mechanism of Action: Anticholinergic drugs inhibit bronchospasm caused by Vagus Nerve stimulation
Form: Available in inhaler and pill configuration
Anticholinergic Drugs
Side Effects: Dry mouth and mouth edema
Common Drugs: Ipratropium, Tiotropium etc
Anticholinergic Drugs
Mechanism of Action: Methylxanthines are derivatives of plants. They cause relaxation of bronchial smooth muscle
Form: Pills
Methylxanthines
Side Effects: Palpitations, tremors, arrythmias
Common Drugs: Theophylline, Aminophylline
Methylxanthines
Mechanism of Action: Corticosteroids reduce the hyper reactivity of the respiratory tract to various stimuli. They also reduce inflammation.
Form: Pill and Inhaler
Corticosteroids
Side Effects: Weakness, weight gain, oral thrush
Common Drugs: Beclomethasone, Fluticasone
Corticosteroids
Mechanism of Action: These drugs inhibit the leukotrienes which are mediators of inflammation. They are effective in bronchial asthma.
Form: Pills
Leukotriene Antagonists
Side Effects: Allergic Reactions, edema, irritablility and drowsiness
Common Drugs: Montelukast, Zafirlukast
Leukotriene Antagonists
Mechanism of Action: They inhibit the release of histamine from mast cells.
Form: Inhaler and pills
Mast Cell Inhibitors
Side Effects: Allergic Reactions, edema, irritablility and drowsiness
Common Drugs: Nedocromil, Cromolyn sodium
Mast Cell Inhibitors
Mechanism of Action: It is a new type of asthma treatment, it is prepared in genetically modified mice. It inhibits the binding of IgE on mast cells.
Form: IV/SC Injections Side Effects: Reaction to antibody can
occur
Anti IgE Antibody - Omalizumab
Clinically for the purposes of treatment Asthma is divided into 4 different categories.
Intermittent Asthma Symptoms less than 2 days per week
Mild Persistent Asthma Symptoms more twice a week
Moderate Persistent Asthma Daily Symptoms
Severe Asthma Continual Symptoms
Treatment Guidelines for Asthma
Intermittent AsthmaSymptoms less than 2 days per week
Mild Persistent AsthmaSymptoms more than twice a week
Moderate Persistent AsthmaDaily Symptoms
Severe AsthmaContinual Symptoms
Status Asthmaticus is an acute attack of asthma that is un responsive to bronnchodilators.
It is a medical emergency It carries a very high risk of death Lets discuss the management of Status
Asthmaticus
Status Asthmaticus
Management Guidelines Patient is admitted in ICU and put on oxygen
therapy. Oxygen saturation should not come below 95%
Patient is given IV or SC Adrenaline to dilate the bronchioles.
Patient is then given systemic Salbutamol infusion. If there is stabilization of patient then he is allowed
to go home with prescription of 2 weeks of:◦ Systemic Corticosteroids (Prednisone 50mg daily)◦ Inhaled Corticosteroids◦ Inhaled B2 Agonists◦ Inhaled Anticholinergics
Patient must strictly come for follow up every 2nd day until his condition improves.
If these treatments fail then patient is given general anesthesia through use of Ketamine and Succinyl Choline. This relaxes the muscles and the condition may stabilize.
Management Guidelines
Many patients do not even require any drug treatment
Every case of asthma is unique and has their own precipitating factors.
Patients are advised to avoid these precipitating factors, and avoid allergens etc.
Preventative Measures
Asthma is a serious health problem that is increasing in incidence worldwide.
Although no cure is possible it can be managed well if the patient strictly adheres to the treatment regimen.
A short video summary to summarize asthma.
Ending notes.
Summary
Video Summary
Thankyou