History Miss A, 22 year old Malay lady, known case of bronchial asthma, presented at ED with shortness of breath for

3 days prior to admission. It was sudden in onset and gradually become worsening towards the end of the day. It not relieved after having MDI salbutamol 4 hourly and it became severe until patient having difficulty to talk normally. The shortness of breath was associated with coughing, wheezing and chest tightness. The coughing was productive in nature and the sputum was greenish in colour, sticky and about 1 tablespoon in volume. It was worsen at late night before she going to bed. Apart from that, patient experienced fever for 3 days. Partially relieved by panadol and associated with headache. Being diagnosed asthma since 5 years old, and used MDI salbutamol and MDI budesonide. Have several episode of admission to the hospital due to asthma, approximately once per year. No other chronic illnesses. Have drug allergic which is penicillin. She is allergic to eat meat. She is allergic to dust and cool air. Her parent does not have asthma, She is the third children out of five. None of her sibling has asthma like her. Currently, she is working as auditor nearby Mid Valley shopping complex. Her working nature is in the office typing the computer. She lives alone in Bangi, and there are carpets in her house. She also has several cats in her house. However, she mention that she does not has allergic to carpets and cats. She is non-smoker and not consumes any alcohol. Physical examination Patient was sitting on bed comfortably. Well-hydrated and pink. Was on nasal prong 02 3L, IV NS on right hand. No tremors. Patient was able to talk in full sentences, but noted to have occasional chesty cough after prolonged conversation. Breathing was not laboured, RR 21/min. Pulse rate was 108/minute No audible wheeze heard. No peripheral & central cyanosis, no clubbing, CRT < 2secs. Respiratory examination reveal generalized rhonchi at both side of lung. Investigation K+- 3.6 (3.5-4.5) normal (to look for hypokalemia) ABGnormal CXRsign of hyperinflated lung PEFR150L/min Management E.Dnebulizer Combivent 2 times, nebulizer salbutamol 1 time, IV hydrocort 200mg, S/C Bricanyl 5 mg. WardNasal P.02 3L/minT. prednisolone 30mg BD, MDI Seretide 2puff BD, Neb AVN 4Hourly, T.Bisolvan 8mg TDS, IV drip 2 pin NS.

Discussion Based on the case, I would like to discuss 2 important learning issues that I think are very important in order to become a good doctor, especially when dealing with asthma case. My learning issues are: What are the best treatments of acute asthma. What are the best treatments of chronic asthma. Before that, I would like to elaborate more about what are the treatments that my patient got during admission. As written in the history, my patient who is well known case of asthma presented at emergency department (ED) with shortness of breath. In the ED, patient peak expiratory flow (PEF) was 66%, and her SpO2 is 100%. Patient had been given 2 times of nebulizer combivent and then proceed to 1 time nebulizer salbutamol. 1 hour after that, her PEF has little improving, which is 70%. Next, IV hydrocort 200mg was given to my patient, as well as subcutaneous bricanyl 5mg. She then being referred to the ward due to not much improved after had 3 times of nebulizer. According to the asthma CPG in Malaysia, when initial PEF is less than 75% which implies to my patient case, the immediate treatment is by giving high concentration O2 (>40%). However, in my patient, she did not received any oxygen aid right after she attended to the ED. She only received O2 support in the ward, and she is on nasal prong 5L only, which is not suitable and best for her. As we can notice, her SPO2 was 100% in the ED, however, SPO2 is not the best indicator to show that she did not had hypoxemia. The best way and accurate way is by monitored her ABG. I agreed with the patient management in terms of giving her Nebulizer Combivent, where it is clearly stated in CPG, that high dose of inhaled beta2-agonist combination with anticholonergic should be given via nebuliser. In addition, we must monitor her potassium level at the same time because one of the common side effects of beta agonist is hypokalemia. A part from that, we must assess again her PEF about 15-30 min later, if she is not improving we should admit her. Meanwhile, if patient does not show good progression after received nebulizer, we can give subcutaneous terbutaline, as in this case, my patient received subcutaneous Bricanyl. Based in the CPG, prednisolone should be commenced immediately. It is not necessarily we give prednisolone in tablet form, we also can give intravenously if the patient is unable to tolerate orally. In relation to my patient, she had IV hydrocort 200mg. In the ward, she had been given T. prednisolone 30mg BD instead of IV Hydrocort. This is because we want to reduce the steroid intake so that we can reduce the side effect of steroid. My patient also received Nebuliser Combivent 4 hourly. Besides that, she had MDI Seretide 2 puff BD in the ward. Seretide is consist of steroid and long acting beta agonist. Based on CPG, long acting beta agonist(LABA) it is not suitable to be given in acute case, it is best for preventive measure as in chronic asthma patient. However, this is contradict to study that was done by Shelley R. Salpeter (2010), showed that the use of long acting beta agonists, with and without concomitant inhaled corticosteroids, was associated with a significant increase in

risk for asthma related intubations and deaths1. Since this meta-analysis study is still new, maybe there will be changes in chronic asthma management in the future, especially regarding the commencement of long acting beta agonist (LABA). My patient was showing vast improvement in the ward as her PEF become 76% on the next day. She was planned for discharge on that day, and being prescribed with MDI Seretide and Tablet Prednisolone for the medication. A study was done by Jerry A. Krishnan (2009) showed that in patients with mild to moderate acute asthma, inhaled corticosteroid (ICS) and oral corticosteroid (OCS) are similarly effective in preventing relapse and there was no significant suggesting that combination with ICS and OCS might be more effective than OCS alone in preventing relapse2. However, this is contradicted to CPG, which we should commence inhaled steroid for at least 48 hours in addition to oral prednisolone. Maybe the study is still new, and the CPG was revised in 2002, so maybe there will be changes in future. A part from that, she was seen by health educator to facilitate her how to control her asthma. She had been advice to do self-management such as home peak flow monitoring, self-action plan and how to use the inhaler correctly. Regarding self-action plan, a study was done by Frank Lefevre (2002) demonstrate that asthma outcome does not improved by use of written asthma action plan, with or without peak flow monitoring3. In my opinion, the action plans is good, however the patient probably does not been educated well how to complete and do the plan. Furthermore, poor compliance to the preventive medication make the action plan become useless and not effective, it is all about attitude. Besides that, I would like to share with some findings in a study done by Jonathan Corren (2011), there is a new drug called lebrikuzab (antiinterleukin-13) that can improve lung function, hence reduce asthma relapse4. However, this drug is still new and it still in the trial clinical phases 2. Maybe in the future, there will be a better drug to control chronic asthma.

Reference 1) Long-acting Beta-Agonists with and without Inhaled Corticosteroids and Catastrophic Asthma Events.
Shelley R. Salpeter, MD, FACP,a,b Andrew J. Wall, MD,a,b Nicholas S. Buckleyc

2) Anti-inflammatory Treatment after Discharge Home from the Emergency Department in Adults with Acute Asthma.
Jerry A. Krishnan1, Richard Nowak2, Steven Q. Davis3 and Michael Schatz4 (August 2009)

3) Do written action plans improve patient outcomes in asthma? An evidence-based analysis

Frank Lefevre Md, Margaret Piper PhD, MPH, Kevin Weiss MD, MPH, David Mark MD, MPH, Noreen Clark, PhD, Naomi Aronson PhD

4) Lebrikizumab Treatment in Adults with Asthma

Jonathan Corren, M.D., Robert F. Lemanske, Jr., M.D., Nicola A. Hanania, M.D., Phillip E. Korenblat, M.D., Merdad V. Parsey, M.D., Ph.D., Joseph R. Arron, M.D., Ph.D., Jeffrey M. Harris, M.D., Ph.D., Heleen Scheerens, Ph.D., Lawren C. Wu, Ph.D., Zheng Su, Ph.D., Sofia Mosesova, Ph.D., Mark D. Eisner, M.D., M.P.H., Sean P. Bohen, M.D., Ph.D., and John G. Matthews, M.B., B.S., Ph.D.

5) Clinical Practice Guidelines For Management of Adult Asthma Malaysia REVISED 2002