Asthma

D I s u s u n

BAB I

Case 6 A 35-year-old woman with a history af asthma presents to your office with symptoms of nasal itching, sneezing, and rhinorrhea. She feels this way most days but her symtomps are worse in the spring and fall. She has had difficulty sleeping because she is always congested. She states she has taken diphenhydramine (Benadryl) with no relief. She does not smoke cigarettes and does not have exposure to passive smoke but she does two cats at home. On Examination, she appears tired but is in no respiratory distress. Her vital signs are temperature, 98.8 0F ; blood pressure, 128/84 mm Hg ; pulse, 88 beats/min ; and respiratory rate, 18 breaths/min. The mucosa of her nasal turbinates appear swollen (boggy) and have a pale, bluish-gray color. Thin and watery secretions are seen. No abnormalities are seen on ear examination. There is no servical lymphadenopathy noted and her lungs are clear.

SURNAME : AGE : 35 years old STATUS : Marriage OCCUPATION : PRESENT COMPLAINT

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FIRST NAMES : SEX : Female MARITAL

/o Asthma , Symptoms of nasal itching, sneezing, and rhinorrhea.

worse in the spring and fall. Difficulty sleeping because congested.

O/E General Condition ENT -Nose Mucosa nasal : nasal turbinates appear swollen, pale and bluish-gray color Thin and watery secretion CVS P = 88x/ min BP = 128/84 mmHg T = 98,8 oF RS RR= 18x/min

IMMEDIATE POST HISTORY -Asthma POINT OF NOTE Taken Diphenhydramine (Benadryl)

INVESTIGATION (-) Cervical Lymphadenopati Lung Clear Diagnosis Asthma

Question : 1. 2. 3. 4. 5. What is your name? Where do you live? How old are you? What is your job? how with your marital status?

Language Fokus 1: 1. Whats brought you along today? 2. What can I do for you? 3. How long have you had them? Language Fokus 2: 1. Which part of your body is affected? 2. What the difficult breathing like? Language Fokus 3: 1. 2. 3. 4. Is there anything that makes them better? Does anything make them worse? What effect does food or drugs have? How about part history of your family have?

Language Fokus : 1. 2. 3. 4. 5. Have you any trouble with your nasal? Whats your appetite like? Any problems with your waterworks? What abaout coughs or wheezing or shorthness of breath? Have you noticed any weakness or itching in your nose?

BAB II

What is asthma? Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems. The characteristics of asthma are three airway problems:

obstruction inflammation hyper-responsiveness

What are the symptoms of asthma? Asthma may resemble other respiratory problems such as emphysema, bronchitis, and lower respiratory infections. It is under-diagnosed - many people with the disease do not know they have it. Sometimes the only symptom is a chronic cough, especially at night, or coughing or wheezing that occurs only with exercise. Some people think they have recurrent bronchitis, since respiratory infections usually settle in the chest in a person predisposed to asthma. What causes asthma The basic cause of the lung abnormality in asthma is not yet known, although healthcare professionals have established that it is a special type of inflammation of the airway that leads to:

contraction of airway muscles mucus production swelling in the airways

It is important to know that asthma is not caused by emotional factors - as commonly believed years ago. Emotional anxiety and nervous stress can cause fatigue, which may affect the immune system and increase asthma symptoms or aggravate an attack. However, these reactions are considered to be more of an effect than a cause.

What is a Risk Factor? A risk factor is anything that may increase a person's chance of developing a disease. It may be an activity, diet, family history, or many other things. Different diseases have different risk factors. Although these factors can increase a person's risk, they do not necessarily cause the disease. For example, some people with one or more risk factors never develop cancer, while others develop cancer and have no known risk factors. Knowing your risk factors to any disease can help to guide you into the appropriate actions, including changing behaviors and being clinically monitored for the disease.

Why is asthma on the rise? Some scientists theorize that the decline in serious illness may be one factor in the increase of allergic asthma. They believe it is possible that an under-utilized immune system may overreact to lesser irritants, inappropriately triggering the release of histamine and other inflammatory substances in the lungs. Other researchers believe that the increased amount of time children are spending indoors is increasing their exposure to carpeting and other allergen-triggers. What are the risk factors for an asthma attack? Although anyone may have an asthma attack, it most commonly occurs in:

children, by the age of 5 adults in their 30s adults older than 65 people living in urban communities

Other factors include:

family history of asthma personal medical history of allergies

Children most susceptible to asthma attacks include the following:

children with a family history of asthma infants and other young children who when they develop a respiratory infection, they also tend to have wheezing children who have allergies children who have exposure to tobacco smoke and other allergens prior to birth

What happens during an asthma attack? People with asthma have acute episodes when the air passages in their lungs get narrower, and breathing becomes more difficult. These problems are caused by an oversensitivity of the lungs and airways.

Lungs and airways overreact to certain triggers and become inflamed and clogged. Breathing becomes harder and may hurt. There may be coughing. There may be a wheezing or whistling sound, which is typical of asthma. Wheezing occurs because: o muscles that surround the airways tighten, the inner lining of the airways swells and pushes inward. o membranes that line the airways secrete extra mucus. o the mucus can form plugs that further block the air passages. o the rush of air through the narrowed airways produces the wheezing sounds.

How is asthma diagnosed? To diagnose asthma and distinguish it from other lung disorders, physicians rely on a combination of medical history, physical examination, and laboratory tests, which may include:

spirometry - a spirometer is a device used by your physician that assesses lung function. Spirometry, the evaluation of lung function with a spirometer, is one of the simplest, most common pulmonary function tests and may be necessary for any/all of the following reasons:

to determine how well the lungs receive, hold, and utilize air o to monitor a lung disease o to monitor the effectiveness of treatment o to determine the severity of a lung disease o to determine whether the lung disease is restrictive (decreased airflow) or obstructive (disruption of airflow) peak flow monitoring (PFM) - a device used to measure the fastest speed in which a person can blow air out of the lungs. During an asthma or other respiratory flare up, the large airways in the lungs slowly begin to narrow. This will slow the speed of air leaving the lungs and can be measured by a PFM. This measurement is very important in evaluating how well or how poorly the disease is being controlled. chest x-ray - a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. blood tests - to analyze the amount of carbon dioxide and oxygen in the blood. allergy tests
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Medications Medications used to treat asthma are divided into two general classes: quick-relief medications used to treat acute symptoms; and long-term control medications used to prevent further exacerbation.[100] Fastacting Salbutamol metered dose inhaler commonly used to treat asthma attacks.

Short-acting beta2-adrenoceptor agonists (SABA), such as salbutamol (albuterol USAN) are the first line treatment for asthma symptoms. They are recommended before exercise in those with exercise induced symptoms Anticholinergic medications, such as ipratropium bromide, provide additional benefit when used in combination with SABA in those with moderate or severe symptoms. Anticholinergic bronchodilators can also be used if a person cannot tolerate a SABA.

Older, less selective adrenergic agonists, such as inhaled epinephrine, have similar efficacy to SABAs. They are however not recommended due to concerns regarding excessive cardiac stimulation.

Longterm control Fluticasone propionate metered dose inhaler commonly used for long-term control.

Corticosteroids are generally considered the most effective treatment available for long-term control. Inhaled forms such as beclomethasone are usually used except in the case of severe persistent disease, in which oral corticosteroids may be needed. It is usually recommended that inhaled formulations be used once or twice daily, depending on the severity of symptoms. Long-acting beta-adrenoceptor agonists (LABA) such as salmeterol and formoterol can improve asthma control, at least in adults, when given in combination with inhaled corticosteroids. In children this benefit is uncertain. When used without steroids they increase the risk of severe side-effects and even with corticosteroids they may slightly increase the risk. Leukotriene antagonists (such as montelukast and zafirlukast) may be used in addition to inhaled corticosteroids, typically also in conjunction with LABA. Evidence is insufficient to support use in acute exacerbations. In children under five years of age, they are the preferred add-on therapy after inhaled corticosteroids. Mast cell stabilizers (such as cromolyn sodium) are another nonpreferred alternative to corticosteroids.

Delivery methods Medications are typically provided as metered-dose inhalers (MDIs) in combination with an asthma spacer or as a dry powder inhaler. The spacer is a plastic cylinder that mixes the medication with air, making it easier to receive a full dose of the drug. A nebulizer may also be used. Nebulizers and spacers are equally effective in those with mild to moderate symptoms

however insufficient evidence is available to determine whether or not a difference exists in those severe symptomatology. Adverse effects Long-term use of inhaled corticosteroids at conventional doses carries a minor risk of adverse effects.[119] Risks include the development of cataracts and a mild regression in stature.[119][120]

When asthma is unresponsive to usual medications, other options are available for both emergency management and prevention of flareups. For emergency management other options include:

Oxygen to alleviate hypoxia if saturations fall below 92%. Magnesium sulfate intravenous treatment has been shown to provide a bronchodilating effect when used in addition to other treatment in severe acute asthma attacks. Heliox, a mixture of helium and oxygen, may also be considered in severe unresponsive cases. Intravenous salbutamol is not supported by available evidence and is thus used only in extreme cases. Methylxanthines (such as theophylline) were once widely used, but do not add significantly to the effects of inhaled beta-agonists. Their use in acute exacerbations is controversial. The dissociative anesthetic ketamine is theoretically useful if intubation and mechanical ventilation is needed in people who are approaching respiratory arrest; however, there is no evidence from clinical trials to support this.

For those with severe persistent asthma not controlled by inhaled corticosteroids and LABAs bronchial thermoplasty may be an option. It involves the delivery of controlled thermal energy to the airway wall during a series of bronchoscopies. While it may increase exacerbation frequency in the first few months it appears to decrease the subsequent rate. Effects beyond one year are unknown. Evidence suggests that sublingual immunotherapy in those with both allergic rhinitis and asthma improve outcomes

Prognosis The prognosis for asthma is generally good, especially for children with mild disease. Mortality has decreased over the last few decades due to better recognition and improvement in care. Globally it causes moderate or severe disability in 19.4 million people as of 2004 (16 million of which are in low and middle income countries). Of asthma diagnosed during childhood, half of cases will no longer carry the diagnosis after a decade. Airway remodeling is observed, but it is unknown whether these represent harmful or beneficial changes. Early treatment with corticosteroids seems to prevent or ameliorates a decline in lung function.

BAB III NHLBI Guideline 2007, pp. 1112 British Guideline 2009, Martinez FD (2007). "Genes, environments, development and asthma: a reappraisal". Eur Respir J 29 (1): 17984. doi:10.1183/09031936.00087906. PMID 17197483. Lemanske RF, Busse WW (February 2010). "Asthma: clinical expression and molecular mechanisms". J. Allergy Clin. Immunol. 125 (2 Suppl 2): S95102. doi:10.1016/j.jaci.2009.10.047. PMC 2853245. PMID 20176271. Yawn BP (September 2008). "Factors accounting for asthma variability: achieving optimal symptom control for individual patients". Primary Care Respiratory Journal 17 (3): 138147. doi:10.3132/pcrj.2008.00004. PMID 18264646. Archived from the original on 2010-03-04. Kumar, Vinay; Abbas, Abul K; Fausto, Nelson et al., eds. (2010). Robbins and Cotran pathologic basis of disease (8th ed.). Saunders. p. 688. ISBN 978-1-4160-3121-5. OCLC 643462931. Stedman's Medical Dictionary (28 ed.). Lippincott Williams and Wilkins. 2005. ISBN 0-7817-3390-1.