CUCMS Final Year

Teaching Module

Dr Nor Shuhaila Shahril

B. Med (Southampton) MRCP (UK)
Putrajaya Hospital
Epidemiology
 Worldwide prevalence increasing
 Common disease under diagnosed and
under-treated
 13.6% on inhaled corticosteroids despite
almost half of them having symptoms of
persistent asthma 1.
 Prevalence of self reported asthma in
adults in Malaysia is 4.1% 2.
1. AIRIAP 2001
2. NHMS 1997
Definition
 Chronic inflammatory disorder of the
airways
 Chronically inflamed airways are hyper-
responsive
 Airway obstruction
 Airway limitation
○ Bronchoconstriction
○ Mucus plugs
○ Increased inflammation
Pathophysiology
Case: Miss Lina Ng
 A 20 year old Chinese lady
 6 months history of dry cough
 Mainly at night and early morning
 Also when laughing or running up the stairs
 Occasionally room mate reported noisy
breathing during sleep at night – wheezing
 No previous hospitalization
 Family history of asthma – mother
 Non-smoker

What other information would you like to know?

Is it asthma?
 Wheezing
 High pitched whistling sounds when
breathing out
 A normal chest examination does not
exclude asthma
 History of any of the following:
 Cough, worse particularly at night
 Recurrent wheeze
 Recurrent difficulty in breathing
 Recurrent chest tightness
Is it asthma?
 Symptoms occur or worsen at night,
awakening the patient
 Symptoms occur or worsen in a
seasonal pattern
 Patient also has eczema, hay fever,
or a FH of asthma or atopic disease
 Patient’s cold “go to the chest” or
take > 10 days to clear
 Symptoms respond to anti-asthma
therapy
Precipitating factors for asthma
 Animals with fur  Smoke
 Aerosol chemicals  Drugs (aspirin, beta
 Changes in blockers)
temperature  Respiratory (viral)
 Domestic dust mites infections
 Pollen  Exercise
 String emotional
expression
Case
 Clinical examination was normal except
for a patch of eczema on her right elbow
flexure.
 How are you going to confirm that she
has asthma?
a. CXR
b. ABG
c. Spirometry
d. CT scan thorax
e. PEF measurements
Spirometry
 Preferred method of measuring airflow
limitation and its reversibility
 An increase in FEV1 of ≥ 12% (or ≥ 200 ml)
after administration of a bronchodilator
indicates reversible airflow limitation
consistent with asthma
 However, most asthma patients will not
exhibit reversibility at each assessment, and
repeated testing is advised.
PEF measurements

 Important aid in both diagnosis and

monitoring of asthma
○ Ideally compared to patient’s own previous best
measurements using his/ her own peak flow
meter
 An improvement of 60L/min (or ≥ 15% of the
pre-bronchodilator PEF) 15 minutes after
inhalation of a bronchodilator or
 Diurnal variation in PEF of > 20% (with twice-
daily readings, > 10%) suggests a diagnosis of
asthma
Good control of asthma means PEF variability is maintained at less than 10%
PREDICTED PEF 480
Additional diagnostic tests
 For patients with symptoms
consistent with asthma, but normal
lung function, measurements of
airway responsiveness to
methacholine, histamine, exercise
challenge may help establish
diagnosis
 Skin tests with allergens or
measurement of specific IgE in serum
 Presence of allergies increases probability
of asthma
 Can help identify risk factors that cause
asthma symptoms in individual patients.
Lina Ng’s spirometry results
Case
 Lina Ng was diagnosed to have
bronchial asthma.
 How would you treat her?
a. Inhaled 2 agonist alone
b. Inhaled 2 agonist plus inhaled
corticosteroids
c. Oral prednisolone
d. Advise to come for PRN nebulization

What are the aims of management of asthma?

Aims of management
 To abolish day and night symptoms
 To restore normal or best possible long
term airway function
 To prevent most acute attacks
 To prevent mortality
3 major groups of medications to
treat asthma
 Anti-inflammatory medications

 Short acting bronchodilators

 Long-acting bronchodilators
Anti-inflammatory medications
Anti-inflammatory medications
Short acting bronchodilators
Long acting bronchodilators
Case
 Lina Ng was prescribed MDI Salbutamol
2p PRN and MDI Beclomethasone 200
mcg BD.
 What other advice would you give?
a. Do not avoid exercise
b. Influenza vaccination
c. Avoid allergens
d. Avoid tobacco smoke
e. All of the above
Case
 She was reviewed again in 3 months.
 According to her, she needed to use her
Salbutamol inhaler at least 3 times per
week.
 She wakes up at night wheezing on 2
occasions per month.
 Otherwise she remained active playing
volleyball.
 Her PEFR is 250
 Is her asthma controlled?
If total score is 19 or less, the asthma plan needs adjusting.
 Assess Severity
Measure PEF: < 50% personal best or predicted suggest severe exacerbation

Note: degrees of cough, breathlessness, wheeze and chest tightness correlate imperfectly with
exacerbation.
Accessory muscle use and suprasternal retraction suggest severe exacerbation

Initial treatment
Inhaled short-acting beta agonist: up to 3 treatments 2-4 puffs by MDI at 20-min
interval or single nebulizer treatment

Good response Incomplete response Poor response

Mild exacerbation Moderate exacerbation Severe exacerbation

PEF > 80% predicted or personal best
No wheezing or shortness of breath
Response to beta agonist sustained up
to 4 hours
•May continue beta agonist every 3-4
hours up to 24-48 hours
PEF 50-80% predicted or personal best
Persistent wheezing or shortness of
breath
•Add inhaled corticosteroids
•Continue beta agonist
PEF < 50% predicted or personal
best
Marked wheezing or shortness of
breath
•Add oral corticosteroids
•Repeat beta agonist immediately

•For patient with inhaled corticosteroids, •If distress is severe and non-
double dose for 7-10 days responsive, proceed to emergency
department or call ambulance

Contact clinician for follow-up instructions Contact clinician urgently (this day) for
follow-up instructions Proceed to emergency department
Case
 What is the next step of management?
a. Change Salbutamol to Terbutaline inhaler
b. Add Monteleukast
c. Stop MDI Beclomethasone
d. Increase dose of MDI Beclomethasone to
400 mcg BD
e. Add a long-acting bronchodilator
Case
 Her medications were optimized as follows:
 MDI Salbutamol 2p PRN
 MDI Budesonide 400 mcg BD
 Monteleukast 10 mg OD

 What must also be done before she leaves

the consultation room, what else must you
do?

Check inhaler technique!

Inhaled medications
 Pressurized metered-dose inhalers (MDIs)
 Breath-accentuated MDIs
 Dry powder inhalers (DPIs)
 Nebulizer

 Spacer device
 for those who lack co-ordination with inhalers
(easier to use)
 Reduce systemic absorption and side effects of
ICS
Case

 Lina was relatively well for the next 2

months with rescue inhaler use only twice
for last 2/12.
 She was brought to Casualty last night
 c/o difficulty in breathing X 2/7
 Chest tightness and wheezing for past 1/7
 Had fever, sore throat, cough with
yellowish phlegm and runny nose for past 3
days
 She has been using her rescue inhalers 4
– 5 times per day
Case
 Tachypnoeic, unable to speak in full
sentences
 Pink on air, spO2 95% on air
 T 37.5C
 BP 130/80 PR 120 bpm good volume
 Tracheal central, accessory muscle use
 RR 36/min
 Lungs scattered wheeze
 What do you think is happening?
Acute Exacerbation of Asthma precipitated by
Upper Respiratory Tract Infection
Features of severe acute asthma
include (true/ false)

a. Pulse rate of > 120/min T

b. PEF < 70% of expected
c. Pulsus paradoxus of 30 mmHg T
d. Arterial PaO2 10kPa
e. Arterial PaCO2 6 kPa T
Pulsus paradoxus

Pulsus paradoxus is an exagerrated decline in BP during inspiration.

A decline of > 10 mmHg is abnormal.
Initial management of severe
acute asthma should include (T/F)
a. 24% O2 delivered by a controlled flow
mask
b. Salbutamol 5 mg by inhalation T
c. IV augmentin 1.2 g 8hrly
d. IV hydrocortisone 200 mg stat, followed
by oral prednisolone 30 mg od T
e. Arterial blood gas and chest x-ray T
Case
 Lina received nebulization (3X).
 She appeared tired and quiet
 Peripheries warm
 RR 18/min
 spO2 93% on high flow mask O2
 PR 70 bpm, BP 90/60 mmHg
 Lungs prolonged expiratory phase,
soft breath sounds.
 Comment please.
Case
 Her ABG are as follows:
 pH 7.3
 pO2 80 mmHg ( 75 – 100)
 pCO2 50 mmHg (35 – 45)
 HCO3 22
 Please comment.
Case
 What is the next step of management?
a. Continue nebulization
b. Give IV antibiotics
c. Refer anaesthesiologist for assisted
ventilation
d. Discharge the patient
Indications for ICU admission
ICU management

IV MgSO4 2g in 50 mls NS over 10 – 20 mins

Monitoring response to treatment
Case
 Lina was in ICU for 2 days – on BIPAP
ventilation
 She completed 24 hrs of IV
Aminophylline infusion.
 She was transferred up to the ward.
 Her PEF improved to 450/L
 Lungs occasional rhonchi
What is your plan for this patient?
Discharge plan for hospitalized patients