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15 months old infant Had recurrent wheezing episodes since 2 months old (responsive to beta-2 agonist) Mother is a known asthmatic Brother has atopic dermatitis Physical exam: normal values: 13 Kg. Age appropriate Pulse rate: 120 / min 70-110 beats per min respiratory rate: 55 / min 20-30 breaths per min Temperature: 38. Degrees Celsius Symmetrical Chest expansion Presence of moderate chest retractions Presence of bilateral expiratory whe
15 months old infant Had recurrent wheezing episodes since 2 months old (responsive to beta-2 agonist) Mother is a known asthmatic Brother has atopic dermatitis Physical exam: normal values: 13 Kg. Age appropriate Pulse rate: 120 / min 70-110 beats per min respiratory rate: 55 / min 20-30 breaths per min Temperature: 38. Degrees Celsius Symmetrical Chest expansion Presence of moderate chest retractions Presence of bilateral expiratory whe
15 months old infant Had recurrent wheezing episodes since 2 months old (responsive to beta-2 agonist) Mother is a known asthmatic Brother has atopic dermatitis Physical exam: normal values: 13 Kg. Age appropriate Pulse rate: 120 / min 70-110 beats per min respiratory rate: 55 / min 20-30 breaths per min Temperature: 38. Degrees Celsius Symmetrical Chest expansion Presence of moderate chest retractions Presence of bilateral expiratory whe
3 A MEDICINE ONLINE SGD Wheezing Disorders Dra. Andaya
Salient Features: C/C: Difficulty of breathing associated with wheezing. 15 months old infant Had recurrent wheezing episodes since 2 months old (responsive to beta-2 agonist). Mother is a known asthmatic Brother has atopic dermatitis Physical exam: Normal Values: Weight: 13 Kg. Age appropriate Pulse rate: 120/min 70-110 beats per min Respiratory rate: 55/min 20-30 breaths per min Temperature: 38.6 degrees Celsius Symmetrical Chest expansion Presence of moderate chest retractions Presence of bilateral expiratory wheezes Presence of irritable Respiratory distress Refuses to feed Fair air entry
Questions: 1. Based on the clinical data given, what is the most probable diagnosis? Non atopic wheezing- wheezing, coughing beginning at early life, often with Respiratory Syncytial Virus; resolves later in childhood without increased risk of asthma. It is associated with bronchial hyper responsiveness near birth. 2. How will you assess the severity of the asthma exacerbation? The patient is classified under severe asthma exacerbation Criteria Severe Asthma Exacerbation Actual findings in patient Suprasternal retraction: usually present Presence of chest retraction Wheeze:
usually loud throughout inhalation and exhalation Presence of bilateral expiratory wheeze
Pulse rate: >120 beats per minute 120 beats per minute Respiratory rate: >30 breaths per minute 55 breaths per minute Alertness: usually agitated Irritable due to respiratory distress Refuses to feed Note: in children no singles assessment tool appears to be the best for assessing the severity and exacerbation or for monitoring response to treatment and predicting hospital admission.
According to table 138-4 Formal Evaluation of Asthma Exacerbation severity in urgent or emergency care setting, the patient is classified under Severe Asthma Exacerbation. Table 138-4 Criteria Actual Severe Pulse rate 120 /min >120/min Respiratory rate 55/min often >30/min Presence of retraction present usually Alertness Irritable respiratory distress usually agitated Refuses to feed Wheeze Presence of bilateral expiratory wheeze Usually loud throughout inhalation and exhalation
According to table 138-7 Assessing and initiating treatment for patient who are not currently taking long term control, the patient will be classified under Persistent Moderate Asthma. Criteria: Persistent Moderate Asthma SABA use for symptoms. Daily Interference with normal activity Some limitation
Rationale: The patient was classified under Persistent Moderate Asthma, because according to this guideline, At the present, there are no inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. So for treatment purposes, for patient who had >/= 2 exacerbations reqiring oral corticosteroids in the past 6 months, or >/= 4 wheezing episodes in the past year, who have risk factors for persistent asthma may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma which is the reason why patient was classified under persistent moderate asthma.
3. How will you assess the level of asthma control? The level of asthma control in the patient is not well controlled Rationale: Patient since 2 months old had recurrent episodes of wheezing up to the present. But the patients drug regimen only consist of SABA for acute control of his recurrent wheezes, the patient does not have yet a drug for long term control of his recurrent wheezes.
4. What test will you request to confirm the diagnosis? Allergy testing to assess sensitization to inhalant allergens Helps with management and prognosis of asthma Identifies patient with inhalant allergen sensitization thru allergy prick skin test
Bronchodilator response To assess if there is any symptom relief thru any of the following: Disappearance of respiratory distress Disappearance of chest retractions Disappearance of wheeze bilaterally
5. What are your differential diagnoses? Lower Respiratory Tract Conditions a. Bronchopulmonary Dysplasia b. Viral Bronchiolitis c. Gastroesophageal Reflux d. Medication Associated With Chronic Cough i. Acetylcholinesterase Inhibitors ii. B-Adrenergic Agonist iii. ACE Inhibitor e. Causes Of Bronchiectasis i. Cystic Tumors ii. Immune Deficiency iii. Allergic Bronchopulmonary Mycoses iv. Chronic Aspiration v. Immotile Cilia Syndrome, Primary Ciliary Dyskinesia f. Bronchiolitis Obliterans g. Interstitial Lung Disease h. Hypersensitivity Pneumonitis i. Pulmonary Eosinophilia, Churg-Strauss Vasculitis j. Pulmonary Hemosiderosis k. Tuberculosis l. Pneumonia m. Pulmonary Edema (Eg. Congestive Heart Failure) Middle Respiratory Tract Disorders a. Laryngotracheobronchomalacia b. Laryngotracheobronchitis (Eg. Pertussis) c. Laryngeal Web, Cyst Or Stenosis d. Vocal Cord Dysfunction e. Vocal Cord Paralysis f. Tracheoesophageal Fistula g. Vascular Ring, Sling, Or External Mass Compressing On The Airway (Eg. Tumor) h. Foreign Body Aspiration i. Chronic Bronchitis And Environmental Tobacco Smoke Exposure j. Toxic Inhalations Upper Respiratory Tract Conditions a) Allergic Rhinitis b) Chronic Bronchitis c) Sinusitis d) Adenoidal Or Tonsillar Hypertrophy e) Nasal Foreign Body
6. What initial measures would you like to give at E.R.? Assessment depends on P.E. Use of accessory muscles, inspiratory and expiratory wheezes, paradoxical breathing, cyanosis and respiratory rate> 60 are key signs of serious distress. Obj. measurements, such as O2 sat. Of 90%, also indicate serious distress. Response to SABA therapy can be variable and may not be a reliable predictor of satisfactory outcome, because infants are at greater risk for respiratory failure, a lack of response noted by either P.E. or objective meas. Should be an indication for hospitalization. Use of oral corticosteroids early in episode is essential but should not substitute for careful assessment by physician. Most acute wheezing episodes result from viral infections and may be accompanied by fever. However, Antibiotics generally are not used.
7. What are the preventive measures? Conventional anti inflammatory intervention is the cornerstone of asthma control Early immunomodulatory intervention might prevent asthma development Hygiene hypothesis purports that naturally occurring microbial exposures in early life might drive early immune development away from allergic sensitization, persistent airway inflammation and remodeling, thus it has Anti- asthma properties.
Non pharmacologic interventions: Avoidance of environmental tobacco smoke Prolonged breastfeeding Healthy diet Immjunizations All standard childhood immunizations are recommended for children with asthma including varicella and annual influenza vaccines.