Acute Exacerbation of Bronchial Asthma

By Tengku Abdul Kadir B Tengku Zainal Abidin.

A&E HSNZ at 7:30pm

CASE STUDY

Elisya, a 5 year old girl with underlying bronchial asthma since 1 yo on MDI Budesonide 200 mcg BD and MDI Salbutamol 2 puffs PRN came with c/o rapid breathing since 3 pm today

 The parents brought the patient to KK Seberang Takir at 5 pm after the symptoms were not relieved after taking 4 puffs of MDI salbutamol. At KK Seberang Takir, she was given neb Ventolin x 2, but still had rapid breathing thus was referred to HSNZ

 What further questions do you want to ask ? What are the differential diagnoses? What are you going to do next?

 From the hx, there is no URTI sx, no fever, patient was still active and tolerating orally well before the episode of rapid breathing Patient had hx of visiting her uncle today at 2pm and was exposed to cigarette smoke from her uncle. She developed rapid breathing after that.

Interval symptoms
Last exacerbation was in November last year No nocturnal cough No daytime symptoms No need for reliever since last exacerbation Patient was active, no exercise induced sx Symptoms usually precipitated by URTI, cold weather or exposure to cigarette smoke

 From the physical examination, patient was alert, good cry, mildly tachypnoeic with mild subcostal recession, pulse volume good and capillary refill immediate Vital signs:
BP 98/50 HR 110 RR 40 spO2 97% under NPO2 2L/min

Lungs: A/E equal, PEP, no crepts, bilateral rhonchi CVS: S1S2 No murmur PA: Soft, not distended, non tender

 This patient was given neb Ventolin x 1. 1 hour post neb, patient still had rapid breathing but she was less tachypnoeic and was able to talk to her mother

Do you want to admit this child?

Criteria for admission

failure to respond to standard home treatment failure of those with mild or moderate acute asthma to respond to nebulised -agonists relapse within 4 hours of nebulised -agonists severe acute asthma

 In 6EF, patient was put under NPO2, was given neb Ventolin 2 hourly, neb Combivent 4hourly, IV Hydrocortisone 4mg/kg stat then qid for one day Patients condition improved after 4hours, was less tachypnoeic, able to tolerate orally and able to sleep comfortably. The lungs had minimal rhonchi with no crepitations.

Initial steps for assessment

Diagnosis - symptoms e.g. cough, wheezing, breathlessness, pneumonia Triggering factors - food, weather, exercise, infection, emotion, drugs, aeroallergens Severity - respiratory rate, colour, respiratory effort, conscious level

Ref: Paediatric Protocol 2nd Edition Page:95

Management Consideration
monitor pulse, colour, PEFR, ABG and SpO: close monitoring for at least 4 hours hydration - give maintenance fluids antibiotics indicated only if bacterial infection suspected avoid sedatives and mucolytics

Ref: Paediatric Protocol 2nd Edition Page:96

Medication given

 On discharge, patients must be provided with an Asthma Action Plan to assist parents or patients to prevent/terminate asthma attacks. The plan must include: - how to recognize worsening asthma - how to treat worsening asthma - how & when to seek medical attention

Take home message

Good initial assessment based on diagnosis, triggering factors and severity Initial treatment with oxygen and medication Discharge patient with Asthma Action Plan

References
Paediatric Protocol For Malaysian Hospitals 2nd edition GINA guidelines of Bronchial Asthma Classifying Asthma Severity and Treatment Determinants : National Guidelines Revisited by R Khajotia MBBS (Bom), MD (Bom), MD (Vienna), FAMA (Vienna), FAMS (Vienna). International Medical University, Seremban, Malaysia

THANK YOU!
ANY QUESTIONS? NO? GOOD!