Asthma Bronchiale

Coass:
Abdi Dzul Ikram H. 0910710020
Nydya Parahita 0910710011
Oktavinayu Sari L. 0910711011
Rosandy Febrianto 0910710117
Supervisor:
Dr. Ali Haedar, SpEM

Introduction

Definition
Asthma bronchiale is a lung disease with
characteristics :

(1)
Reversible Airway
Obstruction (even
spontaneously or by
medication)

(2)
Inflammation of the
airway

(3)
Increasing of
airway response
to any stimulation

PAPDI, Alergi Imunologi

Klinik, 2012

Epidemiology
As age increased, the
prevalence almost
equal and woman
more likely to have
asthma compared with
man.

In the children age,

the prevalence is boy
more likely than girl
with ratio 1,5:1

Asthma

In Indonesia, the
prevalence about 5-7%

Children more often

than adults

PAPDI, Alergi Imunologi

Why We Choose This

Topic?
In 2010, asthma accounted for 3,404 deaths, 439,400
hospitalizations, 1.8 million emergency
department visits, and 14.2 million physician office
visits (CDC, 2013)

In Indonesia, Asthma is top 10 diseases that

causing morbidity and mortality (PDPI,
2003)
Asthma include in 144 diseases that must be treat
completely in Primary Helath Care Service Level
of Competence 4A

When to refer?
1. If often have exacerbation
2. In moderate to severe asthma
attack
3. Asthma with complication

Complication of Asthma:
Pneumothorax,
Pneumomediastinum,
Respiratory Failure, and Asthma
Resistant to Steroid

Predisposing Factor

House dust
Flower powder
Animal hair (cat, dog)
Food: milk, egg,fish, tomatto, etc.
Infection: flu, faringitis
Air pollution, i.e. smoking
Spray: perfumery, mosquito drug
Nervous, emotional and exhausted
Change of weather
Etc
7

The Goal of Clinical

Assessment
Determine the severity of acute
asthmatic attack and treat accordingly

Identify patients who are at high risk of

dying from asthma

Establish the patients current treatment

and level of asthma control
Guide to the essentials in Emergency
Medicine, 2015

Anamnesis
Presenting symptoms : Triad of asthma
symptoms are dyspnoea, wheezing and
cough.
Precipitating factors, e.g. dust and URI
High risk features
Current medications including compliance

Guide to the essentials in Emergency 9

Medicine, 2015

Risk Factors for death from

asthma
Past history of sudden severe exacerbations
Prior intubation and mechanical ventilation for asthma
Prior admission for asthma to an intensive care unit
Two or more hospitalizations for asthma in the past year
Three or more emergency care visits for asthma in the past year
Hospitalization or an emergency care visit for asthma within the past
mounth
Use of more than two canisters per month of inhaled short-acting-2Agonist
Current use of systemic corticosteroids or recent withdrawal from
systemic corticosteroids
Difficulty perceiving airflow obstruction or its severity
Comorbidity, as from cardiovascular diseases or COPD
Serious psychiatric disease or psychosocial problems
Low socioeconomic status and urban residence
Illicit drug use
Not currently using inhaled corticosteroids
Guide to the essentials in Emergency

Physical Examination
General Appearance
Mental state, signs of respiratory distress
and cyanosis

Vital signs
Especially SpO2

Respiratory
Prolonged expiratory phase, rhonchi,
crepitations, and air entry
11

Guide to the essentials in Emergency

LABORATORY FINDING
Chest X Ray
Indicated in patients not responding to initial
therapy. Look for pneumothorax, pneumonia,
or congestive heart failure

Arterial Blood Gas

Usual in severe asthmatic exacerbations to
look for hypercarbia (an ominous sign) and
hypoxia

Others

CBC and renal panel (especially for

hypokalemia d.t. nebulized salbutamol)
12

Guide to the essentials in Emergency

GINA 2009

Severity of Asthma
Exacerbations..
MILD

MODERATE

SEVERE
ARREST
IMMINENT

RESPIRATORY

Breathless

Walking
Talking
At rest
Infants softer
Infants- Stops
shorter cry
feeding
Can lie flat
Prefers sitting
*Hunched forward

Talks in

Sentences

Phrases

Alertness

May be agitated

Usually agitated

Respiratory Rate

Increased

Increased

Words
Usually agitated

*Often >30/minBradypnea

GUIDE TO RATES OF BREATHING ASSOCIATED WITH

RESPIRATORY DISTRESS IN AWAKE CHILDREN
AGE
NORMAL RATE
> 2 months
< 60/min
2-12 months
< 50/min
1-5 years
< 40/min
6-8 years
< 30/min

13

GINA 2009

Severity of Asthma
Exacerbations..
MILD
MODERATE
SEVERE

RESPIRATORY

ARREST IMMINENT
Accessory
Muscles &
Suprasternal
Retraction
Wheeze

None

Present

Present
Thoraco-abdominal
Movement

Present

Audible with
Audible with
Audible w/o
Absence of wheeze
stethoscope
stethoscope
stethoscope
with decreased to
absent breathe sounds

Pulses/min <100

100-120

>120

Bradycardia

GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN

Age
Normal Limits
Infants
2-12 months <160/min
Preschool
1-2 years
<120/min
School Age
2-6 years
<110/min

14

GINA 2009

Severity of Asthma
Exacerbations
MILD
MODERATE
SEVERE
RESPIRATORY
ARREST
IMMINENT

Pulses Paradoxus Absent

May be present Often present Absence suggests
<10mm Hg
1020mm Hg 20-40mm Hg respiratory muscle
fatigue
PEF
80%
%predicted
Or
%personal best
PaO2

60-79%

Normal
test NOT usually
necessary

PaCO2

45 mm Hg

SaO2

95%

<60%

60mm Hg

<60mmHg
Possible Cyanosis

45 mm Hg
>45 mm Hg possible
respiratory failure

90-94%

<90%
15

PEFR

Flowchart Showing the Management of Asthma

(Guide to the essentials in Emergency Medicine, 2015)

Cough
Shortness of
Breath
Wheeze

Patients with
asthma
Symptoms of life-threatenning asthma
No (not
present?
Yes
present)
(Present)
Silent chest
Cyanosis
Feeble respiratory effort
Exhaustion, confusion, or
obtudantion
Supportive MeasuresPEFR < 35% of predicted
Managed in critical care area with high flow supplemental oxygen
Monitoring : ECG, pulse oxymetri, vital signs q 5-10 mnt
IV access 500 ml crystalloid over 3-4 h
Prepare for rapid sequence intubation: Have paralyzing and sedating drugs
readily available
Use serial ABGs to detect triad of progressive hypoxaemia, hypercarbia,
and acidosis
Indicaions
for intubation: Persistent hypercarbia, severe hypoxia with PaO2
Drug
therapy
mmHg
<60
Salbutamol
(ventolin) nebulized therapy: 1 ml (5 mg) salbutamol with 2 ml
CXR : Patients
not responding
to make
initial up
therapy
ipatropium
bromide
& 2 ml NS to
to 5 ml. (In Child 0,03 ml/Kg
17
Ref. GINA Updated 2008
diluted in 2 ml of NS; repeat twice)

Improvement
All Other Astmatics
Check patient and PEFR
(optional and must also
measure height) and
after 2 neb doses
Reassessment: if PEFR
50% and subjective
improvement consider
discharge with early
follow-up within 48 h
(Respiratory Medicine
Clinic)
All patients at
discharge should oral
prednisolone 0,5-1
mg/Kg/d (40 mg max no
tail) for 7-10 d and
follow up
Additional: Inhaled
steroids (pulmicort
turbohaler 200mcg
2x1)

Non-responders/partial
response

Consider
admission

PEFR < 50% predicted

with 60 mnt: Repeat neb 23 times utilizing
salbutamol 5 mg or 7,5
mg with 2 ml Ipatropium,
1,5 ml NS made up to 5 ml
IV MgSO4 1-2 g slow
bolus (20 mnt)
Adrenaline (use with
caution if at all elderly, IHD
or severe hypertension)
0,3-0,5 ml 1:1000 solutions
SC q 20 mnt in adults > 45
Kg or 0,01 ml/Kg (up to 3
ml) 1:1000 solutions om
adults < 45 Kg or children
OR
Terbutaline (More 2
selective than adrenaline)
0,25 ml SC q20-30 mnt prn
in adults , Re0,01 ml/Kg in

Patient unable
to obtain PEFR
50% despite
therapy and
observation 1-2
h
Previous
intubation/ ICU
admission
X-ray evidence
of
pneumothorax.
Infection or
concomittant
CCF

Asthma Observation in Emergency Ward

(Singapore General Hospital Policy and Procedure, 2005)

Patients who are observed have to statisfy the following

criteria:
a) Acceptable vital signs (SBP> 90 mmHg, RR < 25 tpm,
and SaO2 >95% on room air after initial treatment)
b) Alert and oriented
c) PEFR>50% of predicted value
d) PCO2 < 45 mmHg PO2 >70 mmHg in ABG results (if it
is done)
e) Absence of pneumonia
f) No past history of ICU admission

Admitted
Discharge
with:

prednisolone
30 mg om x
5 days and
If Yessalbutamol
inhaler puffs
6 hourly prn
advised to
see family
practicioner
within 72 h

Patients whose PEFR < 75%, RR > 25, or SaO2 <

95% on room air
If No

if their vital signs are acceptable, there are

resolution of breatlessness, bronchospasm and
accessory muscle usage, PEFR > 75% predicted
and SaO2 > 95% on room air
Check vital signs ,PEFR, and SaO2 hourly twice
and 2 hourly thereafter
Administer bronchodilator nebul if indicated

Prior Nebul 2 doses before transfer to

Observation Ward

The Time Table Of

Observation

6
hours
3
hours
2
hours
1
Hour

23

Case Report

Patient Identity
Name : Mrs. LS
Sex : Female
Age : 39 years old
Adress: Kedung Kandang - Malang
Education : Senior High School
Occupation : housewife
Admitted to ER on November 22nd,
2014

Primary Survey
A : Partial Obstruction (Wheezing sound +)
B : symmetrical chest movement, RR 28 x/mnt,
Rh(-), retraction (-), fast and shallow, SaO2 94%
C : BP 134/104 mmHg, PR 124x/mnt, warm acral
(Tax : 35,5C), CRT < 2 s
D : round and isochoric pupils, GCS 456

Initial Treatment
A:

Nebulisation salbutamol + ipatropium

bromide (farbivent) 2 amp

B : O2 4 lpm via Nasal Canule

C : D: -

Anamnesa
Chief complain: shortness of breath
Patient suffered from shortness of breath since a
day before admitted. The shortness of breath
became more severe since the night before,
aggravated by activity and not alleviated by
rest. Patient has also been having productive cough
since a week before admission, with white sputum
and no history of fever. She has been becoming
skinnier in last several months, no night sweating.
Past medical history: diagnosed asthma since 16
years old (exacerbation once a week in the past
year, routinely consumes salbutamol and CTM), had
lung TB in 2005 and was stated to be recovered.
Family history: father and uncles have asthma.
Social history: patient lives at home with her
husband and children.

Secondary Survey
General appearance: looked moderately ill
Consciousness : Compos Mentis GCS 456
A : Patent , Rh (-), Wh (+)
B : RR= 28x/m, symmetric
C : BP= 135/104 mmHg
PR= 124x/m, regular
warm acral, CRT < 2 s
Tax : 35,5C
Head: anemic conjunctiva (-/-), icteric sclera (-/-)
Neck
: lymph node enlargement (-), mass (-)
JVP : R +3 cmH2O

Thorax :
C/
I=
ictus invisible
P=
ictus palpable ICS V MCL
P=
RHM ~ SL (D)
LHM ~ ictus
A= S1 S2 single, m (-)
P/
I = symmetric, retraction (-)
P= SF D=S
P=
S S
S S
S S
A= v v
Rh - - Wh +
v v
- v v
- -

(S)

+
+ +
+ +

Abdomen :
Rounded, soefl, meteorismus (-), bowel
sound (+)
H : unpalpable
L : troube space tympani
Extremities :
an (-), cyan (-), ed (-), ict (-)
warm acral, CRT < 2 s

Management

O2 via Nasal Canule 4 lpm

IV plug
Inj. Methylprednisolone 125 mg (IV)
Nebulisation: Salbutamol +
ipatropium bromide (Farbivent) 2 amp

Laboratory Findings
(November 22nd 2014, 11.00)
Lab

Value

Lab

Value

Leukocyte

11720

4700-11300/uL

Eo/Ba/Neu/Lim
/Mo

22,8/1,0/5
1,7/18,7/5
,8

0-4/0-1/5167/25-33/2-5

Hemoglobine

14,40

11,4-15,1 g/dL

SGOT

19

0-32 U/L

Trombocyte

308000

142000424000

SGPT

0-33 U/L

Hematocrit

44,70%

38-42

RBS

128

<200 g/dL

Natrium
Kalium
Chloride

138
3,83
109

136-145
mmol/L
3,5-5mmol/L
98-100mmol/L

Ureum
creatinine

14,10
0,64

16,6-48,52
<1,2

Workups
ECG
Chest X-ray
Lab : CBC, blood chemicals

Conclusion: sinus rhythm 120 bpm

Chest X-Ray

AP position, enough KV, enough

inspiration
Soft tissue and bone scoliosis
Left and right phrenicocostalis
angle blunting
Left and right hemidiaphragm
flatten
Trachea deviates to the right
Hillus normal
Cor: normal size, normal aorta,
extracted to the right hemithorax
Pulmo: normal vascular pattern,
hyperaerated, fibroinfiltrates and
multiple small cavities in upper
middle lobe lung dextra and upper
area lung sinistra that cause
trachea deviates to the right, the
heart extracted to the right, and
narrow the right ICS.
Conclusion: active lung TB,
pulmonary emphysema

Working
Diagnosis

Dispositio
n

SOB dt
moderate
asthma
attack

Pulmonolog
y
department

Discussion

Anamnesis
Theor
y symptoms :
Presenting

Case

Presenting symptoms :
Dyspnoea 1 days ago,
Triad of asthma
wheezing, and Cough with
symptoms are dyspnoea,
white sputum 1 weeks ago.
wheezing and cough.
Precipitating factors,
Precipitating factors, e.g.
susp.URI
dust and URI
Patient have high risk
High risk features
features to death from
asthma (see next slide)
Current medications
Current medications with
including compliance
Salbutamol and CTM, but
asthma persist at the level
Partially Controlled

Risk Factors for death from

asthma
Past history of sudden severe exacerbations
Prior intubation and mechanical ventilation for asthma
Prior admission for asthma to an intensive care unit
Two or more hospitalizations for asthma in the past year
Three or more emergency care visits for asthma in the past year
Hospitalization or an emergency care visit for asthma within the past
mounth
Use of more than two canisters per month of inhaled short-acting-2Agonist
Current use of systemic corticosteroids or recent withdrawal from
systemic corticosteroids
Difficulty perceiving airflow obstruction or its severity
Comorbidity, as from cardiovascular diseases or COPD
Serious psychiatric disease or psychosocial problems
Low socioeconomic status and urban residence
Illicit drug use
Not currently using inhaled corticosteroids
Guide to the essentials in Emergency

Physical Examination
Theor
General
y

Appearance

Case

General
Appearance

Mental state, signs of

respiratory distress
and cyanosis

Compos Mentis, signs

of respiratory distress
(+), cyanosis (-)

Vital signs

Vital signs

RR, SpO2

RR=28x/minute,
SpO2 94%

Respiratory
Prolonged expiratory
phase, rhonchi,
crepitations, and air
entry

Respiratory

Prolonged expiratory
phase, wheezing (+)
all lung area

Laboratory Findings
Theor
y X Ray
Chest
Indicated in patients
not responding to
initial therapy. Look
for pneumothorax,
pneumonia, or
congestive heart
failure

Arterial Blood Gas

Others

CBC and renal panel

(especially for
hypokalemia d.t.

Case

Chest X Ray
Active Lung TB
and
Emphysematou
s Lung

Others

CBC : Slight
leukositosis
with
Eosinophilia

Lessons Learnt
How to assess patients with SOB
Diagnosing asthma
Management of SOB, especially
asthma
Correlation between asthma and
lung TB
Management of asthma with lung TB

Thank You

TB IRIS
Immune Reconstitution Inflammatory
Syndrome (IRIS) refers to :
a phenomenon experienced by people living
with HIV who have recently initiated
antiretroviral therapy.
a paradoxical inflammatory reaction against
a foreign antigen (alive or dead) in patients
who have started antiretroviral therapy and
who have undergone a reconstitution of
their immune responses against this
antigen. (Colebunders, 2010)

Pathophysiology
The partial reconstitution of the immune
system following initiation of antiretroviral
therapy in these patients can result in an
exaggerated inflammatory response against
any concurrent opportunistic infection.
Sometimes the opportunistic infection
pathogen against which the inflammatory
response is directed remains clinically 'silent'
prior to initiation of antiretroviral therapy,
such that antiretroviral therapy 'unmasks' a
previously undiagnosed disease.

Tuberculosis - Immune Reconstitution

Inflammatory Syndrome (TB-IRIS)
refers specifically to IRIS that occurs
in the context of a patient with active
Mycobacterium
tuberculosisinfection, and is a
relatively common complication for
HIV-infected persons who initiate
antiretroviral therapy in resourcelimited settings, particularly in

Pathogenesis
Increased lymphoproliferative
response to mycobacterium antigens
in vitro
Restoration of cutaneous response to
Tuberculin
Increased [Il-6], activation markers
(CD38)
Associated with TNFA-308*1, IL6174*G

Risk factors for TB/IRIS

Starting ARVs within 6 weeks of TB
treatment
Disseminated, extra-pulmonary disease
Low base line CD4 count (have a CD4
count < 100 cells/mm3)
have a prompt rise in CD4 count in the
initial 3 months of HAART
Fall in viral load
High bacillary burden (?)