PER asthma.pdf

PER Case PER Case Discussion Discussion

VS VS

/ R2 沈倩吟 / R2

General Data General Data

• Name: 林x臻

• Gander: Girl

• Age: 3 years old

• Chart No.: 001687056H

• PER date: 96/11/12 22:26 pm

96/11/13 09:28 am

Chief Complaint Chief Complaint

• Productive cough with dyspnea for

one day

Present Illness Present Illness

• Productive cough, dyspnea today

• No fever, no rhinorrhea, nasal stiffness+

• Ever visited LMD s/p steam inhalation this afternoon

• Vomiting x2 with food material

• No diarrhea, no constipation

• Poor activity and appetite noted after dyspnea

• Contact History:

A cousin was cough for 3 days without no fever

• Past History:

Pneumonia, bronchitis, AOM

• Allergic History: denied

• Family History: denied

• Vaccine History: scheduled, influenza-

Physical examination Physical examination

• Vital signs:

BT: 36.8C, RR: 35/min, HR: 82/min, BP: 195/62mmHg

• Saturation: 82% in room air

• General condition: Ill looking

• Consciousness: Alert

• HEENT: Injected throat, ulcer-, pus-, mild enlarged tonsil

• normal ear drum

• Heart: RHB, no murmur

• Chest & Lung: Course BS, Rales-, rhonchi+, Wheezing+

• Suprasternal retraction with nasal flaring

• Abdomen: soft, no tenderness, normo-active BoS

• Extremities: freely movable

• NE: no focal signs, DTR++/++

CXR (11/12)

• Small infiltration in both lungs,

may result from chronic infection.

Laboratory data

Laboratory data

Impression Impression

• Asthmatic bronchitis

• Acute tonsillitis

Clinical course Clinical course

• Solu-cortef 60 mg IVA Q6H (4mg/kg/day)

• Steam inhalation:

Ventolin 0.5 AMP Q2HPRN

Epinephrine 0.33 AMP Q2HPRN Pulmicort 0.5 EA Q12H

• IV hydration with symptomatic treatment -> Sat: 96% under O2 3L/min

• Due to the dyspnea persisted -> Admitted to ordinary ward!

POCKET GUIDE FOR ASTHMA

MANAGEMENT AND PREVENTION IN CHILDREN

A Pocket Guide for Physicians and Nurses Revised 2006

1. What is known about asthma?

2. Diagnosing asthma

3. Classification of asthma by level of control 4. Four components of asthma care:

- Develop Patient/Family/Doctor Partnership - Identify and Reduce Exposure to Risk Factors - Assess, Treat, and Monitor Asthma

- Manage Exacerbations

What is known about asthma What is known about asthma

• Asthma causes recurring episodes of

wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the

early morning.

• A chronic inflammatory disorder of the airways.

• Chronically inflamed airways are

hyperresponsive: obstructed, limited airflow (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors.

• Common risk factors include exposure to

allergens (such as those from house dust mites, animals with fur, cockroaches, pollens, and

molds), occupational irritants, tobacco smoke, respiratory (viral) infections, exercise, strong emotional expressions, chemical irritants, and drugs (such as aspirin and beta blockers).

• A stepwise approach to pharmacologic

treatment to achieve and maintain control of asthma should take into account the safety of treatment, potential for adverse effects, and the cost of treatment required to achieve control.

• Asthma attacks (or exacerbations) are episodic, but airway inflammation is chronically present.

• For many patients, controller medication must be taken daily to prevent symptoms, improve lung function, and prevent attacks.

• Reliever medications may occasionally be required to treat acute symptoms such as wheezing, chest tightness, and cough.

Treating to Achieve Control Treating to Achieve Control

• At each treatment step, reliever medication should be provided for quick relief of symptoms as needed.

• At Steps 2 through 5, patients also require one or more regular controller medications, which

keep symptoms and attacks from starting.

• Inhaled glucocorticosteroids are the most effective controller medications currently

available.

• For most patients newly diagnosed with asthma or not yet on medication, treatment should be started at Step 2 (or if the patient is very

symptomatic, at Step 3).

• If asthma is not controlled on the current treatment regimen, treatment should be stepped up until control is achieved.

• For children age 5 and younger, a low-dose inhaled glucocorticosteroid is the

recommended initial controller treatment (Figure 5A). If this treatment does not control symptoms, an increase in the glucocorticosteroid dose is the best option.

• Inhaled medications are preferred because they deliver drugs directly to the airways where they are needed, resulting in potent therapeutic effects with fewer systemic side effects.

Manage Exacerbations Manage Exacerbations

• Exacerbations of asthma (asthma attacks) are episodes of a progressive increase in shortness of breath, cough, wheezing, or chest tightness, or a combination of these symptoms.

• Do not underestimate the severity of an attack; severe asthma attacks may be life threatening.

• Children/adolescents at high risk for asthma-

related death require closer attention and should be encouraged to seek urgent care early in the course of their exacerbations:

The patients:

• With a history of near-fatal asthma

• Who have had a hospitalization or emergency visit for asthma within the past year, or prior intubation for

asthma

• Who are currently using or have recently stopped using oral glucocorticosteroids

• Who are overdependent on rapid-acting inhaled 2- agonists

• With a history of psychosocial problems or denial of asthma or its severity

• With a history of noncompliance with asthma medication plan

Patients should immediately seek Patients should immediately seek medical care if

medical care if t t he attack is he attack is severe severe

– The patient is breathless at rest, is hunched forward, talks in words rather than sentences (infant stops

feeding), agitated, drowsy or confused, has bradycardia, or a respiratory rate greater than 30 per minute

– Wheeze is loud or absent

– Pulse is greater than: 160/min for infants

120/min for children 1-2 years 110/min for children 2-8 years

– PEF is less than 60 percent of predicted or personal best even after initial treatment

– The child is exhausted

Patients should immediately Patients should immediately

seek medical care

seek medical care … …

• The response to the initial bronchodilator treatment is not prompt and sustained for at least 3 hours!

• There is no improvement within 2 to 6 hours after oral glucocorticosteroid treatment is started!

• There is further deterioration!

• Mild attacks, defined by a reduction in peak

flow of less than 20%, nocturnal awakening, and increased use of rapid-acting 2-agonists, can

usually be treated at home if the patient is prepared and has a personal asthma

management plan that includes action steps.

• Moderate attacks may require, and severe attacks usually require, care in a clinic or

hospital.

Asthma attacks require prompt Asthma attacks require prompt

treatment treatment

• Oxygen is given at health centers or hospitals if the patient is hypoxemic (achieve O2 saturation of 95%).

• Inhaled rapid-acting 2-agonists in adequate doses are essential:

- Begin with 2 to 4 puffs every 20 minutes for the first hour

- mild exacerbations will require 2 to 4 puffs every 3 to 4 hours

- moderate exacerbations 6 to 10 puffs every 1 to 2 hours

• Oral glucocorticosteroids (0.5 to 1 mg of

prednisolone/kg or equivalent during a 24-hour period) introduced early in the course of a

moderate or severe attack help to reverse the inflammation and speed recovery.

• Methylxanthines are not recommended if used in addition to high doses of inhaled 2-agonists.

• Theophylline can be used if inhaled 2-agonists are not available. If the patient is already taking theophylline on a daily basis, serum

concentration should be measured before adding short-acting theophylline.

Therapies

Therapies not recommended not recommended for for treating attacks

treating attacks

• Sedatives (strictly avoid).

• Mucolytic drugs (may worsen cough).

• Chest physical therapy/physiotherapy (may increase patient discomfort).

• Hydration with large volumes of fluid for adults and older

children (may be necessary for younger children and infants).

• Antibiotics (do not treat attacks but are indicated for patients who also have pneumonia or bacterial infection such as

sinusitis).

• Epinephrine (adrenaline) may be indicated for acute

treatment of anaphylaxis and angioedema but is not indicated during asthma attacks.

• Intravenous magnesium sulphate has not been studied in young children.