Case 3: Nene is a 37-year old call center agent. She is a known asthmatic since childhood.

She is married to Noynoy who is a heavy smoker with whom she has 3 children aged 4, 7 and 10. Her maintenance medications are Salamterol Fluticasone (Seretide) and Salbutamol MDI as needed. However, Nenes compliance to Seretide is poor and she relies only on her Salbutamol inhaler for exacerbations. 2 days ago, she developed low-grade fever, colds and general body malaise. This was followed by dyspnea and nocturnal wheezing. Patient did not seek consult but instead self-medicated with Salbutamol nebulisation. The condition worsened now with notes chest tightness and dyspnea even at rest. She was rushed to the emergency room. Initial physical examination revealed BP 140/0, CR 114/min, RR 32/min with noted use of accessory muscle of inspiration. Chest and lung examination revealed intercostals and subcostal retractions with diffuse wheeze and tight air entry. ABG revealed the following result: pH 7.48, pC02 35 mmHg, HC03 22, pa02 52 mmHg, Fi02 0.21. Questions: 1. What is the expected spirometry result for bronchial asthma? Based on the patients spirometry results, what parameters denote presence of obstructive airway disease? What parameters denote reversibility? Explain. A reduced ratio of FEV1/FVC (i.e., <65 percent) indicates obstruction to the flow of air from the lungs. FEV1 is also reduced. The severity of abnormality of spirometric measurements is evaluated by comparison of the patient's results with reference values based on age, height, sex, and race. In severe cases, the FVC may also be reduced, due to trapping of air in the lungs. Significant reversibility of airway obstruction is defined by an increase of 12% and 200 mL in FEV1 or 15% and 200 mL in FVC after inhaling a short- acting bronchodilator. A positive bronchodilator response strongly confirms the diagnosis of asthma.

2. What lung volume and capacities are affected in bronchial asthma? Compare these changes to normal PFT. Increases in airway resistance, such as those seen in asthma, lead to decreases in all expiratory parameters, including FVC, FEV. and FEV1/FVC. The higher the airway resistance, the more difficult it is to expire air from the lungs. Airway resistance is especially increased during forced expiration, when intrapleural pressure becomes positive and tends to compress, or even close, the airways. Therefore, FVC decreases during an asthma attack because the airways close prematurely during expiration.

3. Define work of breathing What are the factors that affect work of breathing? List and explain all the clinical manifestations of Nene that shows affectation of the work of breathing. During normal quiet breathing, all respiratory muscle contraction occurs during inspiration; expiration is almost entirely a passive process caused by elastic recoil of the lungs and chest cage. Thus, under resting conditions, the respiratory muscles normally perform work to cause

inspiration but not to cause expiration. The work of inspiration can be divided into three fractions: (1) that required to expand the lungs against the lung and chest elastic forces, called compliance work or elastic work; (2) that required to overcome the viscosity of the lung and chest wall structures, called tissue resistance work; and (3) that required to overcome airway resistance to movement of air into the lungs, called airway resistance work. Nenes clinical manifestations that show work of breathing: noted use of accessory muscle of inspiration intercostals and subcostal retractions with diffuse wheeze and tight air entry 4. Interpret initial ABG results? Explain the reason behind the noted abnormality. What abnormality should be the foremost consideration in making corrections? pH pC02 HC03 pa02 Actual 7.48 35 mmHg 22 52 mmHg Normal 7.35-7.45 35-45 mmHg 22-26 95-100 mmHg Interpretation Alkalosis Normal to alkalosis Normal to acidosis Decreased, Hypoxia

The diagnosis is PARTIALLY COMPENSATED RESPIRATORY ALKALOSIS. Hypoxia should be the foremost consideration in making corrections.