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Mahirina Marjani
ASTHMA
Asthma
chronic
inflamatory disease of the
airway
obstruction of
airflow
completely or
partially
BRONCHOSPASM
INCIDENCE
MANAGEMENT
PREVENTI
NG
SYMPTOM Education
P
TREATING Short Treatment
ASTHMA Long Term
ATTACK
Administration
CASE
RT
REPO
A 11 years old boy admitted to dr.
Wahidin Sudirohusodo Hospital with
chief complaint shortness of breath on
November 9th 2011
Alloanamnesis : Mother
HISTORY TAKING:
Shortness of breath experienced since 3 days and
worsening during the last day before admission
cough with white mucus since 1 weeks before
admission
His appetite decrased
There was decrease of apettite
Micturition and defecation were normal
history of shorthness of breath experienced first when
he was 7 years old and got treatment at local hospital,
The next attacked when he was 10 years oldl
Recently, reccurent shortness of breath 4-5 times a
month particularly at night and early morning,
triggered by cold temperature and activity
history of asthma in family is his mother
and there was no history of atopic
PHYSICAL EXAMINATION
GC: moderate ill, undernourished, consciou s(GCS
15)
Vital sign: BP : 100/70, HR 136 x/min, RR 34 x/min,
Temp 36,5o C
Inspection: nasal flare (+), retraction on subcostal,
intercostal and suprasternal regio
Auscultation: BS bronchovesicular, crackles and
wheezing on both right and left lung
LABORATORY FINDING
Hb : 16,3 g/dl
PLT : 501.000 /mm3
WBC : 9.330 /mm3
- eosinophil 0,68%
- basophil 0,68%
- metamyelocyte 82,4%
- granulocyte 26,9%
- monocyte 9,5%
CHEST RADIOGRAPHY
WORKING
DIAGNOSI
S
Frequent Episodic Asthma
With Severe Asthma Attacks
UNDERNOURIS
HED
THERAPHY
- Oxygen 2 liter/minute
- IVFD dextrose 5% 24 drops per minute
- Inhale ipratropium bromida + salbutamol
(combivent)1 tube thinning in NaCl 2,5 cc every 2
hours (if recovey, achieved after 4-6 times of
nebulization, given in 4 hours interval)
- Methylprednisolon 0,5-1 mg/kgBW each day, it means
5 mg/8 hours intravenous
- Aminophyline loading dose 6 mg/ kgBW, it means 150
mg of aminophyline thinning in 20 cc dextrose 5% in
30 minute continous with maintenance dose 0,5-1
mg/kgBW/hour = 300 mg/day
FOLLOW UP
2nd day
3rd day
5th day
Vital Sign
Normal
Normal
Normal
Complaint
dyspneu
Nothing
Nothing
Physical
examination
Minimal retraction
on intercostal,
there were no
crackles &
wheezing
No
retraction,
no crackles
& wheezing
Therapy
IVFD dextrose
5% and stop
methylprednisolo
ne exchange to
prednisone
tablets 3 times
each day
Prednisone
tablets 3
times each
day
Patient
allowed to
discharge
from
hospital
PROGNOSIS
QUA AD
VITAM
BONAM
QUA AD
SANATIONEM
DEFINITIVE DIAGNOSIS
Frequent Episodic
Asthma With
Severe Asthma
Attacks
Undernourished
DISCUSSION
PATHOPHYSIOLOGY OF CLINICAL
SYMPTOMS
AIRWAY
CONSTRICTIO
N
MUCUS
HYPERSECRET
ION
AIRWAY
OBSTRUCTIO
N
SHORTNES
S OF
BREATH
WHEEZING
CHEST
DISTRESS
SOURCE: health.wikinut.com
PATIENT
Shorthness of breath
Cough with
hyersecretion mucus
Wheezing
Respiratory
symptomps triggered
by cold temperature
and activity
Infrequent
parameter,
asthma
drug
asthma)
Frequent
(mild asthma
requirement,
Persistent
asthma
(moderate
(severe
asthma)
asthma)
pulmonary
function
Frequency
of <1x month
>1x/month
Often
attack
Duration
of < 1 week
1 week
Occure almost a
attack
year,
no
Interval
Often
remission
Symptom
at
Often disturbed
May be impared
disturbed
Never in normal
episodes
Sleep
activity
Physical
No symptom
and Undisturbed
exam Normal
Inhalatation/
(anty
minimal dose
oral steroid
inflammatory
of
steroid/nonst
eroid
Pulmonary
PEF/FEV1
function test
80%
> PEF/FEV1
80%
60- PEF/FEV1
<
60%
variability 2030%
Pulmonary
Variability
function
15%
variability
> Variability
30%
> Variability
50%
>
Mild
pulmonary
Moderate
function
Breathless Walking
Can
Talking
lie Infant-softer
Without
With
threat of
threat of
respiratory
respirator
arrest
y arrest
At rest
Infant stops
down
Shorter cry
feeding
Difficult
Hunched
feeding
forward
Prefers sitting
Position
Talks in
Alertness
Could
lying
propped
Sentences Phrases
arm
Words
Maybe
Usually
Usually
Drowsy or
Cyanosis
Wheezing
No
Moderate,
often
No
Loud, almost
Yes
Very
only of expiratory
obvious
audible
expiratory
without
Obvious
loud, Difficult,
no sound
stetoscop
during
expiration
and
Use of
inspiration
Yes
Toracoabd
respiratory
ominal
muscle
paradoxal
Retraction
movement
plus Superficial
Superficial, Moderate,
Within,
intercostal
plus
nostril
retraction
suprasternal
breathing
dissapear
retraction
Respiratory
Increased
Increased
rate
Pulse rate
often
Decreased
>30x/min
<100
100-200
Paradoxus
Absent
Maybe present
pulse
>120
Bradycard
Often
i
Absent
present
suggests
20PEFR or FEV1
(% prediction
value / % best
value)
>60%
40-60%
Pre-
bronchodilator
Over 80%
Approximately
60-80%
Post-
40
mmHg
<40%
<60%
bronchodilator
SaO2%
> 95%
91-95%
90%
Normal
(usually
may not be
>60 mmHg
<
mmHg
60
Chest X-Ray
(posteroanteri
or &lateral
views) in
children with
asthma often
appear to be
normal, aside
from subtle &
nonspecific
findings of
hyperinflation
(flattening of
the
diaphragms)
&
MANAGEMENT OF ASTHMA
Oxygen as supportive
theraphy
Rehydration
-adrenergic agonist
Anthicolinergic
Systemic corticosteroid
Bronchodilation
Oxygen
Theraphy
given oxygen at moderate &
severe attacks
Dehydration
caused by lack of inadequate fluid
intake, increased insensible water
lose, tachypneu & diuretic effects
of theophylline.
-adrenergic
agonist
Ipratropium bromide
Recommended dose is 0,1 ml/kg
BW, nebulized every 4 hours
Systemic
corticosteroid
The recommended doses:
- Methylprednisolone is 0.5-1 mg/kgBW,
given every 4-6 hours, hydrocortisone
intravenous be given 4mg/kgBW, every
4-6 hours
- Dexamethason intravenous at a dose of
0.5-1 mg/kgBW, coninued 1
mg/kgBW/day, administered every 6-8
hours
- Oral preparations : prednisone,
Bronchodilatio
n
Methyl xanthine (theophylline) is
equipotent to 2-agonist :
- Initial dose of aminophyline is 68 mg/kg BW diluted in 20 ml of
dextrose 5% or normal saline
solution given in 20-30 minutes.
- Maintenance dose of 0,5-1
mg/kg BW/hour
Asthma Treatment
Guideline
THANK
YOU