Asthma practical cases Asthma practical cases Asthma differential

Asthma practical cases

Asthma practical cases Asthma differential diagnosis - Questions What is the differential diagnosis in the following cases: • 5 years old child with single episode of cough and wheeze in September of the first year at school.

Asthma practical cases Asthma differential diagnosis – answers What is the differential diagnosis in the following cases: • Acute bronchitis

Asthma practical cases Asthma differential diagnosis - Questions What is the differential diagnosis in the following cases: • 2 ½ years child who developed a fit of coughing during a birthday tea at a friends house

Asthma practical cases Asthma differential diagnosis – answers What is the differential diagnosis in the following cases: • FB

Asthma practical cases Asthma differential diagnosis - Questions What is the differential diagnosis in the following cases: • 55 years lifelong smoker with history of increasing breathlessness on exertion

Asthma practical cases Asthma differential diagnosis – answers What is the differential diagnosis in the following cases: • COPD

Asthma practical cases PFM case – question You take PFM from 20 years old male, height 175 cm A. what is his predicted reading? B. Over the next 3 days his readings are: – day 1 am=400, pm 550 – day 2 am=410, pm 555 – day 3 am=395, pm 550 – is this abnormal?

Asthma practical cases PFM case - answer A. 590 L/min B. Abnormal variability 550 -400/550=27% 555 -410/555=26% 550 -395/550=28%

Asthma practical cases Asthma diagnostic tests - questions Choose the most appropriate diagnostic test for the following patients: • 14 years boy who finds he gets breathless when playing football, PFM is normal when come to your clinic

Asthma practical cases Asthma diagnostic tests - answers Choose the most appropriate diagnostic test for the following patients: • Exercise test

Asthma practical cases Asthma diagnostic tests - questions Choose the most appropriate diagnostic test for the following patients: • 35 years old man who presents for the first time, and has PFM of 250 in the clinic

Asthma practical cases Asthma diagnostic tests - answers Choose the most appropriate diagnostic test for the following patients: • Reversibility test

Asthma practical cases Asthma diagnostic tests - questions Choose the most appropriate diagnostic test for the following patients: • 60 years old heavy smoker who has not responded to high dose B 2 agonists

Asthma practical cases Asthma diagnostic tests - answers Choose the most appropriate diagnostic test for the following patients: • Steroid trial

Asthma practical cases Asthma diagnostic tests - questions Choose the most appropriate diagnostic test for the following patients: • 23 years old who had worse symptoms since starting his job at a bakery

Asthma practical cases Asthma diagnostic tests - answers Choose the most appropriate diagnostic test for the following patients: • Serial PEF for 2 w

Asthma practical cases Delivery systems case - questions Choose the appropriate delivery systems in the followings (one or more): B 2 agonists for 18 month baby?

Asthma practical cases Delivery systems case - answers Spacer device with facemask

Asthma practical cases Delivery systems case - questions Choose the appropriate delivery systems in the followings (one or more): B 2 agonist for 18 year who is unable to use MDIs correctly?

Asthma practical cases Delivery systems case - answers DPI/breathe actuated MDI

Asthma practical cases Delivery systems case - questions Choose the appropriate delivery systems in the followings (one or more): B 2 agonist for 27 year old, successfully controlled since childhood on MDI

Asthma practical cases Delivery systems case - answers MDI

Asthma practical cases Delivery systems case - questions Choose the appropriate delivery systems in the followings (one or more): B 2 stimulant reversibility testing in the clinic

Asthma practical cases Delivery systems case - answers Spacer + MDI or nebulizer

Asthma practical cases Delivery systems case - questions Choose the appropriate delivery systems in the followings (one or more): B 2 stimulant in acute sever asthma

Asthma practical cases Delivery systems case - answers Spacer/nebulizer

Asthma practical cases JAMES CASE James is 18 month old and is presenting for the first time with intermittent cough and wheeze, the history suggest URTI which is possible trigger. In the clinic his symptoms relieved by high dose ventoline via LVS A- If ventoline via LVS had not produce response what you will do?

Asthma practical cases JAMES CASE - answers Send to hospital

Asthma practical cases JAMES CASE James is 18 month old and is presenting for the first time with intermittent cough and wheeze, the history suggest URTI which is possible trigger. In the clinic his symptoms relieved by high dose ventoline via LVS B- His mother is anxious, asks you is it asthma? How do you reply?

Asthma practical cases JAMES CASE - answers Yes it may be asthma, but it can be difficult to be sure at this age because there is no special test can be done, viral infections can cause wheezing in young children. This effect often improve as child get older

Asthma practical cases JAMES CASE James is 18 month old and is presenting for the first time with intermittent cough and wheeze, the history suggest URTI which is possible trigger. In the clinic his symptoms relieved by high dose ventoline via LVS C. What treatment do you recommend?

Asthma practical cases JAMES CASE - answers High dose inhaled bronchodilator + rescue PO Prednisolone to gain rapid control (10 mg up to 3 days)

Asthma practical cases JAMES CASE James is 18 month old and is presenting for the first time with intermittent cough and wheeze, the history suggest URTI which is possible trigger. In the clinic his symptoms relieved by high dose ventoline via LVS D. What inhaler system is appropriate?

Asthma practical cases JAMES CASE – answers LVS + mask if necessary eg volumatic/nebuhaler

Asthma practical cases JAMES CASE James is 18 month old and is presenting for the first time with intermittent cough and wheeze, the history suggest URTI which is possible trigger. In the clinic his symptoms relieved by high dose ventoline via LVS E. How you will respond to James mother questions? 1. (will he grow out of it)? 2. I think the dog make him wheeze, should we get rid of the dog? 3. Can we test to see what's he is allergic to?

Asthma practical cases JAMES CASE – answers E- my response will be: 1. 2. 3. Not all children “grow out of asthma”. Some improves as they get older and they may have periods when they have no symptoms. However asthma can recur at any time because its variable disease Wait and see. It should be possible to control symptoms, without getting rid of the dog. Removing a pet may cause more distress. Give general advice on keeping the dog out of the bedroom etc SPT may be unreliable at this age. It will not affect choice of the treatment. Good history may pinpoint the specific allergen. Invasive procedures in children should be avoided if possible

Asthma practical cases JENNY CASE Jenny is 7 years old and has asthma. She has recently had an asthma attack and was admitted to hospital. She is about to start a new school, and her mother is worried about school attendance. Jenny is worried in case she has another asthma attack and she will not have access to her inhalers A. What treatment does jenny need? What is an appropriate dose for jenny?

Asthma practical cases JENNY CASE – answers Inhaled steroids 100 mcg/twice/day - maximum 400 mcg/day

Asthma practical cases JENNY CASE Jenny is 7 years old and has asthma. She has recently had an asthma attack and was admitted to hospital. She is about to start a new school, and her mother is worried about school attendance. Jenny is worried in case she has another asthma attack and she will not have access to her inhalers B. What inhaler deliver system is suitable for jenny?

Asthma practical cases JENNY CASE – answers LVS or DPI

Asthma practical cases JENNY CASE Jenny is 7 years old and has asthma. She has recently had an asthma attack and was admitted to hospital. She is about to start a new school, and her mother is worried about school attendance. Jenny is worried in case she has another asthma attack and she will not have access to her inhalers C. Give 2 advantages, 2 disadvantages of starting PEF monitoring

Asthma practical cases JENNY CASE – answers PEF monitoring gives a regular objective indication of asthma control. It can demonstrate a response to treatment. If technique is poor the measurement is unreliable. Regular PEF monitoring can become a tedious chore for many children and is often forgotten

Asthma practical cases JENNY CASE Jenny's mother is concerned by treatment prescribed. You spend time reassuring her. At jenny's next appointment 2 weeks later, you find that her PEF is still below her previous best and her symptoms persist D. Suggest 2 reasons why the treatment has not been successful

Asthma practical cases JENNY CASE – answers Poor inhaler technique dosage and medication not taken as prescribed

Asthma practical cases JENNY CASE Jenny's mother is concerned by treatment prescribed. You spend time reassuring her. At jenny's next appointment 2 weeks later, you find that her PEF is still below her previous best and her symptoms persist E. Give 2 advantages, disadvantages of inhaled steroids

Asthma practical cases JENNY CASE – answers Effective anti-inflammatory treatment twice/day delivered directly to lung etc. oral candidiasis, dysphonia (parents sometimes don’t accept)

Asthma practical cases EDNA CASE Edna is 70 years old ex-smoker with chronic bronchitis. She was always chesty as a child. Her breathlessness and cough are worse in cold air and after URTI. PEF is 200 L/minute. Twenty minutes after 400 mcg of inhaled ventoline there is no change A. what further tests do you consider? Give dosage where drugs are used

Asthma practical cases EDNA CASE - answers A. Higher dose up to 2. 5 mg salbutamol (or equivalent via nebulizer, detailed LFT, oral steroid trial 30 mg/day/2 weeks

Asthma practical cases EDNA CASE Edna is 70 years old ex-smoker with chronic bronchitis. She was always chesty as a child. Her breathlessness and cough are worse in cold air and after URTI. PEF is 200 L/minute. Twenty minutes after 400 mcg of inhaled ventoline there is no change B. Inhaled steroids are prescribed. What delivery system do you recommend?

Asthma practical cases EDNA CASE - answers B. LVS/small volume spacers and MDI

Asthma practical cases EDNA CASE Edna is 70 years old ex-smoker with chronic bronchitis. She was always chesty as a child. Her breathlessness and cough are worse in cold air and after URTI. PEF is 200 L/minute. Twenty minutes after 400 mcg of inhaled ventoline there is no change C. What is significant about EDNAS past history?

Asthma practical cases C. EDNA CASE - answers EDNAS past history indicates that she probably had asthma as a child. It may not have been treated because there were no effective asthma treatments available when she was young. She may have mixed airway disease because of her smoking/bronchitis history

Asthma practical cases RICHARD CASE Richard 45 new patient recently hospitalized for acute sever asthma. His record show regular inhaled steroids (800 mcg daily) and inhaled bronchodilators PRN, and frequent exacerbation of symptoms A. How can Richards asthma control be improved?

Asthma practical cases RICHARD CASE – answers - Review medication requirements, dosage, compliance, techniques. - Add in a long acting bronchodilator. - Teach PEF self monitoring, - prescribe him a home supply of oral steroids and advice should he need to take them. - Advise that his asthma needs regular review

Asthma practical cases RICHARD CASE Richard 45 new patient recently hospitalized for acute sever asthma. His record show regular inhaled steroids (800 mcg daily) and inhaled bronchodilators PRN, and frequent exacerbation of symptoms B. What would help Richards manage an acute attack in the future?

Asthma practical cases RICHARD CASE – answers He needs a written personalized asthma action plan. Discuss with him what to look for, and what to do if asthma control deteriorates

Asthma practical cases SARAH CASE Sarah is 20 years old girl who has just come to your clinic for the first time when you see her you note she is slightly wheezy A. What are the important issues to be covered when taking history from her? Justify your answers

Asthma practical cases SARAH CASE - answers A. History include: • • • Respiratory symptoms – try to exclude acute sever asthma Current symptoms Personal history of asthma, atopy Severity of symptoms – frequency, seasonal, episodic etc Previous hospital admissions for asthma if any FH of asthma, atopy Asthma triggers Other health issues Current, past medications Previous inhaler advice Occupation – current, previous Smoking status

Asthma practical cases SARAH CASE Sarah is 20 years old girl who has just come to your clinic for the first time when you see her you note she is slightly wheezy B. You find out she has had asthma since childhood but has not had any treatment for the last few years. Explain what assessments you will do and mention their relevance

Asthma practical cases SARAH CASE – answers B. • • • Asthma diagnosis has been made since childhood but she needs further work to identify severity of current symptoms and test: Current PEF reading, compare against predicted peak flow for age, height Consider reversibility test specially she is slightly wheeze. This is not a diagnostic test but to see if there is any airway reversibility. Serial peak flow.

Asthma practical cases SARAH CASE Sarah is 20 years old girl who has just come to your clinic for the first time when you see her you note she is slightly wheezy C. Discuss the possible reasons for her asthma re-occurrence

Asthma practical cases SARAH CASE - answers C. The natural asthma history needs to be explained to her and why her asthma symptoms have recurred, it may be hormonal effect, smoking, occupation etc. she is likely to have concerns about the recurrence of her symptoms. Please address any concerns from her then answer them.

Asthma practical cases SARAH CASE Sarah is 20 years old girl who has just come to your clinic for the first time when you see her you note she is slightly wheezy D. How you will manage, what information you will give her?

Asthma practical cases SARAH CASE - answers D. She needs to start inhaled asthma drugs. Explain the aims of treatment to her. She needs short acting bronchodilator, mention what device you suggest to her. If she has persistent symptoms she will need to have inhaled steroids as well. she may need rescue course oral steroids to gain rapid control, with review to re-assess control again give asthma action plan, FU appointment extra points: give her literatures (NAC booklet), NAC website