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    PBL Case 1

    Uploaded by

    Irina Luciana Dumitriu
    Saleh, a 19-year-old student, came to the emergency room due to shortness of breath, cough, and tiredness for the last few days. He had been at a dusty, cold motorbike show on the weekend and felt unwell the next day with repeated coughing. On examination, he had wheezing and used extra muscles to breathe. His breathing rate and heart rate were elevated. A diagnosis of bronchial asthma was made based on his symptoms and medical history of similar attacks with exercise. He was given oxygen, intravenous fluids, and an inhaler treatment of salbutamol, which improved his symptoms and oxygen levels.

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    PBL Case 1

    Uploaded by

    Irina Luciana Dumitriu
    284 views11 pages
    Saleh, a 19-year-old student, came to the emergency room due to shortness of breath, cough, and tiredness for the last few days. He had been at a dusty, cold motorbike show on the weekend and felt unwell the next day with repeated coughing. On examination, he had wheezing and used extra muscles to breathe. His breathing rate and heart rate were elevated. A diagnosis of bronchial asthma was made based on his symptoms and medical history of similar attacks with exercise. He was given oxygen, intravenous fluids, and an inhaler treatment of salbutamol, which improved his symptoms and oxygen levels.

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    PBL

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    Saleh, a 19-year-old student, came to the emergency room due to shortness of breath, cough, and tiredness for the last few days. He had been at a dusty, cold motorbike show on the weekend and felt unwell the next day with repeated coughing. On examination, he had wheezing and used extra muscles to breathe. His breathing rate and heart rate were elevated. A diagnosis of bronchial asthma was made based on his symptoms and medical history of similar attacks with exercise. He was given oxygen, intravenous fluids, and an inhaler treatment of salbutamol, which improved his symptoms and oxygen levels.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    284 views11 pages

    PBL Case 1

    Uploaded by

    Irina Luciana Dumitriu
    Saleh, a 19-year-old student, came to the emergency room due to shortness of breath, cough, and tiredness for the last few days. He had been at a dusty, cold motorbike show on the weekend and felt unwell the next day with repeated coughing. On examination, he had wheezing and used extra muscles to breathe. His breathing rate and heart rate were elevated. A diagnosis of bronchial asthma was made based on his symptoms and medical history of similar attacks with exercise. He was given oxygen, intravenous fluids, and an inhaler treatment of salbutamol, which improved his symptoms and oxygen levels.

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    PBL

    First Case
    I am short of breath

    Case scenario:
    o Saleh, a 19 year old student came to the ER because of shortness of breath for
    the last couple of days associated with cough and tiredness.
    o A few days ago, Saleh spent the weekend in a motorbike show. The weather was
    dusty and cold, on the following day he didnt feel good and he had repeated
    coughing at night.

    o He uses his sternocleidomastoid muscles and alae nasi during breathing.


    o Couldnt sleep because of the shortness of breath and cough, and he was
    wheezing. His cough was dry and he has no phlegm. While sleeping he needed
    to place two pillows behind his head.
    o Took two tablets of Aspirin but his condition got worse.
    o No fever, no running nose and no sore throat.
    o Saleh had similar attacks for the last three years, specially
    when he exercises.

    Diagnosis:
    Bronchial Asthma

    Examination:

    Pulse rate <high>


    Respiratory rate is <high>
    Expiratory wheezing on both sides.
    No clubbing of fingers. (Exclude heart diseases)
    PEF = 350 L/Min <abnormal>
    Oxygen saturation: 89% <below normal> (Normal 95-100%)

    Management:

    After examination, he was connected to a pulse oximeter to his index finger.


    Oxygen mask.
    Saline/glucose solution, given via the IV line.
    The Dr continues Saleh on Salbutamol inhalation through a spacer. (7-10 minutes)

    Terms:
    1. Wheezing: To breathe with difficulty, producing a hoarse whistling sound.
    2. Phlegm: sticky mucus secreted by the mucous membrane of the respiratory
    tract, as during a cold or other respiratory infection.
    3. Sternocleidomastoid muscles: Either of two muscles of the neck that serve to
    flex the neck and rotate the head.
    4. Alae nasi: the expanded outer wall of cartilage on each side of the nose
    5. Cyanosis: a bluish or purplish discoloration (as of skin) due to deficient
    oxygenation of the blood
    6. Pulse oximeter: a device that measures the oxygen saturation of arterial blood
    in a subject by utilizing a sensor attached typically to a finger, toe, or ear to
    determine the percentage of oxyhemoglobin in blood.
    7. Salbutamol: A sympathomimetic agent used as a bronchodilator, especially in
    the treatment of asthma
    8. Spacer: A device attached to a metered-dose inhaler that aids delivery of
    inhaled medications.
    9. PEF: (peak expiratory flow), the greatest rate of airflow that can be achieved
    during forced expiration, beginning with the lungs fully inflated. (Important)

    Bronchial Asthma
    Definition:
    o A chronic inflammatory disease of the airways that causes
    periodic "attacks" of coughing, wheezing, shortness of
    breath, and chest tightness.

    Symptoms:
    o
    o
    o
    o

    Difficulty breathing.
    Wheezing.
    Cough, specially at night.
    Speech is fragmented when he talks. (shortness of breath)

    Risk factors:
    o Changing weather and place.
    o Dusty places
    o Exercising

    Causes:
    o Outdoor allergens. (Dust)
    o Conditions. (Cold weather)
    o Emotions. (Stress)

    Management:
    o He had a moderate asthma attacks, which are related to exercising and
    exposure to dusty and cold air.
    o Saleh continues on a bronchodilator for two hours.
    o His condition got much better.
    o The reading on the PFE measurement shows improvement (80% of
    predicted value) <due to the inhalation of Bronchodilator>
    o Oxygen saturation has improved (94%)

    Videos Corner
    Asthma
    PEF

    Salbutamol
    Short-acting selective 2-adrenergic receptor agonist. Rapid relief onset relax
    bronchial smooth muscle and may decrease mediator release from mast cells
    and basophils.
    It may also inhibit airway microvascular leakage. It's marketed
    as Ventolin among other brand names.

    Medical Uses
    Used for the relief of bronchospasm in conditions such as asthma and chronic
    obstructive pulmonary disease.
    Used in second line anaphylactic shock treatment.

    Adverse effects
    The most common side effects are fine tremor, anxiety, dry mouth,
    and palpitation.

    Rout of Administration
    Given orally, by inhalation or parentally.

    Why didnt he respond to Aspirin?


    Aspirin causes the body to produce excess amounts of a class of
    chemicals known as leukotrienes. Leukotrienes cause the muscles
    surrounding the bronchial tubes to contract, resulting in wheezing
    and shortness of breath. And because
    NSAIDs induce bronchoconstriction.

    Questions
    Q1: Discuss the main differences between salbutamol and cortisol
    inhalers?
    Salbutamol inhaler:

    Bronchodilator

    It can be used either alone or combined.

    Salbutamol + Ipratropium

    Short acting 2 agonists

    main choice in acute attack of asthma


    It causes: Adenyl cyclase & cAMP

    Cortisol inhalers:
    Anti-inflammatory drugs
    (prophylactic)
    (Inhibits phospholipase A2)
    Dexamethasone, Fluticasone
    and Budesonide.

    Q2: The pathological changes encountered during an acute asthma


    attack?
    1- Intermittent and reversible airway obstruction that causes:
    acute bronchoconstriction
    airway edema
    chronic mucous plug formation
    airway remodeling
    2- Chronic bronchial inflammation with eosinophils
    3- Bronchial smooth muscle cell hypertrophy and hyper-reactivity causes exaggerated bronchoconstriction.

    Q3: Discuss the physiological gas exchange.

    1.
    2.

    1.
    2.

    External respiration:
    At the alveoli the inhaled (O2) travels through the pulmonary capillaries and ultimately reaches
    the heart.
    Through the left atrium of the heart, the oxygenated blood is then travels to the tissue.
    Internal respiration:
    The oxygenated blood travels through the systemic circulation and oxygenates the tissue.
    Carbon dioxide (co2) is carried by the systemic capillaries and finally reaches the right atrium of
    the heart which pumps it to the lungs alveoli where it is then exhaled.

    Q4: Discuss the pharmacology of drugs used in the management of


    acute asthma and those used in prevention.
    Anti
    asthmatic
    drugs:

    Control
    therapy
    (prophylactic
    drugs)

    Quick relief
    medications

    Bronchodilators
    used to relieve
    acute episodic
    attacks of asthma.

    Anti-inflammatory drugs
    used to reduce the
    frequency of attacks, and
    nocturnal awakenings.

    Q4: What are the differences between obstructive and restrictive lung
    diseases?
    Obstructive lung diseases:

    Is a category of respiratory disease characterized by airway obstruction . It is generally characterized by inflamed


    and easily collapsible airways, obstruction to airflow and problems exhaling.
    Pulmonary function test: decreased FEV1 and decreased FEV1/VC.
    Examples: Bronchial asthma, COPD.

    Restrictive lung diseases:

    Are a category of diseases that restrict lung expansion, resulting in a decreased total lung capacity, increased
    work of breathing, and inadequate ventilation and/or oxygenation.
    Both FEV1 and FVC are decreased, with normal to high FEV1/VC.

    Q5: The pathogenesis of bronchial asthma.

    Principal cells in asthma: mast cells, eosinophils, epithelial cells, macrophages, and activated T lymphocytes
    (TH2 subset) and neutrophils.
    T lymphocytes play an important role in the regulation of airway inflammation through the release of numerous
    cytokine
    Bronchospasm is induced by inhaled antigens.
    Salbutamol is used for acute asthma attacks

    Best of luck!
    Done by:
    The PBL team

    Contact info:
    [email protected]

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