BONCHIAL ASTHMA

1. Definition - 

Reversible by bronchodilator

Recurrent episode

Chronic airway inflammaton

Triggered by multitrigger

Heterogenous (not single thing, change phenotype)

2. Different phenotype

- Allergic Asthma (most common)

- Excercise Induce

- Non Allergy

* United Airway Disease - Upper and lower airway (Allergy Rhinitis + Asthma)

3. Patophysiology

Trigger - Hyperresponse - Narrowing – Symptoms

4. Risk Factor for asthma

- Food (Allergy)

- Eczema

- Asthma

- Allergic Rhinitis

5. Physical Examination

- Harrison Sulci (asthma, possible ricket juga) - sign chronicity

- Wheezing

- Recession

- Pigeon Chest

6. Make diagnosis

- Base on history and clinical exam

7. Assesment Asthma Severity

- Persistent : Start corticosteroid

8. Asses asthma control

9. Before step up medication

- Assess Technique

- Compliance

- Trigger (smokers)

- Co morbidities

10. GINA assessment

11. Steping up treatment

- LABA- Long acting Beta Agonist

- Increase dose LABA

- Steroid

12. Mx acute asthma

- Admission

~ Failure home treatment

If you think pt exacerbation, give patient steroid (short course also can give - 3 days)

✓ Mild - use inhaler (and steroid)

✓ Moderate - Nebulizer

✓ Severe (cynose, talk in word) 

Life threatening (silent chest, unable to speak)

➢ Mild 

o Neb salbutamol

o Oral prednisolone 1mg/kg/ day x 3@5 dayNeb Salbutamol

➢ Moderate        

o +|- Ipratropium Bromide (anticholinergic)

o Oxygen 8L facemask for moderate case

 

13. Management Intubated patient

- Cont IVI Salbutamol
- Aminophyline
- Mgso4
- Corticosteroid
- Iprapropium Bromide

14. Monitoring patient with acute exacerbation

- PEFR – peak expiratory flow rate

- Spo2

- ABG (usually VBG in practical)

- Chest X ray (if not improving, we look for pneumothorax)

- ABX ( if only there is sign infection)

15. Montelukast - who can we give?

- Adjunct Allergic Rhinitis

- Viral Induce Wheeze

Acute Bronchiolitis

High Risk untuk RSV

- Immunocompromise

- Cynotic Heart Problem

- Chronic Lung Disease

- Vaccine : Palivizumab : Passive Imunity (kita bagi antibodi, dia ada, kemudian dia tak ada dah) - RSV Immunoglobulin - give every month

2. Clinically

- Fine crepitation

3. CXR

- Hyperinflated lung

4. Investigation

- VBG or CBG

5. Nutrition

- By Ryles Tube feeding if cannot tolerate orally. 

6. Oxygen?

- Depend on spo 2

- Nasal prong 

- Optiflow - 2ml per kg

- CPAP - if not tolerate, because patient struggle – need Ventilated (intubate), 

(SIMV setting, if not pick up à HFO : High Flow Oxygen

 

CLERK-RESPIRATORY CASES

Differential dx : Asthma/Acute Bronchiolitis/Pneumonia/Croup/Pertussis

2 year old malay boy, Full Term / SVD

ANC : Uneventful

PNC:Uneventful

-Thid is 2nd hospitalization

- 1st hospitalization at 1 year old : AGE (acute gastroenteritis) admit x 2/7 at HRPZ

- Immunization up to age

- Presented with

·         Rapid breathing x 2/7

  - Worsening on day admission at 12 noon

 - Noted Chest indrawing                                                                                                                                                                                                                                                                                                                                                                                       

 - Chesty in nature

- No prolong bout cough (tro pertussis)

- No barking cough (TRO croup)

- Post-tusive vomiting x 2                                                                                                                                                                    (non billious, no blood, milk content)                                                                                                                           

·         Fever x 3/7

- Continous

- No rigor

- Temporarily relieved by syrup PCM 6 hourly

- Highest documented temperature 38.6 C at home

·         Runny Nose x 1/7

- Clear nose discharge

·         Associated with

- Lethargy - mother noted pt sleep all day, usually active and playful

- Reduce oral intake 1/7, usually take 6 bottle (4 onz), however today only take 2 onz

·         Otherwise

- Unsure about PU (passed urine) - claimed as usual

- No diarrhea

- Sick contact with brother had URTI x 1/52 (fever but already resolved)

- Not from dengue prone area                                                                                                                                                                                            

- No h/o travelling

- No water activity

✅  Interval Symptom (If we thinking of asthma, in patient had strong family history, had multiple admission or nebulization before)

- No daily symptoms

- No nocturnal symptoms

- No exercise induce sympoms

* Ada tak anak puan batuk- batuk atau bersin pada waktu pagi-pagi ketika dia sihat sebelum ni? Malam? Atau ketika dia kuat bermain?

- Patient no allergy rhinitis, but had eczema under HRPZ follow up

- Strong family history of asthma, both parent have allergy rhinitis, maternal auntie has asthma, brother has eczema

 - Multiple history of nebulization before, since 6 month old, about once every 2 month. No admission

- Trigger : URTI/Cold whether, cold drink/dust/cat

*Biasanya, apa yang membuatkan dia mudah nampak lelah atau batuk-batuk sebelum ni?  Contoh  jawapan : Oh doktor, biasa kalau dia selsema atau batuk, dia mudah kelihatan lelah (URTI adalah trigger factor untuknya)

- No cat or carpet at home                    

- Father smokers

PREMATURE

Issue in premature

1. Respiratory distress syndrome

2. Hypothermia - Mostly during transportation

3. Hypoglycemia

4. Intraventricular Haemorrhage - eg cause hypercarbia

Grade 1, 2?

5. ROP (Retina of Prematurity)  - check by opthal about 4 to 5 weeks before discharge

6. Jaundice

7. PDA (Patent Ductus Artery) - sebab tu kita jarang bagi fluid bolus, takut open up the PDA. Feature - Murmur, pulse, wide pulse pressure 

Need restriction of fluid.  

Sign PDA open - urea will be high
Prem usually self closed (functional), unless kalau DM, which is anatomical

8. NEC (Necrotizing Enterocolitis) - Xray , what to look?

9. Rickets of prematurity

Planned to discharge baby premature? What to do?

1. Teach mother for Basic Life Support (sign of apnea)
2. Biweekly weight monitoring.
3. Immunization - some advice to take extra - Pneumococcal
4. Avoid sick contact, avoid crowd, restrict visitor
5. Hand hygiene

OTHERS :

1. When we need to do Ballard Score?

➢ As soon as possible

➢ Not valid to assess if patient on sedation

2. How to know baby is anemic? Level Hb?

➢ Hb less than 15. If anemia, check?

Reticulocyte, Mother Blood Group/ Baby BG, DCT – Direct Coombs Test

Infection? - Hemolysis. Any history cord round neck?

What is placenta weight? (usually 1/5th baby weight)

If huge? What significance?

3. What is Kleirhour test? Check mother blood.

What we want to see?

4. Definition hypotension?

➢ Depend on BP chart)

➢ Small baby we rarely give bolus. Howevet if really needed start 10 cc/kg...Then need to consider inotropic support.

5. Choice of antibiotic

➢ C. Penicillin - more on gram positif  (group B streptococcus)

➢ Gentamicin - more on gram negative  (E coli)

6. Why some patient given Aminophyline? 

- to stimulate baby to prevent apnea

- not given in ventilated patient        

7. When to off caffeine in premature with PDA? 

- Given if patient can tolerate orally

- Its is long acting medication – need  off 3 days before discharge, if

- usually given after CGA 34 weeks