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Title: ground rand 4

1
HUBERT KAIRUKI MEMORIAL UNIVERSITYDEPARTMENT
OF INTERNAL MEDICINEGRAND ROUND PRESENTATION

PRESENTERSFATMA MSUYA,CELESTINA MSUBA,
ELIZABETH MSITA,ABDULRAHIM ,MSINDE NELSON
MSANGI
FACILITATORS SR SARA DR NEEMA

2
PATIENT PARTICULARS

Name Kidawa .H. Said
Age66 years old
Sex Female
Address Kijitonyama
Tribe Kaguru
Religion Muslim
Marital status Married
Next of kin daughter
Informant herself
Occupation Petty trader
Education level grade 4
Referral status self from home
Date of admission 5th jan,2024 Date of
clerkship 6th jan, 2024
Number of days in the ward 1 days

3
CHIEF COMPLAINT

Difficulty in breathing 7days

4
HISTORY OF PRESENTING ILLNESS

The patient presented with of DIB for 7 days , of
gradual onset after being in a dusty environment,
more marked at night .
Aggravated by dust, perfume use and cold.
Relieved by use of salbutamol inhaler and resting
thereafter her DIB was progressive and not
relieved by use of inhaler(Salbutamol) that she
used before
DIB associated with
chest tightness, dry cough, whistling sounds,
inability to complete a sentence.
central chest pain that does not radiate to the
jaw, shoulder and back , difficulty in breathing
when lying flat
lower limb swelling
Easy fatigability
No history of
awareness of heartbeat, air hunger at night

5
REVIEW OF THE OTHER SYSTEMS

EENT (Ears ,eyes , nose and throat)
No ear pain or discharge
No eye pain or discharge
No nasal pain or discharge
No throat pain or swelling
Gastrointestinal system
No of loss of appetite
No weight loss
No difficulty in swallowing
No painful swallowing
No heartburn
No abdominal pain
No vomiting
No passage of lose stools
No difficulty in passing stool

6
ROS cont

Genitourinary system
No genital itching
No Excessive urination
No painful urination
No blood in urine
No urine urgency
No inability to control urine
No blood in urine

Endocrine system
no excessive thirst
no excessive sweating
no weight loss or gain
no cold or heat intolerance
no excessive hair growth
Nervous system
No headache
No convulsions
No dizziness
No loss of consciousness
No Numbness or tingling sensation
No blurry vision

8
ROS cont

Musculoskeletal system
No muscle pain, weakness or stiffness
No joint pain , swelling or stiffness
Hematopoietic system
No easy bruising
No prolonged bleeding tendencies
Integumentary
No skin rashes
No skin itching and redness
No skin swelling
No hair and nail loss

9
PAST MEDICAL HISTORY

This is her 4th admission ,
1st at Lugalo hospital 14 years ago,
diagnosed with fibroid
underwent hysterectomy, treated and was
discharged with no complication.
2nd at Kairuki hospital 3 years ago due to
severe headache
Diagnosed with HTN DM Kept on medication T.
Glimepiride Metformin Tablets (2mg and 500mg )
BD x 1/12 T. candesartan 16mg od x 1/12,T.
spironolactone 25mg od for 1/12 and discharged
3rd at kairuki hospital, 2 years ago due to
diabetic mellitus complication ,
Was treated ,recovered to continue with
medication at home

10
Cont.

She is a known
asthmatic patient diagnosed about 25 years ago
on salbutamol inhaler and tablets.
DM patient diagnosed
3 years ago at Kairuki Hospital
currently on T. Glimepiride Metformin Tablets
(2mg and 500mg ) BD x 1/12
HTN diagnosed 3 years ago, currently on
T. candesartan 16mg od x 1/12,
T. spironolactone 25mg od for 1/12

11
Cont

She has h/o surgery hysterectomy
due to fibroids
She has h/o multiple OPD visit for
drug refill of HTN,DM and ASTHMA
She has h/o using powdery herbal
medications twice a day for 1/12
as she believed she could cure asthma
She had no
h/o blood transfusion
h/o food and drug allergy
h/o trauma

12
GYNAECOLOGICAL HISTORY

She is 14 years post menopausal woman who is
P5L4 with no h/o
painful coitus and post coitus bleeding
She has no history of contraceptive use

13
FAMILY HISTORY

2nd born out of 5 children
Parents are alive and well.
All other siblings are alive and well.
Has h/o HTN on paternal side- her aunt.
has no h/o
other known familial disease asthma, sickle
cell ,epilepsy
Sudden death in the family

14
SOCIAL HISTORY

Married and living with her husband
Has 5children ,
1 died due to severe abdominal pain 4 alive
She has no h/o
alcohol use, cigarette smooking and illicit use
of drugs
She lives in a well ventilated house,
windows allow air and light in and out
She uses charcoal stove for cooking

15
DIETARY HISTORY

She takes 3 meals in a day
Morning tea and brown bread
Afternoon roasted bananas or potatoes,
with meat and vegetables.
Boiled fish with vegetables
Evening she usually has fried banana and fruits
She drinks about 2-3 liters of water per day.
She uses salt in her diet
Diet is not satisfactory to diabetic and
hypertension.

16
SUMMARY 1

K.H.S a 66 year old female who is a
known asthmatic, hypertensive and diabetic on
medication,
presented with DIB for 7 days,
with
chest tightness, central chest pain, dry cough,
wheezes, inability to complete sentences,
orthopnea and bilateral lower limbs swelling.
With no palpitation, paroxysmal nocturnal dyspnea

17
CLINICAL DIAGNOSIS BASED ON HISTORY

DIAGNOSIS 1
ACUTE SEVERE ASTHMA
Reasons
Known asthmatic patient
Increasing chest tightness
wheezing dyspnea not relieved by salbutamol
inhaler
cannot complete a sentence in 1 breath or too
breathless to talk.
DIFFERENTIAL DIAGNOSIS
1. COPD
Reason for chest tightness, wheezing, DIB,
cough,
Reason against no h/o cigarrete smoking,
2. Community acquired pneumonia
reasons for-difficult in breathing,
cough, chest pain
reasons against-presence wheezes
no hx fever

18
DIAGNOSIS

2. CONGESTIVE CARDIAC FAILURE secondary to HTN
Reasons Orthopnea ,Central chest pain,
Bilateral LL edema, dry cough
-known HTN patient
DIFFENTIAL DIAGNOSIS
Myocardial Infarction
Reasons for Central chest pain
-difficult in breathing
Reasons against chest pain does not radiate jaw
and left arm, gradual onset of DIB

19
DIAGNOSIS

OTHER DIAGNOSIS
Type 2 diabetes mellitus
Hypertension

20
PHYSICAL EXAMINATION

GENERAL EXAMINATION
Conscious, ill looking with non-rebreather oxygen
mask
Pink cannula on the dorsum of left thumb for IV
medications
urinary catheter with urine output of 500mls
collected over the past six hours.
normal hair texture ,colour and distribution
which were not easily pluckable
She was not pale, not jaundiced, not cyanosed
No Eye, Nose and Ear swelling ,discharge nasal
bleeding.

21
GENERAL EXAMINATION

She had no
angular stomatitis, angular cheilitis and
atrophic glossitis
Janeway lesions,Oslers nodes, splinter
haemorrhage,
Palmar Erythema, Koilonychia, Leukonychia, finger
clubbing
Normal Capillary refill less than 2 seconds
No palpable peripheral Lymph nodes
Bilateral Pitting LL oedema at pedal and pretibial

22
VITALS

Temperature 36.5C
Pulse rate 108bpm
Respiratory rate 30 b/m
Blood pressure 138/92mmHg
Spo2 on 15L/min 99
SP02 ON RA 75-84
CONCLUSION
She was tachycardic, tachypnoeic and desaturating
in RA

23
SYSTEMIC EXAMINATION

1. Respiratory Examination
On inspection-
Patient had an oxygen mask for breathing
Normal chest contour that moves with respiration
Respiratory rate- 30 B/MIN
No traditional or therapeutic marks on the
chest.
Symmetrical chest movement
Uses accessory muscles and has intercostal
recession

24
SYSTEMIC EXARESP CONTI

Palpation
Supraclavicular, axillary and cervical LNs
were not palpable
Trachea was centrally located
No palpable superficial mass tenderness,
Apex beat was located at 6th intercostal space
lateral to the Mid clavicular line
Normal tactile vocal fremitus and chest
expansion on both anterior and posterior.

25
SYSTEMIC EXA.RESP CONT.

Percussion
Both lungs were resonant on percussion
Auscultation
wheezes
bilateral crackles on the bases of the lungs
Normal vocal resonance
Negative whispering pectoriloquy

26
CARDIOVASCULAR SYSTEM

Right Radial pulse was 108 beats per minute
Regular rhythm and strong in volume.
The pulse was
non-collapsing synchronous to peripheral
pulses. radial, femoral, carotid
The blood pressure was 138/92 mmHg
Heard at Korotkoff phase 1 to 5.
The state of arterial walls was normal
Neck veins were not distended.
Negative abdominal jugular reflux

27
CARDIOVASCULAR SYSTEM

Precordial examination
Inspection
there were no surgical or traditional scars.
There was no precordial hyperactivity or bulging.
There was no prominent superficial veins
Palpation
The apex beat was located on the 6th ICS
lateral to the mid clavicular line
It was non tapping and non heaving.-
There were no heaves and thrills.

28
CARDIOVASCULAR SYSTEM

Auscultation
S1 and S2 were audible in
aortic, pulmonary, tricuspid and mitral areas.
No added sounds like gallop rhythm were heard
Bilateral fine crackles were heard on lung bases
No palpable tender liver.
liver span 15cm

29
GASTROINTESTINAL SYSTEM

Oral examination
No oral thrush, angular cheilitis/stomatitis
dental erosion
Per abdomen
Inspection
Normal abdominal contour Symmetrical
move with respiration.
The umbilicus is inverted and retracted
There was healed sub umbilical scar
There were no any distended veins

30
Cont.

Palpation
There was no tenderness or any palpable mass
during superficial palpation
On deep palpation liver, spleen, left and right
kidneys were not palpable
No muscle guarding no rebound tenderness
Percussion
Tympanic note was heard.
Liver span was 15cm
Auscultation
Bowel sounds were heard normally 3 bowel sounds
per minute.
There were no abdominal bruits heard

31
NERVOUS SYSTEM EXAMINATION

Higher centres
The patient was conscious with GCS 15/15
both long and short-term memories were intact
Fluent speech and coherent language
Had good concentration
she was oriented to person place and time

32
Cranial nerve examination

CN 1 (olfactory)
The patient could smell an orange peel with each
nostril
CN2 (OPTIC)
She was able to see clearly objects from
the distance and from near through both eyes
She responded positively pupillary constriction
upon light
She was able to see sideway objects while looking
forward object(pen) with both eyes and on one eye
closed
CN3, 4, 6 (OCULOMOTOR, TROCHLEAR, ABDUCENS)
The patient tracked an object (pen) in a H
shaped track
The patient was able to move eyes in all direction

33
Cranial nerves

CN V. TRIGEMINAL
Motor root The patient could clench the
teeth,open jaw against resistance
Sensory roots the patient responded to light
touch on
ophthalmic, maxillary and mandibular areas
CN VII. FACIAL
The patient could
wrinkle the forehead, raise eyebrows, show teeth,
blow both cheeks on resistance
shut both eyes and open against resistance
Sensory
The patient was able to detect
sweet, salt, sour bitter when tested with sugar
and salt

34
Cranial nerves

CN 8 (vestibulocochlear)
Able to hear normal sound and whisper
Air conduction was better than bone conduction
in both ears
as demonstrated by Rinnes tests. - Webers test
was negative as
she heard equally on both ears.
CN 9 and 10 (glossopharyngeal, vagus) -
Patient could swallow Uvula was not deviated.
CN 11 (accessory)
The patient could
shrug her shoulders against turn her neck
sideways against resistance.
CN 12 (hypoglossal)
The patient could
protrude her tongue and move it side to side with
no deviations present.

35
PERIPHERAL NERVOUS SYSTEM

Motor examination
Coordination was intact she performed the finger
nose and heel shin test

R.U.L L.U.L R.L.L L.L.L
Bulk NORMAL NORMAL NORMAL NORMAL
Involuntary movements NIL NIL NIL NIL
Gait Not assessed - - -
Tone NORMAL NORMAL NORMAL NORMAL
Power 5/5 5/5 5/5 5/5
36
Motor examination

Reflexes
SUPERFICIAL REFLEXES Abdominal reflexes present

DEEP TENDON RIGHT SIDE LEFT SIDE
BICEPS REFLEX NORMAL NORMAL
TRICEPS REFLEX NORMAL NORMAL
PATELLA REFLEX NORMAL NORMAL
ACHILLES REFLEX NORMAL NORMAL
BABINSKI DOWNWARD DOWNWARD
37
Sensory examination

She could sense
pain, pressure and crude touch on
both upper and lower limbs
She could perceive vibrations and fine touch on
both upper and lower limb.
Meningeal signs
No neck stiffness
Kernings and Brudzinski's sign negative

38
SUMMARY 2

K.H.S a 66 year old female who is a known
asthmatic, hypertensive and diabetic on
medication, presented with DIB for 7 days,
With chest tightness, central chest pain, dry
cough, wheezes, inability to complete sentences,
orthopnea and lower limb swelling.
She denied palpitation, PND

39
Cont.

she had bilateral pitting edema
With labored breathing (tachypneic, tachycardiac
and desaturating in RA),
using accessory muscles and had intercostal
recession
with wheezes and bilateral fine crackles at lung
bases
Displaced cardiac apex beat to 6th ics lateral
to MCL

40
Clinical diagnosis based on history and physical
examination

1. ACUTE SEVERE ASTHMA
Reasons forKnown asthmatic patient ,chest
tightness, wheezing dyspnea not relieved
salbutamol inhaler ,cannot complete a sentence in
1 breath or too breathless ,tachycardic,
tachypneic, desaturating in RA, with generalized
wheezes.
DIFFERENTIAL DIAGNOSIS
1. COPD
Reason for chest tightness, wheezing, DIB,
cough, labored breathing with (tachypnea and
tachycardic and desaturate in RA) and use
Reason against no h/o cigarrete smoking,
2. Community acquired pneumonia
Reasons for-difficult in
breathing,cough,chest pain, tachypnea, use of
accessory muscles and intercostal recession
Reasons against-presence wheezes ,no hx
fever

41
Diagnosis

2.CONGESTIVE CARDIAC FAILURE secondary HTN
Reasons Orthopnea, Lower limb oedema,Cardiomegaly
due to shifting of the CAB,bilateral fine
crackles at lung bases
DIFFERENTIAL DIAGNOSIS
2. Dilated cardiomyopathy
Reason for known HTN ,orthopnea, central chest
pain, known htn patient, tachypneic,tachychardic
,displaced cardiac apex beat to 6th ics lateral
to mcl
Reason againstno PND,

42
Management

INVESTIGATION DONE IN THE WARD
FBP
ESR
CRP
Serum electrolyte
Serum troponin
D dimer
Liver enzymes
Serum urea and creatinine
Chest X-ray

43
FBP
44
CRP ESR

ESR 10.230 NORMAL
CPR 1-3 mg/l

45
SERUM TROPONIN I D.DIMER

Troponin I normal ranges0-0.04ng/ml

46
SERUM UREA LEs

AST normal range 8-48 u/l
ALT normal range 7-55 u/l

47
SERUM CREATININE
48
SERUM ELECTROLYTES
49
CHEST X-RAY
50
ECHOCARDIOGRAPHY
51
INVESTIGATIONS TO BE ADDED

ECG
ABG
Lipid profile
spirometry

52
TREATMENT

Non-pharmacological
Oxygen support-high flow oxygen 15l/min
Pharmacological
Inj aminophylline 250mg start
Nebulization with budesonide twice a day for 1/7
Inj hydrocortisone 100mg tds for 1/7
Inj amoxiclav 1.2mg bd for 5/7
Inj furosemide 20mg tds for 2/7
T.spirolactone 25mg od for 5/7
T. Glimepiride Metformin Tablets (2mg and
500mg ) BD x 1/12
T. candesartan 16mg od x 1/12

53
PREVENTION

Avoiding exposure to allergens dust, cold air,
pollen, perfumes
Maintaining good indoor air quality
Health education
Use the charcoal burner outdoors
Exercises
Diet modification
Adherence to prescribed medication

54
ASTHMA

PRESENTERS Sr Sara Deogratius
Dr Neema Lweno

55
Bronchial asthma

A chronic disorder of airways involving a complex
interaction of
airway inflammation,
airflow obstruction
bronchial hyperresponsiveness
following exposure to stimuli
Commonly co exist with COPD
Episodic reversible broncho constriction but
in some there may be a degree of irreversible
obstruction.

56
Types of Asthma

Two types
Extrinsic/Atopic/Allergic
associated with exogenous substance
Intrinsic /non atopic

57
Pathophysiology of asthma

Involves three components
Airway inflammation
Intermittent airflow obstruction
Bronchial hyper responsiveness

58
Pathophysiology of asthma

Airway Inflammation
Antigen presenting cell, dendritic cell, present
to naïve T-lymphocyte with help of IL2 and IL12,
T-Helper cause cell mediated immunity
and neutrophilic inflammation
Mediator of inflammation
e.g. Histamine and Prostaglandins are released
with help of IgE, mast cell basophils, and
eosinophilis
leading to airway inflammation

59
Pathophysiology of asthma

Airflow Obstruction
Caused by acute
bronchoconstriction, airway edema,
chronic mucus plug formation and airway
remodeling
Acute bronchoconstriction is a consequence of
IgE-dependant mediator release after exposure
to aeroallergens early asthmatic response
Chronic mucus plug formation consists of exudate
of serum proteins cell debris that may take
weeks to resolve

60
Pathophysiology of asthma

Bronchial Hyper responsiveness
??Bronchoconstrictor response to
multiple inhaled triggers that would have
no effect on normal airways.
Linked to the frequency of episodes
Most of the triggers seem to act indirectly
by causing release of Bronchoconstrictors from
mast cells.

61
Risk factors

Environmental allergens
E.g. dust, cat, dog hair, pollen
Viral respiratory tract infection
(infancy rhinovirus illness)
Gastro esophageal reflux disease
(via vagal acid in esophagus?
?airway resistance and reactivity)
Obesity especially infancy rapid weight gain
Environmental pollutant, smoke
Emotional factors

62
Clinical features

Characteristic symptoms
Wheezing
Dyspnea
Cough
Worse at night with early morning awakening.
Increased mucus production which is thick and
difficult to expectorate.
Use of accessory muscles of ventilation
due to increased ventilation

63
Clinical features

Physical findings
Rhonchi (expiratory gt inspiratory)
Hyperinflation
No findings if asthma is under control

64
Pulmonary Function Tests

?? FEV1, FEV1/FVC ratio
Reversibility
demonstrated by gt 12 and 200 ml increased
in FEV1 15 minutes after an inhaled short-acting
ß2-agonist
Exercise testing may demonstrate post
exercise broncho constriction if there is
history of Exercise induced Asthma

65
Other investigations

Hematological Tests
Total serum IgE and specific IgE to inhaled
allergens
may be measured
Skin tests
Skin prick tests to common allergens are positive
in allergic asthma but negative in intrinsic
asthma
This may help convince patients to avoid certain
allergens
Imaging
Chest imaging may show hyper inflated lungs
In exacerbations, there may be evidence
ofpneumothorax

66
Management of Asthma

The ultimate goal
prevent symptoms
minimize morbidity from acute episodes and
prevent functional and psychological morbidity to
provide near health lifestyle
Pharmacological rx is achieved by 2 groups of
drugs
Bronchodilators (Relievers) rapid relief of
symptoms
Controllers reduces the underlying inflammation

67
Management of Asthma

Bronchodilators
Act on the airway smooth muscle and
reverse the broncho constriction
Consists of
ß2-agonists
anticholinergics
theophylline.

68
Management of Asthma

ß2-agonists
Given by inhalation to reduce side effects.
SABAs
salbutamol (albuterol) and terbutaline
duration of action of about 3-6 hours.
LABAs
E.g salmeterol
longer duration of action (12 hours)
given with ICS(inhaled corticosteroids)
to reduce exacerbations.

69
Management of Asthma

Anticholinergics
Muscarinic receptor antagonists such as
ipratropium bromide
prevent cholinergic nerve-induced
bronchoconstriction
and mucus secretion
Usually given after therapy with ß2-agonists has
failed.
Theophylline
Used after therapy with ß2-agonists is not
sufficient
In low doses, it has anti-inflammatory effects
and
is additive to the effects of ICS
IV aminophylline
used in severe exacerbations but has been
replaced by
high doses of inhaled SABAs, but is still used
in asthma
refractory to SABAs

70
Management of Asthma - Controllers

Inhaled Corticosteroids
The most effective controller
Given once or twice a day depending on severity.
Long term use can help control airway
hyper responsiveness
First-line to prevent persistent asthma, but it
is usual
to add a LABA when symptoms are not controlled
with
ICS alone. Eg budesonide,

71
Management of Asthma - Controllers

Systemic Corticosteroids
IV formulations are used for acute severe asthma
OCS for 5-10 days are effective for acute
exacerbations without the need for tapering
About 1 of patients may require OCS
for maintenance treatment. E.g prednisolone.
Antileukotrienes
Include montelukast and zafirlukast
Used as an add-on therapy in patients
not responding to low dose ICS,
but are less effective than LABA

72
Management of Asthma - Controllers

Cromones
Cromolyn sodium and nedocromil sodium inhibit
mast cell activation and therefore useful in EIA
and
allergen and Sulphur dioxide-induced asthma
Short duration of action (four times daily
dosage)
and hence replaced by ICS
Anti-IgE
Omalizumab inhibits IgE-mediated reactions
Limited to those that do not respond to
maximum doses of inhaler therapy
Given as subcutaneous injection every 2-4 weeks
Objective benefit is seen after 3 4 month
therapy

73
Treatment of asthma according to severity

Based on category of severity of asthma rx
consists of
Preventing the inflammation leading to
bronchospasm
Controllers- ICS e.g Beclomethasone
Relieving bronchospasm
Short acting beta 2 agonists i.e salbutamol

74
Treatment of asthma according to severity

STEP 1
Intermittent asthma
Intermittent symptoms once/week symptomatic
Night time symptoms twice/month
Normal physical activity
Treatment
Inhaled Salbutamol when symptomatic.
No long-term treatment

75
Treatment of asthma according to severity

STEP 2
Mild persistent asthma
Symptomsgt once/week but lt once/day
Night time symptoms gt twice/month
Symptoms may affect activity
Treatment
Continuous treatment with inhaled
Beclomethasone
100-250mcg twice daily
-Inhaled Salbutamol when symptomatic

76
Treatment of asthma according to severity

STEP 3
Moderate persistent asthma
Daily symptoms
Night time symptoms once/week
Symptoms affect activity
Daily use of Salbutamol
Treatment
Continuous treatment with inhaled
Beclomethasone 250-500mcg twice daily
Inhaled Salbutamol 1-2 puffs 4times/day

77
Treatment of asthma according to severity

STEP 4
Severe persistent asthma
Daily symptoms
Frequent night time symptoms
Physical activity limited by symptoms
Treatment
Continuous treatment with inhaled
Beclomethasone 500mcg twice daily
Inhaled Salbutamol 1-2 puffs 4-6 times/day

78
Acute Severe Asthma - Diagnosis

Increasing chest tightness, wheezing and dyspnea
that is not relieved by regular reliever inhaler
therapy.
Patients can become so breathless that they are
unable
to complete sentences and may become cyanotic
Examination shows
increased ventilation, hyperinflation and
tachycardia.
Marked reduction in
spirometry values and PEF (peak expiratory flow)
rate
ABG shows hypoxemia and low PCO2 due to
hyperventilation
A rising PCO2 indicates impending respiratory
failure
Chest imaging may show pneumothorax or pneumonia

79
Acute Severe Asthma - Treatment

High concentration of oxygen by face mask to
achieve saturations of gt90
Use high dose SABAs delivered by
nebulizer or MDI(metered dose inhaler) with
spacer.
IV formulations may be used in severely ill
patients
Anticholinergics may be added if there
is no response, as there are additive effects
IV aminophylline has been shown to be useful in
refractory cases
Magnesium sulphate can be added to SABAs
but is not routinely recommended

80
(No Transcript)
81
Acute Severe Asthma - Treatment

Prophylactic intubation may be done
in patients with impending respiratory failure
In respiratory failure, patients should be
intubated an anesthetic may be considered
if bronchodilator therapy has failed
Sedatives should be avoided as they
suppress ventilation
Antibiotics can be given if there are signs of
pneumonia

82
Refractory Asthma

About 5 of patients will not respond to
maximal inhaler therapy.
Some of these may be require OCS maintenance
Mechanisms
Noncompliance, especially to ICS
Over exposure to allergens or unidentified
occupational agents
Upper airway disease
Drugs e.g. beta-blockers, aspirin, COX-inhibitors
Premenstrual worsening
Thyroid disease

83
Refractory Asthma

Differentials
Vocal cord dysfunction
COPD
Brittle Asthma Unpredictable changes in lung
functions
Type 1 Persistent variability requiring OCS or
IV ß2-agonists infusion
Type 2 Normal lung function with sudden falls in
lung function resulting in death
Rx Subcutaneous epinephrine
Some patients may have corticosteroid-resistant
asthma

84
Aspirin-Sensitive Asthma