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PGI ADMITTING CONFERENCE

AGUILAR. BALABAG. GACUTAN. SAGORSOR


OBJECTIVE
To present a case of an 8 year old male who was diagnosed with
obstructive sleep apnea and bronchial asthma
To present the algorithm in the management of asthma in severe
exacerbation
8 year old
Male
Filipino
Iglesia ni Cristo
School age
February 13, 2009
4 Upper QM,Baguio City
Admitted for the second
time on 9/21/2017
CHIEF COMPLAINT

Difficulty of breathing,
Noisy and Rapid breathing

4
20 days PTA (+) Recurrent asthma attacks
characterized as difficulty of
breathing, shortness of breath,
HISTORY OF and rapid breathing
PRESENT (+) During morning, evening,
after school activities and
ILLNESS exposure to newly painted
school gym
(+) Relieved by Salbutamol neb
during morning, evening, and as
necessary for asthma attacks

(+) Sleeps in supine/


prone position
(+) intermittent, frequent, 4
loud snoring
Fourteen days PTA (+) Productive cough, yellowish, scanty
(+) Clear nasal discharge
(+) Nasal congestion
(+) Difficulty of breathing
(+) Weak looking
(-) Fever
(-) Vomiting
HISTORY OF
PRESENT Good oral intake
ILLNESS

(+) Consult- Cefixime


100mg/5ml, 5 ml BID x 5 days
(ED- 6-8,CD- 4.38) 4
Provided relief of symptoms
One day prior to
admission (+) Recurrence of productive
cough and colds
(+) DOB
(+) SOB
(+)Nasal congestion
HISTORY OF (+) Fair oral intake
PRESENT
ILLNESS
No associated fever,
fever and weakness

(-) Consult done


(+)Salbutamol 1 nebulization 4
offering slight relief of
symptoms
Eighteen hours
prior to admission (+) Sleep apnea lasting less than a
minute and very loud snore noted
as the patient was sitting

With associated facial


cyanosis and difficulty
to arouse

Cyanosis spontaneously
resolved upon awakening

No medications 4
taken and no
consult was done
Six hours prior to
(+) Persistence of
admission
productive cough
(+) DOB
(+) SOB
(+) Rapid breathing
(+) Nasal congestion
(+) Dysphagia with
solid foods
(+) Poor appetite
(-) Vomiting
(-) Fever
Slightly relieved with one
dose of Salbutamol
nebulization

4
Four hours prior to
admission Persistence of symptoms

(+)Difficulty maintaining sleep,


prefers sitting position with the
head extended
(+) Apnea lasting less than a
minute, with persistent, very loud, (+) Labored breathing
snore (+) Facial cyanosis
(+) Difficulty to awaken (+) Weak looking
(+) ER consult Salbutamol nebulization 1 neb
(+) Salbutamol 3 doses given was given offering no relief
With no relief
(+) Witnessed episode of apnea >1 4
minute
Hence admitted
REVIEW OF SYSTEMS

GENERAL: (-) febrile episodes, (+) weakness, (+) poor oral intake, (-)
lethargy
SKIN: (-) rashes, (+)cyanosis
HEENT: (+) Allergic Rhinitis, (+) Progression of snoring (soft to loud,
intermittent to persistent), (+) OSA, (+) frequent mouth breathing, (+)
voice change
RESPIRATORY: (+) productive cough, (+) DOB, (-) post tussive vomiting, (-)
hemoptysis
CARDIAC: (-) edema (+) severe pulmonary hypertension
REVIEW OF SYSTEMS
GASTROINTESTINAL: (+) poor oral intake, (-) Abdominal pain, (-)
vomiting, (-) changes in bowel movement
GENITOURINARY: (-) dysuria, (-)incontinence, (-)frequency
MUSCULOSKELETAL: (-) swelling, (-) trauma
HEMATOLOGIC: (-) anemia, (-)bleeding, (-)bruising
NERVOUS: (-) seizures, (-) tremors
FEEDING HISTORY
MEALS BEFORE ILLNESS CALORIC INTAKE SUBTOTAL BEFORE ILLNESS CALORIC INTAKE SUBTOTAL
SPECIFIC INTAKE (Percentage) SPECIFIC INTAKE (Percentage)
Before Dietary Restriction On Dietary Restriction
Breakfast 1 1/2 cup rice 339 kcal 699 kcal 1/2 cup rice 113 kcal 223 kcal
2 slice meat 360 kcal 1 serving 110 kcal
vegetables
Snack 2 piece apple 80 kcalx2 160 kcal None None

Lunch 1 cup rice 226 kcal 696 kcal 1/2 cup rice 113 kcal 293 kcal
1 serving veg 110 kcal 2 stick barbecue 180 kcal
4 stick 360 kcal
barbecue
Snacks 1 piece wheat 90 kcal 90 kcal 1 piece wheat 90 kcal 90 kcal
bread w/ tuna bread w/ tuna
Dinner 1 cup rice 226 kcal 336 kcal 1/2 cup rice 113 kcal 223kcal
1 serving veg 110 kcal 1 serving vegetables 110 kcal

TOTAL 1, 981 TOTAL 829 kcal*


kcal*
Growth and
HOME: Interacts well with family
Development without discipline problems

EDUCATION: Grade 3
Elementary student with
good grades
ACTIVITY: He is fond of watching
TV while playing Rubrics, Clash of
Clans and Mobile Legends on his
tablet

DRUGS: No known 4
history of illicit
drug use
Growth and
Development SEXUAL: Has a girl crush at school

SPIRITUAL: Patient goes to


church regularly

4
Given as Penta vaccine in a private clinic
IMMUNIZATION ** Vaccination which were advised to the patient but
was refused by the mother
Vaccine 1st dose 2nd dose 3rd dose Booster Place Reaction
BCG Given BeGH Scar
DPT Given* Given* Given* None
OPV Given* Given* Given* None
HiB General
Given* Given* Skin
Given* HEENT None

Hepatitis B Given Given BeGH, Private None


Respiratory, Cardiac Gastrointestinal
Pediatrician
Measles ** None
MMR **
Pneumococcal ** None
Influenza **
Rotavirus None
Hepatitis A
Varicella
PAST MEDICAL HISTORY

MVA: 2011 ADHD: 2012


(+) bruises on the face (-) Medications
and chest (+) Health
(-) Changes in sensorium Education to
CXR- no fracture mother
PAST MEDICAL HISTORY
FEB 2017
2015: BAIAE and (+) dysphagia (+) Measles and
PCAP-C (+) frequent, persistent, Varicella Infection
Admitted to the very loud snore with (unrecalled)
ICU due to episodes apnea &
severe cyanosis (+) Allergies Seafood,
exacerbation >Scheduled for Egg, Chicken, animal
Trans-out after Adenoidectomy dander
12 hours >Severe Pulmonary
Discharged Hypertension through a
after 3 hospital 2D Echo
days > Deferred for surgery
due to recurrent URTI
and was lost to follow-
up
FAMILY HISTORY

Maternal
Paternal
(+) ADHD
(+) Bronchial
(+) Arthritis
Asthma
(+) HPN
(-) OSA
(-) OSA
(-) Obesity
(-) Obesity
(-) DM
(-) Ca
(-) CA
(-) DM
SOCIAL AND ENVIRONMENTAL HISTORY

Father: 35 years Patient is the only Sleeps at around 8pm


old, high school child and lives along with noted interrupted
graduate, works sleep, snoring and
a congested difficulty awakening
as an OFW neighborhood
Mother: 27 years old, Daytime Somnolence
and frequent napping in
BS Accountancy graduate,
school
Housewife, Primary caregiver
SOCIAL AND ENVIRONMENTAL HISTORY

One pet cat living No household


inside the house member with same (+) Exposure to
and one pet dog secondhand smoke
signs and symptoms
living outside the (+) lives near the road
house
PHYSICAL EXAMINATION
General Survey

Awake, Conscious, Coherent, Ambulatory, Talks in phrases, on O2 inhalation at 3-4 lpm


per nasal cannula
Vital SIgns

BP: 110/80 mmHg


CR: 84 bpm
RR: 34 cpm
Temp: 36.5 C
SpO2: 96 % at 3-4 lpm per NC - AWAKE
80% - <90% at 3-4 lpm per NC - ASLEEP
PHYSICAL EXAMINATION
Anthropometric Measurements

Anthropometric Actual Measurement Z-score Interpretation


index

Weight 46 kg 3 Obese

Height 131 cm 0 Normal

BMI 26.80 kg/m2 3 Obese


PHYSICAL EXAMINATION
Skin

(-) cyanosis, (-) pallor, warm to touch, good skin turgor

HEENT
Non sunken eyeballs, anicteric sclera, pink palpebral conjunctiva, (+) alar flaring,
(+) nasal discharges, (+) congested nasal turbinates, dry lips, moist buccal
mucosa,
(+) circumoral cyanosis while asleep, (+) Kissing, congested tonsils
Chest and Lungs
(+) Brassy cough, Symmetrical Chest Wall Expansion, (+) subcostal retractions,
(+) Use of accessory Muscles for respiration, Tachypneic, (+) Inspiratory Stridor,
(+) Tight air entry (+) Decreased breath sound (-) Wheeze (-) Crackles
PHYSICAL EXAMINATION
Heart

PMI @5th ICS LMCL, (-) thrills, (-) heaves, tachycardic, regular rhythm, (-)murmurs

Abdomen

Flabby, non-distended, NABS, tympanitic, non tender

Extremities
(-) gross deformities, (-) clubbing of fingernails, (+) cold extremities,
Capillary refill of <2secs

Neurologic Examination
Problem Oriented Medical Record
1. Difficulty of breathing, noisy breathing,
tachypnea, brassy cough
2. OSA
3. Obesity
4. ADHD
5. Financial difficulty
Problem #1: Difficulty of breathing, noisy
breathing, tachypnea, brassy cough
Subjective Objective
8 y/o, male G/S: awake, ambulatory, conscious, talks in
(+) difficulty of breathing phrases, in O2 inhalation @ 3-4 LPM/NC
(+) fast breathing HEENT: Congested nasal turbinate, nasal discharges,
(+) Recurrent cough & colds mouth breather, pink palpebral conjunctiva
(+) nasal congestion C/L: Brassy cough, SCWE, (+) subcostal retractions,
(-) fever (+) use of accessory muscles (+), (+)tachypneic, (+)
(+) Bronchial Asthma inspiratory stridor, (+) tight air entry, (+)decreased
(+) Family history of Asthma breath sounds, (-) wheeze, (-) crackles
(+) Allergic Rhinitis Heart: tachycardic, normal rhythm, (-) murmurs
(+) Salbutamol nebulization at home: Extremities: cold, with capillary refill <2 seconds
no relief of symptoms
BRONCHIAL ASTHMA IN ACUTE
EXACERBATION
t/c Acute Laryngotracheobronchitis
r/o Vocal Cord Dysfunction

4
PATIENTS SIGNS & BAIAE ALTB VOCAL CORD
SYMPTOMS DYSFUNCTION
(+) difficulty of breathing + + +
(+) cough + + +
(-) fever -
+ -
(+) Bronchial Asthma +
(+) No relief with Salbutamol +/- - +/-
nebulization +
(+) tachypneic + + +
(+) inspiratory stridor - + +
(+) tight air entry, (+)decreased +/- - +/-
breath sounds
+/-
(-) wheeze +/- -
PLAN
Admit patient to ward

Diagnostics:
CBC
CXRAY AP, including the neck
Lateral xray of the neck
PLAN
Therapeutics:
D5NM 1L x 28-29 gtts/min (M%)
Salbutamol neb, 1 nebulization Q20 minutes x 3 doses then
RA
Prednisolone 20mg/5ml, 4ml TID
Montelukast 10mg OD HS
Continue O2 inhalation and titrate to maintain O2
saturation of > 94 98%
Problem #2: Apneic episodes, very loud
snore, Kissing congested tonsils
Subjective Objective
8 y/o, male
G/S: awake, ambulatory, conscious, talks in phrases, in
(+) sleeps in a sitting position, with noted very loud snore
and an episode of apnea which lasted less than a minute
O2 inhalation @ 3-4 LPM/NC
(+) facial cyanosis during apneic episodes VS: SpO2: 96 % at 3-4 lpm per NC - AWAKE
(+) difficult to awaken 80% - <90% at 3-4 lpm per NC ASLEEP
(+) cyanosis spontaneously resolved upon awakening BMI: 26.80 kg/m2 (Obese)
(+) Difficulty maintaining sleep, prefers sitting position with
head extended HEENT: mouth breather, (+) circumoral cyanosis/facial
(+) Stridor cyanosis noted while sleeping, Kissing, congested tonsils
(+) Daytime Somnolence and frequent napping in school C/L: (+) use of accessory muscles, (+) inspiratory stridor
(+) Diagnosed with OSA Heart: tachycardic, normal rhythm, (-) murmurs
>Scheduled for Adenoidectomy Extremities: cold, with capillary refill <2 seconds
> Deferred for surgery due to recurrent URTI and was lost
to follow-up
8 year old male, Obese Noted interrupted sleep, with very loud snore, prefers
sitting position
DOB, Stridor Diagnosed case of Obstructive Sleep Apnea

Circumoral cyanosis noted while Kissing, congested tonsils


asleep

Obstructive Sleep Apnea secondary


Waking to
with
Daytime
Hypertrophic Tonsils gasping,
Apnea
somnolence
choking

Breath holding4 Loud snoring


Pathophysiology

Obesity
Collapse of the
pharyngeal
airway during Soft tissue Hypertrophy
sleep
Craniofacial Characteristics
PLAN
Dx: Polysomnogram
Tx: Medical: CPAP
Surgical: Adenoidectomy
COURSE IN THE
WARD:

UPON ADMISSION:
Initial treatment-
supplemental
oxygen D5NM 1L x 28-29 gtts/min (M%)
inhaled b agonist -Hooked to CPAP
therapy every 20 min Neb with 2.5mL (1
for 1 hour and if amp Epi + 9cc NSS) q
necessary, 20 x 3 doses
systemic
corticosteroids VS: 120/80 mmHg, 135
given either orally bpm, 44 cpm, T: 36.6
or intravenously. 4
LABS: CBC, CXR
CEFUROXIME 750 mg IV Q8
5 Hours After Admission
(+) persistence of cough and
stridor, labored breathing

(+) wheezing and


tight airway entry,
Inhaled ipratropium occasional rales
may be added to the b Salbutamol +
agonist treatment if no
significant response is Budesonide neb x
seen. 3 cont doses, O2 Another Salbutamol
driven neb, 3 cont doses
VS:
BP: 100/70
CR: 148
ABGs done RR: 44
4 T: 36.6
SpO2: 100%
ABG after 16 hours

COMPENSATED RESPIRATORY ALKALOSIS


8 HOURS AFTER
ADMISSION
PICU
(+) stridor,
(+) DIFFUSE
wheezing
(+) tight airway (+) cyanosis, (+) change in
Admission
entry to an sensorium, (+) desaturation (30%)
intensive care
(+) labored
unit breathing
intramuscular (+) Intubation
injection of
epinephrine or Diazepam 5mg now
other b agonist
Magnesium Sulfate
intravenous 1.15g IV
magnesium
sulfate Epinephrine 0.3mg
4
(1: 1000) stat dose
10 Hours AFTER ADMISSION
Asleep
w/ Normal and stable VS

Serum Electrolytes:
Na, K, Cl, Mg
Na: 139
K: 5.23 (high)
Cl: 99.1 VS:
Mg: 0.81 BP: 110/80
CR: 132
RR: 30
Midazolam Drip: 50 cc
x 8-33 cc/hr via
4 T: 36.6
SpO2: 100%
infusion pump
ABGs after 16 Hrs

METABOLIC ACIDOSIS
1st Hospital
Day
VS: Asleep most of the time, w/ occasional
BP: 110-140/70-90 cough, no febrile episode
CR: 75-115
RR: 27-32
T: 36.4-36.7 Asleep(irritable when
SpO2: 94-97% on awake), on 4 point
MV restraint, with
intact ET tube SCWE, no retractions, no
wheezing, (+) bibasal rales
more on the right
FIO2 was at 70% then 4
decreased by 10% Q2 to NGT was inserted
reach 30%
VS:
BP: 110-140/70-90,
2nd Hospital
CR: 75-115,
RR: 27-32,
Day
T: 36.4-36.7,
SpO2: 94-97% via
MV (+) occasional cough, no DOB, no
vomiting, no febrile episodes
Awake, irritable, with intact
ET tube, and NGT
no pallor, no cyanosis
With Grade 3 Tonsils, non-
exudative SCWE, no retractions, VS:
BP:120-140/80-90
(+) diffuse wheezing, (+) CR: 57-117
4 bibasal rales RR: 22-35
T: 36.5-36.8
(+) Extubation SpO2: 96-100% at
1 LPM
3nd Hospital
Day

(+) occasional cough, no DOB, no


vomiting, no febrile episodes
Awake, irritable, on O2
inhalation at 1-2 LPM,
no pallor, no cyanosis
With Grade 3 Tonsils, non-
exudative SCWE, no retractions, VS:
BP:130-140/70-90
(+) diffuse wheezing, (+) CR: 85-131
4 bibasal rales RR: 24-35
T: 36.5-36.7
NGT was removed: SpO2: 96-98% at 1
LPM
DAT with SAP
4th Hospital
Day

(+) occasional cough, no DOB, no


vomiting, no febrile episodes
Awake, irritable,
no pallor, no cyanosis
With Grade 3 Tonsils, non-
exudative
SCWE, no retractions, VS:
BP:120-140/80-90
(+) diffuse wheezing, (+) CR: 57-117
4 fine bibasal rales RR: 22-35
T: 36.5-36.8
Weaned off from O2 SpO2: 96-100% at
room Air
inhalation
A ST H M A
Chronic Airway Inflammation

Respiratory Symptoms

Variable Expiratory Airflow


Limitation

Ely, J.W. Osheroff J. A., et. Al. Evidence Based Clinical Medicine: Approach to
Leg Edema of Unclear EtiologyJ Am Board Fam Med 2006;19:14860
ETIOLOGY

Environmental
Exposure Biological
Allergens and Genetic
Infections Risk
Pollutants
Stress
Common Asthma Triggers:
Viral Infections

Allergens

Exercise and Stress


ASTHMA EXACERBATION

Progressive
Progressive
decrease in
increase in
lung
symptoms
function
Asthma is an inflammatory disease of the lower respiratory
tract, manifesting as intermittent constriction of the bronchial
airways. Obstructive sleep apnea (OSA), on the other hand, is a
state-dependent condition that is characterized by intermittent
obstruction of the upper airway during sleep leading to
hypoxemia and sleep fragmentation [8].
The pathophysiology of these two conditions seems to overlap
significantly, as airway obstruction, inflammation, obesity, and
several other factors are implicated in the development of both
diseases
Moreover, OSA is generally linked to worse asthma outcomes.
The effects of the direct pathophysiologic consequences of OSA
(e.g., chronic intermittent hypoxemia, circadian alteration
of autonomic functions, and increased intrathoracic pressure
swings related to the occluded upper airway) on the clinical
severity of asthma are poorly understood [1]. Moreover, the
National Asthma Education and Prevention Program Expert
Panel Report recommends evaluating for OSA as a potential
contributor to poor asthma control [10]. Thus, clarifying the
nature of the relationship between OSAS and asthma is a
critical area with important therapeutic implications.