ASTHMA

INTRODUCTION

Muhammad Ismail is a 30-month-old Malay boy with a history of frequent episodic asthma now presenting with cough, fever and shortness of breath.

HISTORY

Presenting complaint

He has been unwell for about 1 week with a distressing hacking cough with no sputum production. He had been intermittently febrile and was anorexic and lethargic. He developed symptoms of respiratory distress two days later consisting of shortness of breath without wheezing and was seen by a GP. He was given paracetamol and nebulization with Ventolin, but the fever did not subside and he was subsequently sent to NUH.

Birth & developmental history

He is a premature baby at 8 months by normal vaginal delivery. There were no complications arising from the delivery. His mother said that after birth, he was in the PICU of KK Hospital for 6 weeks initially because of neonatal jaundice and then subsequently because he developed some breathing difficulties which she is unable to point out to the exact etiology. Was unable to obtain additional information about the pulmonary pathology as she did not bring the health booklet, but suspect to be due to respiratory distress syndrome or bronchopulmonary dysplasia. He was diagnosed to have asthma at 1 month of age, however she was unsure what tests the doctors did in order to arrive at the diagnosis. He was not breast-fed and commenced on solid foods at 6 months of age. Immunization schedule is followed accordingly. Development milestones are normal. He was able to walk at 2 years of age and made simple sentences.

Severity of symptoms

The frequency of his asthmatic attacks is once a month. The symptoms are wheezing and dyspnoea. They usually subside within half an hour after use of inhaled salbutamol which Ismail is able to administer himself. He was never admitted to hospital in the past because of asthma. Ismail is occasionally woken up from sleep complaining of dyspnoea, but these episodes are infrequent and only happened once or twice last year. His mother is not aware of any possible trigger factors of Ismail�s monthly asthmatic attacks. Ismail is an active child and his asthma has no negative impact on his daily activities.

Risk factors for asthma

Ismail�s mother and grandmother have asthma. He has no associated atopic diseases such as eczema, allergic rhinitis or conjunctivitis. He lives together with his parents, an older brother and grandmother. Nobody in the family smokes. He lives on the 11th floor of a flat and the air was generally clean without dust or pollutants. No pets are kept. She changes his bedsheets once a month and washes them with normal detergent. The flat does not have any door-mats or carpets. Ismail does not play with flurry toys.

Medical

Ismail is currently on 3-monthly follow-up with Dr. LH LOH of NUH. He is on Beclotide MDI and Ventolin MDI, 2 puffs each, twice a day, once in the morning and once in the evening. He is prescribed these medications last year November and had been taught the proper technique of using the MDI. Ismail demonstrated the use of the MDI and the method was correct. He has been compliant on taking his medicines.

Social

Ismail�s daily activities are not disrupted by his asthma. His family has no financial difficulties in paying for his medical expenses.

PHYSICAL EXAMINATION

Muhammad Ismail is well, comfortable at rest and not in any respiratory distress. He is not dysmorphic or cyanosed. His height, weight and OFC are between 50th & 75th percentile for his age. His vital signs are as follows: Temp: 37.4C, Pulse rate: 110/min, Respiratory rate: 24/min, Blood pressure: 90 / 60 mmHg. There are no peripheral signs of chronic lung disease such as digital clubbing. There are no chest deformities or scars. Trachea is not deviated. No wheezing is heard. Air entry is slightly decreased over the lower lobe of his left lung and percussion note is dull compared to the right side. Auscultation reveals rhonchi and scattered crackles over the left lower lobe. The pharynx is not injected and the tonsils are not enlarged.

SUMMARY

Muhammad Ismail is a 30-month old Malay boy with a history of asthma now presenting with a 1- week duration of intermittent fever, dry unproductive cough and shortness of breath. Examination reveals decreased air entry and scattered crackles over the left lower lobe of the lung.

My diagnoses are:

1) URTI-triggered asthma.

2) Viral pneumonia.

I would order the following investigations:

1) Chest-X ray to detect any consolidation.

2) PEFR to assess severity of asthma.

3) Spirometry.

4) Arterial blood gases to assess degree of hypoxaemia.

MANAGEMENT

Acute measures

1) Check pulse oximetry, gives nebulized oxygen, keep SAO2 above 90%.

2) Give nebulized salbutamol and/or ipratropium bromide.

3) IV hydrocortisone if symptoms are not relieved.

Issues

1) Compliance on long-term treatment.

2) Difficulty in use of inhaled medication for a young child.

3) Difficulty in recognizing asthma symptoms.

4) Effect of disease/therapy on growth.

Treatment goals

1) Control symptoms.

2) Unrestricted lifestyle.

3) Least medication used for effective control.

4) Limit medication side effects.

Education

Education plays an important role in the long-term control and treatment of asthma. The responsibility of disease management lies squarely on the patient and his primary care-giver. Both Ismail and mother should be educated on recognizing symptoms of an asthmatic attack so that they can institute treatment early, the role of different drugs, e.g. beclotide for preventive treatment and ventolin for symptomatic treatment, the need for continued prophylaxis and the proper inhaler technique. Their fears, concerns and expectations should also be adequately addressed.

Prevention

Prevention of exposure to allergen is the best way to reduce disease occurrence and severity. House dust mites are the commonest allergens in the home environment after air pollutants, cigarette smoke and moulds. Exposure to house dust mites can be reduced by changing bed-sheets regularly, washing them in hot water above 60C and drying them in direct sunlight which kills the mites, and covering mattresses and pillows with barrier materials.

Pharmacotherapy

Ismail is currently using a beta-2 bronchodilator and a steroid. He and his mother must be warned of their side effects, ventolin � tremors, tachyarrhythmias, beclotide � oropharyngeal candidiasis, osteoporosis, osteopenia and short stature and inform their doctors should they discover any of these symptoms.

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