Special issues:

geriatric
His 2038
asthma
Name: nurdina afini binti izamudin
(031390)

Introduction
Definition:
Clinical syndrome characterized by attacks of
wheezing and breathlessness due to narrowing of
the intrapulmonary airways. Remission may be
spontaneous or as a result of treatment. During an
asthma attack, the muscles surrounding the airways
tighten. The lining of the air passages swells. Less
air is able to pass through as a result.

During an asthma attack smooth

muscles located in the
bronchioles of the lung constrict
and decrease the flow of air in the
airways. The amount of air flow
can further be decreased by
inflammation or excess mucus
secretion.

Types of asthma
EXTRINSIC (atopic)

INTRINSIC (non-atropic)

occur in younger age groups .

readily form antibodies to
allergens.
sensitive to different factors
(eg: pollen, feathers, food, fur,
and occasionally food or drug).
family history of similar
sensitivities.
exposure to the percipitating
factor causes a mucosal
inflammatory allergic reaction.
tends to be episodic.

tends to occur in the older pt.

as a chronic condition.
no apparent allergic cause or
family history.
precipitated by, or associated
with bronchial infections ,
chronic bronchitis, strenous
exercise, stress or anxiety.

AETIOLOGY
The underlying causes of childhood asthma aren't
fully understood. Developing an overly sensitive
immune system generally plays a role. Some factors
thought to be involved include:
Inherited traits
Some types of airway infections at a very young age
Exposure to environmental factors, such as cigarette
smoke or other air pollution

Increased immune system sensitivity causes the

lungs and airways to swell and produce mucus
when exposed to certain triggers. Reaction to a
trigger may be delayed, making it more difficult to
identify the trigger. These triggers vary from child
to child and can include:
Viral infections such as the common cold
Exposure to air pollutants, such as tobacco smoke
Allergies to dust mites, pet dander, pollen or mold
Physical activity
Weather changes or cold air
Sometimes, asthma symptoms occur with no
apparent triggers.

pathology
Main pathological changes occur during an asthmatic attack
are:
Spasm of the smooth muscle in the walls of the bronchi and
bronchioles.
Oedema of the mucous membrane of the bronchi and
bronchioles.
Excessive mucus production.

the wall

These changes result in airways obstruction.

Bronchial walls become infiltrated with eosinophils
thickening of the epithelial basement membrane.
At the end of an attack these changes are totally reversible BUT
if the attacks occur frequently long-standing changes will occur
such as:
Hypertrophy of the smooth bronchial muscle,
the efect of
bronchial spasm during and attack .
Permanent thickening of the mucous membrane with an the
no. of goblet cell and mucous gland.

Where the predominant factor precipitating asthma is an

allergic reaction.
There is antigen mediated bronchoconstriction.
This means that the antigen binds to two IgE molecules
(immunoglobulin antibodies) on the membrane of mast cells
present in bronchial lining.
Release mediators which act on receptor sites on smooth
muscle cell
changes in intracellular cyclic AMP levels
which
muscular contraction.
The mediators histamine, neutrophil chemotactic factor
(NCF-A), platelet activating factor(PAF), and eosinophil
chemotactic factor (ECF-A) are stored in granules within mast
cells as performed mediators.
This antigen-antibody reaction is a part of the body s
immune response, and previous exposure to the antigen
results in bronchoconstriction.

Clinical featurs
Wheezing: A musical, high-pitched whistling sound
produced by airflow turbulence is one of the most common
symptoms of asthma. The wheezing is usually during
exhalation.
Cough: Usually, the cough is nonproductive and
nonparoxysmal; coughing may be present with wheezing
Cough at night or with exercise: Coughing may be the only
symptom of asthma, especially in cases of exercise-induced
or nocturnal asthma; children with nocturnal asthma tend to
cough after midnight, during the early hours of morning
Shortness of breath
Chest tightness: A history of tightness or pain in the chest
may be present with or without other symptoms of asthma,
especially in exercise-induced or nocturnal asthma

Sputum production
In an acute episode of asthma, symptoms vary according to the
episodes severity. Infants and young children suffering a severe
episode display the following characteristics:
Breathless during rest
Not interested in feeding
Sit upright to assist the accessory muscles of respiration. The
chest is held in inspiration.
Talk in words (not sentences)
Usually agitated
With imminent respiratory arrest, the child displays the
aforementioned symptoms and is also drowsy and confused.
However, adolescents may not have these symptoms until they
are in frank respiratory failure.
Cyanosis may occur centrally but not usually until the later
stages of the disease.

Dr.
management

Physical examination:

Findings during a severe episode include the following:

Respiratory rate is often greater than 30 breaths per minute
Accessory muscles of respiration are usually used
Suprasternal retractions are commonly present
The heart rate is greater than 120 beats per minute
Loud biphasic (expiratory and inspiratory) wheezing can be
heard
Pulsus paradoxus is often present (20-40 mm Hg)
Oxyhemoglobin saturation with room air is less than 91%

Findings in status asthmaticus with imminent respiratory arrest

include the following:
Paradoxical thoracoabdominal movement occurs
Wheezing may be absent (in patients with the most severe airway
obstruction)
Severe hypoxemia may manifest as bradycardia
Pulsus paradoxus may disappear: This finding suggests respiratory
muscle fatigue

Diagnosis

Tests used in the diagnosis of asthma include the following:

Pulmonary function tests: Spirometry and plethysmography
Exercise challenge: Involves baseline spirometry followed by
exercise on a treadmill or bicycle to a heart rate greater than
60% of the predicted maximum, with monitoring of the
electrocardiogram and oxyhemoglobin saturation
Fraction of exhaled nitric oxide (FeNO) testing: Noninvasive
marker of airway inflammation
Radiography: Reveals hyperinflation and increased bronchial
markings; radiography may also show evidence of parenchymal
disease, atelectasis, pneumonia, congenital anomaly, or a
foreign body
Allergy testing: Can identify allergic factors that may
significantly contribute to asthma
Histologic evaluation of the airways: Typically reveal
infiltration with inflammatory cells, narrowing of airway lumina,
bronchial and bronchiolar epithelial denudation, and mucus
plugs

ASTHMA MEDICINES
There are two basic kinds of medicine used to treat asthma.
Long-term control drugs are taken every day to prevent asthma
symptoms. Pt. should take these medicines even if no symptoms
are present. Some children may need more than one long-term
control medicine.
Types of long-termcontrol medicinesinclude:
Inhaled steroids (these are usually the first choice of treatment)
Long-acting bronchodilators (these are almost always used with
inhaled steroids)
Leukotriene inhibitors
Cromolyn sodium

Quick reliefor rescue asthma drugs work fast to control asthma

symptoms.
Children take them when they are coughing, wheezing, having
trouble breathing, or having an asthma attack.
Examples of quick relief medicines include Proventil, Ventolin,
and Xopenex.
Some of child's asthma medicines can be taken using
aninhaler.
Children who use an inhaler should use a"spacer" device. This
helps them to get the medicine into the lungs properly.
If the child uses the inhaler wrong way, less medicine gets into
the lungs.
Younger children can use anebulizerinstead of an inhaler to take
their medicine. A nebulizer turns asthma medicine into a mist.

pt.management
Aims of tx.
Assist in the removal of secretions.
Gain relaxation of the neck, shoulder girdle, and
upper chest muscles.
Teach the pt. breathing control
Maintain mobility of the neck, shoulder girdle,
thoracic spine and thorax.
Educate postural awareness.
Maintain or improve exercise tolerance.
Encourage a full, active lifestyle.

Removal of secretions
Postural drainage
Vibrations
Effective coughing
FET without increasing bronchospasm.
Suction
Relaxation and breathing control

Mobility exercises and postural awareness

To ensure ventilation of the basal alveoli the pt be
encouraged to adopt a balance relaxed posture.
Thoracic, neck, and shoulder mobility exercises shhould be
performed daily together with strengthening exercises for
weak muscle(e.g.shoulder girdle retractor, abdominals and
thoracic spine extensors).
Exercise tolerance
To gain breathing control during all daily activities.
To increase the pt. ability to perform exercises which
produce breathlessness without bringing on an asthmatic
attack.
The breathlessness is overcome by the breathing control.

lessness

Full active lifestyle

Keep encouraged to keep fit.
Avoid with smoking person
Eat sensibly
Live a normal life in relation to school, hobbies and social
activities.
Swimming helps to gain relaxation amd improve breathing
control.
For children who suffer mild attacks and exercise programme
should be developed and they should be encouraged to attend
keep fit classes. Children may attend group class.
Children with chronic asthma may benefit from residential
courses offering activities such as weight training, skipping,
football, static bicycle, swimming and water polo.
Very young children like made up games such as mimicking
different zoo animals to include relaxation, hopping, blowing out
and waving arms.

references
www.mayoclinic.org
www.nlm.nih.gov

CASE
STUDY
Geriatric
aeba

Name: Mrs. T
Age: 65y/o
Gender: female
Race: Malay
R/N: 12234
Date of Admitted: 5 / 9 / 2014
Date of Assessment: 8/ 9 / 2014
Dr. Diagnosis:
AEBA
Dr mx:
Conservative mx. and refer physio

SUBJECTIVES ASSESSMENT
Problems:
Pt. c/o SOB and cough.
Pt. c/o unable to spit out phlegm.
Current hx:
h/o SOB on 5/9/2014. Seek for medical tx.Then
admitted to ward on the same day.Dr. refer her to
physio for further mx.
Past hx:NIL

Past medical hx:

- HPT since 1 years ago and on medication
- AEBA since 1 years ago and on inhaler
Family hx:NIL
Drug / medication:
HPT medicine since 1 years ago
Inhaler since 1 years ago
Social hx:
Occ: housewife
Stay with husband in a single-storey house
Marital status: Married with 3 children
Not smoking or alcohol intake
Recreation: Gardening

Investigation:
Lab values: NIL
Ct-scan: NIL
MRI : NIL
Chest x-ray:NIL

General Observation: An endomorphic body size of

malay female, sitting on bed. Conscious, alert, obey
command and able to talk full sentences.
Local observation:
Hands: no clubbing, no cyanosis, no pale, iv drip on Rt
hand
Chest: no tube inserted
Examination on chest: no deformity
Breathing pattern : Eupnea
Breathing level: Apical breathing
Cough: dry cough; productive and not effective

Palpation:
Chest expansion:
Level

Symmetrical/assymetrical

Manobriosternal junction

Symmetrical

Xiphisternal junction

Symmetrical

10th rib

Symmetrical

Auscultation:
Level

Right

Left

Apical

Normal and crepts

Normal and crepts

Medial

Normal

Normal

Lower

Reduce breath sound

Reduce breath sound

Interpretation: both apical lobe presents of crepts d/t

secretion retention and both lower lobe reduce breath
sound d/t incorrect breathing pattern.

Functional activity:
Bed mobility-well
ANALYSIS:
PT impression:
SOB d/t incorrect breathing pattern
Cough d/t secretion retention
Reduce breath sound d/t incorrect breathing
pattern

Short Term Goal:

To reduce SOB within 2 days
To reduce secretion retention within 3 days
To improve breath sound over bilateral lower lobe
within 4 days

Long Term Goal

To improve QOL
To optimize respiratory function
To prevent secondary complication such as lung
collapse.

PLAN OF TREATMENT:
PLB
Relaxation position
Manual techniques-vibration,percussion,shaking
Breathing exs
ACBT
TME
Circulatory exs
Pt. edu.
HEP

INTERVENTIONS
Pt. in high sitt. on edge of bed, teach PLB 5x 2set
Pt. in high sitt. on edge of bed, breathing exs
diaphragmatic breathing- 3x 2set
Pt. in high sitt. on edge of bed, chest vibration
Pt. in high sitt. on edge of bed, ACBT 2x 2 set.
Pt. in high sitt. on edge of bed, TME, 3x 2 set.
Circulatory exs-ankle pumping 10x
Relaxation position , pt. in forward lean sitting.
Pt education: continue breathing exs, PLB is advice
when SOB; positioning- change every 2 hours;
HEP: Advise to do all exs. regularly at home.

EVALUATION:
Pt can tolerate all tx given
Pt feel tired after tx
Pt. able to cough affectively and productively.
Sputum analysis: Yellowish, thick, small amount.

REASSESSMENT:
Continue same tx as above
Focus more to breathing exs