Case No. 12 SH, 25 years old with a history of asthma since childhood presented to the OPD clinic with complaints of worsening dyspnea and wheezing. He had similar intermittent symptoms over the past 3 months, usually requiring E.R visits. Last E.R visit was 2 weeks earlier where he was discharged on inhaled bronchodilators and a 10 days course on steroids. He has received oral glucocorticoids patient still has multiple episodes of wheezing and shortness of breath. His present medications include time released theophylline 300 mg BID and salbutamol metered dose inhaler 2 puffs every hour. Previous pulmonary function tests revealed normal lung volumes except for the residual volume which is increased. P.E showed a well developed male in respiratory distress: BP=130/80, PR=112/min, RR=40/min, T°=36.6°C. Lungs: diffuse inspiratory and expiratory wheezes.

Diagnosis: Asthma Asthma is a chronic disease of the respiratory system in which the airway occasionally constricts, becomes inflamed, and is lined with excessive amounts of mucus, often in response to one or more triggers. It’s divide into 2 phase 1. Early phase which is IgE mediated, associated with histamin release from mast cells. 2. Late phase is associated with cytokine release.

Causes: 1. Inhalant allergens and oral ingestion. 1. Inhalant allergens and oral ingestion. 2. Irritants and others. 2. Irritants and others. Sign and symptom: Sign and symptom: 1. Triad – dyspnea, cough, and wheezing. 1. Triad – dyspnea, cough, and wheezing. 2. Bronchospasms. 2. Bronchospasms. 3. Bronchiole edema. 3. Bronchiole edema. 4. Hypersecretion. 4. Hypersecretion.

Lab and Physical exam: 1.Spirometry: FEV1 is <80% of the predicted value. FEV1 is <80% of the predicted value. FEV1/FVC is <75% of the predicted value. FEV1/FVC is <75% of the predicted value. (FEV1: Forced expiratory volume in 1 second. FVC: Forced vital capacity.) (FEV1: Forced expiratory volume in 1 second. FVC: Forced vital capacity.) 2.Oxygen saturation <95%. 3.Wheezing on exhalation. 4.Retractions of sternocleidomastoids. 5.Blood cultures: ↑IgE and eosinophil.

Prescription for asthma

Drugs used to treat asthma <Bronchodilator>  Sympathomimetic agents  β  β 2 – Adrenergic angonists   Theophylline   Cromolyn and Nedocromil   Corticosteroids   Montelukast, Zafirlukast, Zileuton

Bronchodilator MOA : Relax airway smooth muscle by stimulating adenyl cyclase and increase the formation of cAMP in the airway tissues that results in bronchodilatation Side effect: Anorexia, N/V, abdominal discomfort, headache and anxiety. Seizures or arrhythmia.

Anti-inflammatory agents MOA: - - Inhibit production of inflammatory cytokines. - - Reduce bronchial reactivity. - - Increase airway caliber. Side effect: oral candidiasis, throat irritation, cough, mouth dryness, myositis, gastroenteritis.

Luekotriene antagonists MOA: - - inhibition of 5-lipoxygenase and binding of leukotriene D 4 to its receptor on target tissues, thereby preventing its action. Side effect: Less effect than others two.

Compare Inhaled bronchodilators AndGlucocorticoids Theophylline Mechanism Salbutamol Inhibit PDE and increase cellular cAMP levels Classify Xanthines β β2 – agonist Corticosteroids Reducing bronchial inflammatory reactions (e.g. edema and mucus hypersecretion) and by modifying allergic reactions. Relaxes smooth muscle by increase intracellular cAMP, which activate Guanylyl cyclase

Complementary treatments Sometimes called “alternative” treatments that work with your traditional medical care to aid in your health. Ex: Yoga Yoga

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