Bronchial Asthma - A Long Case Study Approach

Chief Complaints: 

• Difficulty in breathing for … years
• Cough for … months
• Wheeze and tightness in the chest … months.

History Of Presenting Complaints: According to the statement of the patient, he has been suffering from difficulty in breathing for the last … years. Initially, for a few years, it was episodic, occurring mainly during the winter seasons, and he was asymptomatic in between the attacks. But for the last … years, it is persistent with occasional exacerbations. His breathlessness is worse at night and sometimes during the daytime. It is aggravated by cold, dust and activity. There is no history of orthopnea or paroxysmal nocturnal dyspnea.

The patient also complains of cough which is usually dry, with occasional scanty mucoid sputum

expectoration, but no history of hemoptysis. Cough is present throughout the day and night, more on

exposure to dust or cold. He also experiences wheeze and tightness of the chest during coughing.

For severe attack of breathlessness and cough, he was hospitalized twice within the last ... months.

On query, the patient agreed that he has occasional attack of running nose and sneezing, more

marked on exposure to dust. There is no history of chest pain, weight loss or fever. His bowel and

bladder habits are normal.

History of past illness: He is non-hypertensive, no history suggestive of cardiac illness or reflux

esophagitis.

Family history: His brother is suffering from bronchial asthma and food allergy.

Personal history: He is a school teacher, smokes 10 to 15 cigarettes daily for the last 10 years. There

is no history of exposure to cotton, coal, etc.

Drug history: He uses bronchodilator and steroid inhalers, and used to take tablets like aminophylline, ketotifen and montelukast.

General Examination: 

• The patient is dyspneic
• Decubitus is propped up
• No anemia, jaundice, cyanosis, edema, clubbing, koilonychia or leukonychia
• No lymphadenopathy or thyromegaly
• Neck vein: Not engorged
• Purse lip: Absent
• Nasal polyp: Present on both sides

Vital signs: 

• Pulse: 120/min
• BP: 120/70 mm Hg
• Respiratory rate: 24/min.

Systemic Examination: 

1. Respiratory examination: 

Inspection:

• Shape of the chest—Normal
• There is indrawing of intercostal spaces, suprasternal and supraclavicular excavation and prominent accessory muscles of respiration.

Palpation:

• Trachea: Central. Tracheal tug absent
• Apex beat: In the left 5th intercostal space in midclavicular line, 8 cm from midsternal line, normal in character
• Chest expansion: Reduced
• Vocal fremitus: Normal.

Percussion:

• Percussion note: hyperresonance in both sides
• Area of liver dullness: In 5th ICS in the right midclavicular line
• Area of cardiac dullness: Normal.

Auscultation:

• Breath sound: Vesicular with prolonged expiration
• Vocal resonance: Normal
• Added sounds: High pitched rhonchi are present in both sides of the chest, more marked on expiration.

FET (forced expiratory time): > 6 seconds (normally <6 seconds).

Examination of other systems reveals no abnormalities.

Provisional Diagnosis: Chronic bronchial asthma.

Differential Diagnosis: COPD (Chronic obstructive pulmanary disease).

Questions likely to be asked by the examiner: 

1. Why is it not chronic bronchitis?

Answer. In chronic bronchitis, there is presence of cough with sputum production not attributable to other causes, on most of the days for at least 3 consecutive months in a year for at least 2 successive years.

2. Why is it not cardiac asthma?

Answer. Cardiac asthma means left ventricular failure in which the patient usually presents with sudden severe dyspnea and cough with profuse mucoid expectoration. On examination, there are bilateral basal crepitations and no rhonchi or wheeze.

3. What investigations do you want to do in bronchial asthma?

Answer. As follows:

1. Full blood count.

2. X-ray chest of PA view.

3. Sputum for eosinophil count.

4. Lung function tests:

5. Blood gas analysis: PaO2 (reduced )and PaCO2 (raised or normal).

6. Bronchoprovocation test (with methacholine or histamine or hypertonic saline – fall of FEV1

> 20% indicates hyperresponsiveness of airways. This is found in cough variant asthma, mild

intermittent asthma, chronic bronchitis with hyperresponsive airways). It is useful when asthma

is suspected, but spirometry is not diagnostic.

7. Skin prick test.

8. Allergen provocation tests.

9. Serum IgE level.

10. ECG (to exclude RVH in cor pulmonale).

4. What is bronchial asthma?

Answer. It is a chronic airway inflammatory disorder characterized by hyper-responsiveness of the airways to various stimuli, presenting as breathlessness, cough, chest tightness and wheeze. It is reversible.

5. What are the cardinal pathophysiologic features of bronchial asthma?

Answer. Three cardinal features:

• Airflow limitation – it is usually reversible spontaneously or with treatment
• Airway hyper-responsiveness – airway is hyper-responsive to a wide range of nonspecific stimuli like exercise, cold air
• Airway inflammation – there is inflammation of the bronchi with infiltration of eosinophils, T cells and mast cells. Also there is plasma exudation, edema, smooth muscle hypertrophy, matrix deposition, mucus plugging and epithelial damage

(In chronic asthma, inflammation may lead to irreversible airflow limitation due to airway wall

remodeling, involving the large and small airways with mucus impaction.)

6. How can you diagnose a case of bronchial asthma?

Answer. Typical history (cardinal features like paroxysmal breathlessness, cough, wheeze and chest

tightness) plus any of the following:

• FEV1 ≥ 15 % (and 200 mL) increase following the inhalation of bronchodilator. (Global Initiative for Asthma accepts an increase of 12%).
• FEV1 ≥ 15 % decrease after 6 minutes of exercise.
• PEFR shows > 20% of diurnal variation on ≥ 3 days in a week for 2 weeks.

7. What are the types of bronchial asthma?

Answer. Four groups based on frequency of symptoms, severity of attack and pulmonary function tests abnormality:

1. Intermittent asthma: About 2 or less than 2 nocturnal symptoms (cough, wheeze, shortness of

breath at night or early morning) in a month. Between the episodes, the patient remains symptom

free and lung function tests are normal.

2. Persistent asthma: Frequent attacks at least more than two occasions in a month. In between the

attack, the patient may or may not have symptoms and lung function tests are abnormal, except

in mild case. It may be:

• Mild – usually the patient has nocturnal attack of dyspnea more than 2 times per month and baseline (i.e. during symptom free state) PEFR or FEV1 is usually < 80 to 65% of predicted value. Occasionally, lung function tests may be normal in between attacks.
•  Moderate – usually the patient has almost daily attack of dyspnea and baseline PEFR or FEV1 is < 65 to 50% of predicted value.
•  Severe – usually the patient has dyspnea to some extent continuously for 6 months or more and baseline PEFR or FEV1 is less than 50% of predicted value.

3. Acute exacerbation: Loss of control of any class or variant of asthma. It is again classified as –

• Mild – The patient is dyspneic, but can complete a sentence in one breath.
• Moderate – The patient is more dyspneic and cannot complete a sentence in one breath.
• Severe (severe acute asthma) – The patient is severely dyspneic, talks in words and may be restless, even unconscious.

4. Special variants. There are 5 types:

• Cough variant asthma
• Exercise induced asthma
• Occupational asthma
• Drug-induced asthma (aspirin, other NSAID, b blocker)
• Seasonal asthma.

8. What is cough variant asthma?

Answer.  It is a type of asthma in which there is chronic dry cough with or without sputum eosinophilia, but no abnormalities in airway function. It is also called eosinophilic bronchitis, common in young children. Cough is the only symptom, mostly at night. Examination during day may not reveal any abnormality. Cough may be increased with exercise, exposure to dust, strong fragrances or cold air. Methacholine challenge test is positive.

Clinical criteria for diagnosis:

• Dry cough persisting more than 6 to 8 weeks
• Presence of bronchial hyper-responsiveness
• Absence of dyspnea and wheeze.

Treatment: Should be according to the stepwise approach for long-term. Nedocromil sodium is

effective. Also consider the following points: 

• Allergic rhinitis should be treated, if present.
• Gastroesophageal reflux disease should be treated with proton pump inhibitor (e.g. omeprazole) and/or gastric prokinetic agent (e.g. domperidone).
• Any environmental factors like cold, dust, fume, etc. should be avoided.
•  β blocker, aspirin should also be avoided.

9.  What is exercise-induced asthma?

Answer. When exercise produces asthma, it is known as exercise-induced asthma. 

10% or more reduction of FEV1 after exercise is diagnostic.

Cold dry air that enters into the lungs during exercise is the main trigger factor. Increased ventilation

results in water loss from the pericellular lining fluid of the respiratory mucosa trigger mediator release. Heat loss from the respiratory mucosa is also involved.

Treatment:

• Single dose short acting b2 agonist, sodium chromoglycate or nedocromil sodium immediately before exercise should be used.
• Inhaled corticosteroid twice daily for 8 to 12 weeks reduces severity.
• If abnormal spirometry and persistent symptoms- inhaled corticosteroid with long acting b2 agonist.
• Leukotriene receptor antagonist may be used.

10. What is occupational asthma?

Answer. It may be defined as “asthma induced at work by exposure to occupation related agents, which are mainly inhaled at the workplace”. The most characteristic feature is symptoms that worsen on work days and improves on holidays.

Atopic individual and smoker are at increased risk. Commonly found in chemical workers, farmers,

grain handlers, cigarette manufacturers, fabric, dye, press and printing workers, laboratory workers,

poultry breeders, wood and bakery workers. 

Measurement of 2 hourly peak at and away from work is helpful for diagnosis.

Treatment:

• Avoidance of further exposure
• Using mask at work
• If no response, step care asthma management plan.

11. What is drug induced asthma?

Answer. Symptoms of asthma that occurs after use of certain drugs such as aspirin, beta blocker, some nonsteroidal anti-inframmatory drugs (NSAIDs), etc. These drugs can cause bronchospasm.

Treatment: Avoidance of triggering drugs. Safe NSAIDs are paracetamol, tramadol, also etoricoxib.

12. What is intrinsic asthma and extrinsic asthma?

Answer. As follows:

Intrinsic asthma (non atopic or late onset asthma): When no causative agent can be identified. It is

not allergic, usually begins after the age of 30 years, tends to be more continuous and more severe.

Extrinsic asthma (atopic or early onset asthma): When a definite external cause is present. There is history of allergy to dust, mite, animal danders, pollens, fungi, etc. It occurs commonly in childhood and usually shows seasonal variations.

12. What are the features of life threatening or very severe asthma?

Answer . As follows:

• Exhaustion, confusion or coma
• Cyanosis
• Silent chest
• Feeble respiratory effort
• Bradycardia or hypotension or arrhythmia
• PEFR < 33% of predicted (< 100 L/min)
• Blood gas analysis – SpO2 < 92% or PaO2 <8 kPa (60 mm Hg) even with O2
• Normal or raised PaCO2 (> 6 kPa) and low or falling blood pH.

13. How to treat acute severe bronchial asthma?

Answer. As follows:

• High flow O2—40 to 60% (to maintain O2 saturation above 92%).
• Nebulized sulbutamol 5 mg or terbutaline 10 mg. May be repeated 2 to 4 hourly.
• Nebulized ipratropium bromide 0.5 mg may be added with nebulized sulbutamol.
• Injection hydrocortison 200 mg IV 4 hourly. After 24 hour, oral prednisolone 60 mg daily should be given for two weeks, then taper.
• If no response, IV infusion sulbutamol 3 to 20 mg/min or terbutaline 1.5 to 5 mg/min or magnesium sulphate IV 1.2 to 2 gm over 20 minutes may be given.
• In some cases, injection aminophyllin 5 mg/kg loading dose over 20 minutes, then continuous infusion at 1 mg/kg/h.
• Correction of fluid and electrolytes (repeated use of salbutamol may cause hypokalemia).
• If no response with this regime, the patient may be shifted ICU for assisted ventilation.

14. How to monitor a patient with acute severe bronchial asthma?

Answer. As follows:

• Repeated PEFR in every 15 to 30 min
• Pulse oxymetry (SaO2 should be kept > 92%)
• Repeat arterial blood gas analysis
• X-ray chest to exclude pneumothorax.