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sayu

HSM/ 6.2 yrs/ Malay girl


Past medical history of bronchial asthma

Presented to A&E with cough and shortness of breath of 1/7


Cough preceded SOB by a few hours
no sputum production, no haemoptysis

Symptoms worse during the night therefore transported to ED Admitted to B3

Other associated features:

+Fever : low grade without chills and rigors +Runny nose +Sore throat +Wheeze

Negative findings

Haemoptysis Facial pain Post-tussive vomiting Chest pain, Palpitations Gastrointestinal symptoms (nausea, vomiting, diarhhoea) Neurological manifestations (headache, syncope, dizziness) Genitourinary symptoms No LOW or LOA

PMH
Bronchial asthma since the age of 2 Frequency of exacerbations: 1 in 3 months Last exacerbation: one month ago where the GP provided nebuliser Not on medication First time requiring hospitalization Triggers :
Cold air Respiratory infection Smoke, dust , pollution NOT exercise

Symptoms:
No day time or night time symptoms No hindrance to daily activity (plays as normal)

History of atopy
Has allergic rhinitis no eczema

PSH: none Drugs and allergies: none Family history:


Mother, 34, secretary. No known medical illnesses Father, 38, sales executive
History of childhood asthma

Perinatal history:
Uncomplicated SVD, to term, 3.1kg.

Immunisation: up to date Development:


Attending school Alert. Good relationship with mother

Social history:
Adult diet Father smokes in the house Lives in an apartment with her parents and elder sister (8 years, healthy) No pets or carpets in the house Her neighbor (cousin) had the flu few days ago Close quarters.

BP: 100/60 RR: 45 bpm HR : 140 bpm spO2: 98% Temp: 37.3C Nebuliser administered 3X but no resolution Admitted to B3

General appearance:

Patient propped in bed. Patient looks tired and using accessory muscles to breathe. Can talk few words at a time. Good nutritional status On nasal prong O2 Tachypnoeic Branula inserted in left hand No peripheral cyanosis or clubbing Warm peripheries Tachycardia (120bpm) CRT<2s
Good volume

Hands:

Face
No conjunctival pallor No engorged turbinates

Mouth
Mildly injected pharynx No tonsillar hypertrophy Tongue: mild dehydration, no cyanosis

Lymph node enlargement


bilateral; anterior cervical chain

Chest

Lungs:

Cardiac:

No chest wall deformities No tracheal deviation Air entry equal into both lungs Widespread rhonchi Occasional crepitations (more on R side)

S1&S2 no murmurs

Abdomen

Soft and non-tender No organomegaly

No skin lesions Other systems examination unremarkable

Relevant Investigations:
Pulse oxymetry: 98% FBC
WBC 24.8 Neutrophils 91.9%

BUSE CXR : hyperinflated lungs PVD: acute exacerbation of asthma secondary to a upper respiratory tract infection

Monitor vital stats

Nasal prong O2 Nebulised salbutamol every 4 hrs Prednisolone (15mg) Sy Penicillin 225mg QID No signs of improvement!
Repeat pulse oximetry showed sPO2: 91%
IV hydrocortisone (QID) Neb ipratropium (atrovent) 4hrly Neb salbutamol 2hrly

to maintain sPO2 >95%

Can the addition of Montelukast help reduce the dosage of oral corticosteroid required for maintenance?

Anti-inflammatory properties
Less adverse side effects compared to corticosteroids

Relieves symptoms of seasonal allergies

Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial

J Pediatr2009;155:795-800

Sept 2005- Feb 2008 Randomized double blind double dummy trial 130 children (ages 2-17 yrs) Mild to moderate acute asthma Subjects: stabilised in the ED and discharged by the 8th hour Randomized into 2 groups

Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial

J Pediatr2009;155:795-800

Each patient receiving 2 tablets per dosage.


63 patients: Oral Prednisolone + placebo 67 patients: Oral Montelukast + placebo

Drugs to be taken at days 1,2,3,4, and 5 after randomization Inhaled 500mcg albuterol every 4 hourly for 5 days Inhaled 100mcg of fluticasone twice a day from day 7

Home visit at 48 hours to assess respiratory status Home visit on the 8th day to assess primary outcome

PRIMARY OUTCOME: Treatment failure within 8 days Hospitalization Unscheduled visit related to asthma The need for additional corticosteroid therapy

Proportion of patients remaining without additional therapy over time

Conclusion from study:


No comparable outcome for Montelukast Montelukast has a higher rate of treatment failure when compared to oral prednisolone
Children with mild-moderate asthma should continue oral corticosteroid after ssdischarge

Anti-Leukotriene Rc Antagonist has a milder anti-inflammatory effect.


Prednisolone exerts effect on T cell, eosonophils and other inflammatory cells

Synergistic effect with LABA for optimum efficacy.

Would the influenza vaccine benefit my patient in reducing future exacerbations of asthma?

Influenza is a common cause of hospitalization in asthmatic children. The inactivated vaccine is 80% effective in preventing influenza in the general population. However it is used only in approximately 10% of asthma patients

-American Journal of Respiratory and Critical Care Medicine.

2004;169:488493

Objective : to determine whether parenteral influenza vaccination is more effective than placebo in 618-year-old children with asthma. DESIGN: randomized, double-blind, placebocontrolled trial 347 children: vaccine, 349: placebo Airway symptoms recorded in a diary and according to a pre-defined severity score.
At the score of 4, a throat swab was taken

Primary outcome:
Number of asthma exacerbations associated with virologically proven influenza infection.
Throat swab

Secondary outcome :
Duration and the severity of each exacerbation Adverse reactions to vaccine Any upper respiratory tract symptoms Unscheduled visit to family doctor

Results

Primary outcome:
It was 31% less in the placebo group (95% CI: -34% to 161% increase)

Secondary outcome:
Similar severity in both groups. 3.1 days shorter duration in the vaccine group. Adverse reactions seen significantly more in the vaccine group (injection site erythema, stiffness of arm, myalgia)
(95% CI: -6.2 to 0.002 days)

Influenza vaccination did not result in a significant reduction of the number, severity, or duration of asthma exacerbations caused by influenza

For my patient: It is beneficial in preventing influenza

infection

However, if my patient does get the infection and thus the exacerbation, the course will be similar to the population who has not been vaccinated.

Ethical issue: Painful placebo injection administered Consent from parent for child