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HIPOTIROID KONGENITAL

DISERTAI SINDROM DOWN


Laporan kasus

Mahirina Marjani

ASTHMA
Asthma
chronic
inflamatory disease of the
airway
obstruction of
airflow
completely or
partially
BRONCHOSPASM

Asthma affects an estimated


300 million people worldwide
WHO report 250.000 deaths
of asthma worldwide
Approximately 500.000
hospitalization (34,6% in
individuals aged 18 years or
younger) are due to asthma
ln The United States

INCIDENCE

Asthma vary in age including


infants, children & adolescents with
problems & implications of each
specific therapy

MANAGEMENT
PREVENTI
NG
SYMPTOM Education
P
TREATING Short Treatment
ASTHMA Long Term
ATTACK
Administration

CASE
RT

REPO
A 11 years old boy admitted to dr.
Wahidin Sudirohusodo Hospital with
chief complaint shortness of breath on
November 9th 2011

Alloanamnesis : Mother
HISTORY TAKING:
Shortness of breath experienced since 3 days and
worsening during the last day before admission
cough with white mucus since 1 weeks before
admission
His appetite decrased
There was decrease of apettite
Micturition and defecation were normal
history of shorthness of breath experienced first when
he was 7 years old and got treatment at local hospital,
The next attacked when he was 10 years oldl
Recently, reccurent shortness of breath 4-5 times a
month particularly at night and early morning,
triggered by cold temperature and activity
history of asthma in family is his mother
and there was no history of atopic

PHYSICAL EXAMINATION
GC: moderate ill, undernourished, consciou s(GCS
15)
Vital sign: BP : 100/70, HR 136 x/min, RR 34 x/min,
Temp 36,5o C
Inspection: nasal flare (+), retraction on subcostal,
intercostal and suprasternal regio
Auscultation: BS bronchovesicular, crackles and
wheezing on both right and left lung

LABORATORY FINDING
Hb : 16,3 g/dl
PLT : 501.000 /mm3
WBC : 9.330 /mm3
- eosinophil 0,68%
- basophil 0,68%
- metamyelocyte 82,4%
- granulocyte 26,9%
- monocyte 9,5%

Showed bronchovascular pattern within


prominent border and no active process on
both lungs, suggested bronchitis appereance

CHEST RADIOGRAPHY

WORKING
DIAGNOSI
S
Frequent Episodic Asthma
With Severe Asthma Attacks

UNDERNOURIS
HED

THERAPHY
- Oxygen 2 liter/minute
- IVFD dextrose 5% 24 drops per minute
- Inhale ipratropium bromida + salbutamol
(combivent)1 tube thinning in NaCl 2,5 cc every 2
hours (if recovey, achieved after 4-6 times of
nebulization, given in 4 hours interval)
- Methylprednisolon 0,5-1 mg/kgBW each day, it means
5 mg/8 hours intravenous
- Aminophyline loading dose 6 mg/ kgBW, it means 150
mg of aminophyline thinning in 20 cc dextrose 5% in
30 minute continous with maintenance dose 0,5-1
mg/kgBW/hour = 300 mg/day

FOLLOW UP

2nd day

3rd day

5th day

Vital Sign

Normal

Normal

Normal

Complaint

dyspneu

Nothing

Nothing

Physical
examination

Nasal flare, retraction on


subcostal, intercostal &
suprasternal regio, crackles
& wheezing on both right &
left lung

Minimal retraction
on intercostal,
there were no
crackles &
wheezing

No
retraction,
no crackles
& wheezing

Therapy

O2, IVFD dextrose 5%


nebulization given in 4-6
hours interval,
methylprednisolone 5mg/8
hours intravenous and
aminophyline intravenous
maintenance dose 0,5-1
mg/kgBW/hour = 300
mg/day, it means 100 mg
aminophyline thinning in
500 cc dextrose 5% 24
drops/minute every 8 hours
Patient was allowed drink in
a little amount

IVFD dextrose
5% and stop
methylprednisolo
ne exchange to
prednisone
tablets 3 times
each day

Prednisone
tablets 3
times each
day

Patient
allowed to
discharge
from
hospital

PROGNOSIS

QUA AD
VITAM

BONAM
QUA AD
SANATIONEM

DEFINITIVE DIAGNOSIS
Frequent Episodic
Asthma With
Severe Asthma
Attacks

Undernourished

DISCUSSION

2 Main Types Of Childhood Asthma


1

Recurrent wheezing in early


childhood
common viral infections of the
respiratory
Chronic asthma
allergy
tract
that persists into later
childhood and
often adulthood

PATHOPHYSIOLOGY OF CLINICAL
SYMPTOMS

AIRWAY
CONSTRICTIO
N

MUCUS
HYPERSECRET
ION

AIRWAY
OBSTRUCTIO
N

SHORTNES
S OF
BREATH
WHEEZING
CHEST
DISTRESS
SOURCE: health.wikinut.com

Airway Remodelling In Asthma

CLINICAL SIGN OF ASTHMA


LITERATURE
Intermittent dry
coughing and/or
expiratory wheezing
Shorthness of breath
Chest distress
Intermittent chestpain
Respiratory
symptomps can be
worse at night
triggered by
respiratory infection or
inhalant allergens

PATIENT
Shorthness of breath
Cough with
hyersecretion mucus
Wheezing
Respiratory
symptomps triggered
by cold temperature
and activity

INDONESIAN NATIONAL GUIDELINE FOR


PEDIATRIC ASTHMA CLASSIFY ASTHMA
Clinical

Infrequent

parameter,

asthma

drug

asthma)

Frequent

(mild asthma

requirement,

Persistent
asthma

(moderate

(severe

asthma)

asthma)

pulmonary
function
Frequency

of <1x month

>1x/month

Often

attack
Duration

of < 1 week

1 week

Occure almost a

attack

year,

no

Interval

Often

remission
Symptom

at

Often disturbed

night and noon


Severely

May be impared

disturbed
Never in normal

episodes
Sleep
activity
Physical

No symptom
and Undisturbed
exam Normal

Drug control Unnessesary Inhalation

Inhalatation/

(anty

minimal dose

oral steroid

inflammatory

of

steroid/nonst
eroid

Pulmonary

PEF/FEV1

function test

80%

> PEF/FEV1
80%

60- PEF/FEV1

<

60%
variability 2030%

Pulmonary

Variability

function

15%

variability

> Variability
30%

> Variability
50%

>

ASSESSMENT OF THE DEGREE OF ASTHMA


ATTACKS
Clinical
Severe
parameter,

Mild

pulmonary

Moderate

function

Breathless Walking
Can

Talking

lie Infant-softer

Without

With

threat of

threat of

respiratory

respirator

arrest

y arrest

At rest
Infant stops

down

Shorter cry

feeding

Difficult

Hunched

feeding

forward

Prefers sitting

Position

Talks in
Alertness

Could

Rather sitting Sitting

lying

propped

Sentences Phrases

arm
Words

Maybe

Usually

Usually

Drowsy or

Cyanosis
Wheezing

No
Moderate,
often

No
Loud, almost

Yes
Very

only of expiratory

obvious

at the end- inspiratory

audible

expiratory

without

Obvious
loud, Difficult,
no sound

stetoscop
during
expiration
and
Use of

Usually not Usually yes

inspiration
Yes

Toracoabd

respiratory

ominal

muscle

paradoxal

Retraction

movement
plus Superficial

Superficial, Moderate,

Within,

intercostal

plus

nostril

retraction

suprasternal

breathing

dissapear

retraction

Respiratory

Increased

Increased

rate

Pulse rate

often

Decreased

>30x/min

<100

100-200

Paradoxus

Absent

Maybe present

pulse

< 10 mmHg 10-25 mmHg

>120

Bradycard

Often

i
Absent

present

suggests

20PEFR or FEV1
(% prediction
value / % best
value)

>60%

40-60%

Pre-

bronchodilator

Over 80%

Approximately

60-80%

Post-

40

mmHg

<40%

<60%

bronchodilator

SaO2%

> 95%

91-95%

90%

Normal
(usually
may not be

>60 mmHg

<
mmHg

60

BASED ON THE GUIDELINES


ABOVE, THE ATTACKS THAT
OCCURRED IN OUR PATIENTS IS
DUE TO
Frequent Episodic Asthma
With Severe Asthma
Attacks

Patients Chest X-Ray showed bronchovascular


pattern within prominent border and no active
process on both lungs, suggested bronchitis
appereance

Chest X-Ray
(posteroanteri
or &lateral
views) in
children with
asthma often
appear to be
normal, aside
from subtle &
nonspecific
findings of
hyperinflation
(flattening of
the
diaphragms)
&

MANAGEMENT OF ASTHMA
Oxygen as supportive
theraphy
Rehydration
-adrenergic agonist
Anthicolinergic
Systemic corticosteroid
Bronchodilation

Oxygen
Theraphy
given oxygen at moderate &
severe attacks

Dehydration
caused by lack of inadequate fluid
intake, increased insensible water
lose, tachypneu & diuretic effects
of theophylline.

-adrenergic
agonist

fundamental & first line


regimen on asthma attack

Ipratropium bromide
Recommended dose is 0,1 ml/kg
BW, nebulized every 4 hours

Systemic
corticosteroid
The recommended doses:
- Methylprednisolone is 0.5-1 mg/kgBW,
given every 4-6 hours, hydrocortisone
intravenous be given 4mg/kgBW, every
4-6 hours
- Dexamethason intravenous at a dose of
0.5-1 mg/kgBW, coninued 1
mg/kgBW/day, administered every 6-8
hours
- Oral preparations : prednisone,

Bronchodilatio
n
Methyl xanthine (theophylline) is
equipotent to 2-agonist :
- Initial dose of aminophyline is 68 mg/kg BW diluted in 20 ml of
dextrose 5% or normal saline
solution given in 20-30 minutes.
- Maintenance dose of 0,5-1
mg/kg BW/hour

Asthma Treatment
Guideline

THANK
YOU