This instance was clerked in Seremban Hospital, Malaysia. The patient is a 67 twelvemonth old Muslim patient. She weighs 62kgs and has a tallness of 158cm. Her deliberate BMI is 24.8 which is normal. She is married for 39 old ages and has 3 kids. On admittance to infirmary, she ailment of shortness of breath ( SOB ) for 1 twenty-four hours ; febrility, lassitude and cough for 3 yearss ; running nose and sickness. She was sent to the infirmary ‘s accident and exigency section by her boy. She suffered from asthma since childhood. Her past medical history includes high blood pressure for 10 old ages and one-sided exophthalmos. She lives with her hubby, boy and daughter-in-law. She is a homemaker. She does non smoke and does non devour intoxicant overly. She has a household history of high blood pressure as both her parents suffered from high blood pressure. Before admittance, she was on metered dose inhalator ( MDI ) Salbutamol inhalator when required ( PRN ) , metered dose inhalator Beclomethasone 200mcg twice daily ( BD ) for asthma and Tablet Amlodipine 10mg one time day-to-day ( OD ) for high blood pressure.

for measure 2 control of asthma.

On scrutiny, she was found to be pyretic with a temperature of 38.3oC. She besides had cough with productive phlegm, SOB which is non relieved by inhalator and lassitude. Her pulse rate was 100 beats per minute, respiratory rate was 22 breaths per minute and blood force per unit area was 140/78. She was diagnosed with acute aggravation of asthma secondary to respiratory tract infection. Several probes were ordered such as full blood count, nephritic maps trials and liver map trials. Consequences of the probes were as follows:

Full Blood Count appears to be normal EXCEPT



WBC ( 7.5A±3.5 x 109/L )



Nephritic Function Trials appears to be normal EXCEPT


Plasma K ( 3.4-5.2 mmol/L )



Plasma Creatinine ( 50-80Aµmol/L )



Creatinine clearance = ( 140 – age ) ten weight ( kilogram ) x 1.04 ( if female ) x 1.23 ( if male )

Serum creatinine

= ( 140 – 67 ) x 62 tens 1.04


= 46.76ml/min

A creatinine clearance of 46.76ml/min indicates moderate nephritic damage.

Liver Function Test appears to be normal

On twenty-four hours 1, she was pyretic with a temperature of 38.3oc, coughing with production of xanthous phlegm, lethargic and had hapless appetency and shortness of breath. Her blood force per unit area, pulse rate and respiratory rate were as above. The physician program to get down her on a class of Prednisolone 40mg one time day-to-day ( OD ) for five yearss, Combivent nebulizer instantly so every 4 hourly and Paracetamol 1g instantly so every 6 hourly. She was continued on the medicines she was taking antecedently which were metered dose inhalator ( MDI ) Salbutamol inhalator when required ( PRN ) , metered dose inhalator Beclomethasone 200mcg twice daily ( BD ) and Tablet Amlodipine 10mg one time day-to-day ( OD ) . Besides that, the physician besides ordered for antibiotic therapy to be started with Azithromycin 500mg OD for five yearss and Augmentin 625mg BD for 7 yearss. The physician besides asked the patient to administrate oculus medicine by herself.

On twenty-four hours 2, patient was witting and speaking in full sentences, her SOB improved but the coughing persisted. She still had decrease in appetency. The druggist came by the ward to look into the technique of MDI use and counseled the patient on the right usage of the MDI. She was still pyretic with a temperature of 39oc. Her blood force per unit area was 140/80. Pulse rate was 100 beats per minute and spO2 was 98 % . Medicines that were given were continued. The physician besides prescribed bisolvon ( bromhexine ) for her cough. A K addendum, KCl 1.5g OD was besides given for hypokalaemia. The physician besides ordered spO2 monitoring to guarantee that the degrees do non fall below 95 % .

On twenty-four hours 3, patient was witting and qui vive. She was able to eat somewhat and there was no SOB or sickness and emesis. However, she still had cough. Her blood force per unit area was 130/70, temperature has gone down to 37.5oc, spO2 was 97 % and pulse rate was 98 beats per minute. The program for the twenty-four hours was to go on unwritten antibiotics and proctor temperature. Potassium addendum was stopped.

On twenty-four hours 4, the patient was experiencing much better. She was merely holding cough. Her temperature, spO2, blood force per unit area and respiratory rate were normal. The physician allowed discharge with azithromycin 500mg OD for a twenty-four hours, augmentin 625mg BD for 3 more yearss, amlodipine 10mg BD, MDI beclomethasone 200mcg BD and MDI salbutamol when required.

Summary of patient medicine:

Drug & A ; Route

Dose & A ; Frequency

Start Date


Amlodipine ( O )

10mg Doctor of optometry


CCB for high blood pressure

Combivent ( Neb )

Stat so 4 hourly



Prednisolone ( O )

40mg OD ( 5/7 )


Corticosteroid for asthma

Beclomethasone ( MDI )

200mcg BD


Corticosteroid for asthma

Salbutamol ( MDI )

2 whiffs PRN


Bronchodilator for asthma

Theophyllin ( O )

250mg Doctor of optometry


Bronchodilator for asthma

Paracetamol ( O )

1g stat and every 6 hourly


Non opioid analgesic for febrility

Azithromycin ( O )

500mg OD ( 5/7 )


Macrolide for infection

Augmentin ( O )

625mg BD ( 1/52 )



Bisolvon ( O )

8mg TDS


Cough mixture

Thymol ( mouthwash )



Oral hygiene

Potassium Chloride ( O )

1.5g Doctor of optometry


Potassium addendum

The World Health Organization defines asthma as a long term status which causes perennial onslaught of wheezing and shortness of breath which frequence and badness varies among persons. Asthma is caused by air passage redness which leads to obstruction that is most likely reversible. The redness of air passages is due to increased hyperresponsiveness of the air passages caused by bacterial or viral infections or allergens which lead to bronchospasm, increased secernment of mucous secretion and oedema.1 In the UK, more than 5 million people are diagnosed with asthma and more than 8 million people have one time been diagnosed with asthma.2,3 In twelvemonth 2006-2007, there were 80,593 instances of asthma onslaughts that require hospital admittances. 4

Narrowing of the air passages in asthma can be caused by overresponsiveness of the immune system to certain substances. In respond to these foreign substances, the immune system produces Ig E antibodies which are specific to the allergen. These antibodies so bind to mast cells. In the early stage response, the antibody and mast cell complex binds to the allergen triping the release of inflammatory go-betweens like histamine and eicosanoids on the 2nd brush of the allergen. Histamine and eicosanoids cause inordinate mucous secretion secernment and bronchial wall hydrops which leads to airway obstructor. The symptoms looking at this phase might non be terrible, for illustration, watery eyes and fluid olfactory organ. In the late stage response, eosinophils infiltration stimulates the release of more inflammatory go-betweens by release of O derived free groups and basic proteins.5 The redness of the air passages worsen as bronchoconstriction occur as a consequence of hypersensitivity in airway smooth musculuss doing declining symptoms like wheezing, coughing, chest stringency and SOB.6 The pathophysiology of asthma is farther proven by characteristics like goblet cell peeling of epithelial cell, mucous secretion stoppers, hydrops in mucous membrane, smooth musculus hypertrophy, infiltration of air passages by eosinophils and mast cells, and submucous secretory organ hyperplasia in patients who died from asthma.7

Many allergens can trip asthma onslaughts and put off the immune system cascade. This include bacterial and viral infections in the respiratory piece of land, dust from environment, coffin nail fume, pollens, waste and pelt of pets, insects such as cockroaches, cast, drugs such as penicillin, and other chemical substances. Stress, exercising and cold conditions may increase opportunities of asthma onslaughts. The diagnosing of asthma is made depending on symptoms, hearing a widespread wheeze on auscilation, household history of asthma, low forced expiratory volume in 1 2nd, FEV1/ peak expiratory flow rate, PEFR and peripheral blood eosinophilia.8 Symptoms of asthma include shortness of breath, wheezing, coughing and chest stringency which worsens early forenoon and at dark, when exerting, exposed to cold air or allergens, after taking certain drugs like acetylsalicylic acid or beta blockers.8 Spirometry measuring is widely used and extremely effectual in finding the grade of airflow obstructor. The best of 3 FEV1 readings and 3 forced expiratory blows after a maximal intermission of 2 seconds should be used to find airflow obstruction.9 Eosinophil count and exhaled azotic oxide concentration ( FENO ) is besides used to mensurate redness of the air passages as surveies show that in 70-80 % of patients with untreated asthma, there is a raised phlegm eosinophil count or raised FENO.10 Diagnosis of acute aggravation of asthma should be based on FEV1 reading, respiratory rate, bosom rate and clinical marks such as inability to finish sentence in a breath, hypotension, cyanosis and arrhythmia.

The direction of asthma is based on a stepwise attack. Harmonizing to the SIGN guidelines and British Thoracic Society ( BTS ) , the badness of asthma can be classified into 5 stairss, each with a different direction program. In measure 1, patient is controlled with a short-acting bronchodilator such as inhaled short-acting I?2 agonist ( salbutamol ) , inhaled ipratropium bromide which is an antimuscarinic bronchodilator or theophyllines.8 Short-acting I?2 agonist plants by I?2 adrenoceptor stimulation in the respiratory airways thereby doing bronchial smooth musculus relaxation and mast cell stabilization.11 The consequence of a short playing I?2 agonist merely last up to 3 or 4 hours and can bring forth side effects such as musculus spasms, shudder and nervous tenseness. Step 2 asthma is managed by add-on of a regular preventor therapy such as an inhaled corticoid ( beclomethasone ) .8 Inhaled corticoids are anti-inflammatory agents moving by suppressing cytokines production which will do a decrease in epithelial tissue go-between cells, lessening vascular permeableness and eosinophil infiltration, and do suppression of eosinophil and macrophage action. There is a hazard of moniliasis with corticoids, hence patient is advised to rinse oral cavity exhaustively after use.

In measure 3 asthma, a long-acting I?2 agonist such as salmeterol is added8 which has the same mechanism of action as short-acting I?2 agonists with longer continuance of action, for at least 12 hours11 but a longer oncoming of action. Step 4 asthma is managed by increasing dosage of inhaled corticoid, adding leukotriene receptor adversaries, adding Elixophyllins or utilizing slow release I?2 agonist tablets.8 Theophylline is a bronchodilator which acts by increasing histone deacetylases HDAC to cut down written text of inflammatory go-betweens by suppressing acetylation of histones.12 It besides inhibits phosphodiesterase and antagonise adenosine receptor which contributes to the side effects like sickness and emesis, concern and tachycardia. In measure 5 direction, patient is controlled with a low dose unwritten corticosteroid.8 Acute aggravation of asthma can be managed by the usage of high-dose inhaled I?2 agonist, a combination of ipratropium bromide and I?2 agonist and unwritten steroids such as Pediapred.

Harmonizing to the categorization guidelines given by the BTS and SIGN guidelines, the patient is presently enduring from moderate ague asthma based on clinical marks and symptoms, respiratory rate, pulsation rate and arterial O impregnation. Combivent atomizer ( combination of ipratropium bromide 500mcg and salbutamol 2.5mg/2.5ml ) is used in this patient. From randomized tests and 2 meta-analyses comparing patients having combination of ipratropium bromide and I?2 agonist to patients having I?2 agonist therapy by itself in AEBA showed betterment in FEV1 and PEFR.13,14 Another grounds showed that a two-base hit blinded, randomized survey was performed in patients showing with acute asthma. The survey evaluates the consequence of a individual dosage of combivent compared to a individual dosage of salbutamol. The consequences of this survey show that the average absolute difference in FEV1 between combivent and salbutamol entirely was 113ml ( P & lt ; 0.005 ) .15 Therefore, combivent shows clinically important extra bronchodilator consequence compared to intervention utilizing merely salbutamol. In a meta-analysis of 10 surveies, the add-on of ipratropium bromide shows important betterment in lung fuction and besides a lessening rate of admittance to infirmaries for AEBA in adults.16 In another double-blind, randomized test, there was significantly greater betterment in FEV1 and increase continuance of response with add-on of ipratropium bromide to salbutamol compared to salbutamol entirely in patients with moderate to severe acute asthma.17 In another survey of ipratropium bromide given to patients who are non reacting adequately to salbutamol shows that salbutamol has bronchodilator consequence by itself, the add-on of ipratropium bromide has extra consequence particularly in patient with terrible airflow obstruction.18 From all the grounds given above, the use of Combivent atomizer in intervention of this patient is sensible.

The physician besides managed the acute aggravation of asthma in this patient utilizing Prednisolone 40mg for 5 yearss. Prednisolone is a corticoid that is indicated in the guidelines as portion of the direction of ague asthma. In a meta-analysis to find the usage of steroids in ague asthma showed that there is betterment in pneumonic map, decreased in backsliding rate and a decreased admittance to infirmary. Therefore, steroid therapy is good to patients with AEBA.19 A survey of 100 patients with moderate or terrible ague asthma was carried out utilizing unwritten Pediapred as the corticoid treatment.20 The consequences show a important ( p & lt ; 0.001 ) addition in the FEV1 and PEFR. Another survey besides showed that unwritten Pediapred is as effectual ( if patient is able to digest orally ) as injected corticoids like methylprednisolone or endovenous hydrocortisone.21 Therefore, the usage of unwritten Pediapred in this patient is justified.

The patient was besides on Salbutamol 2 whiffs when required. Salbutamol is a short-acting I?2 agonist used in the direction of chronic asthma. It can besides be used to handle acute asthma. In this patient, salbutamol was given in combination with ipratropium bromide ( Combivent ) as a atomizer in add-on to the MDI salbutamol.

The patient was besides continued on 200mcg beclomethasone BD that she was antecedently on. Beclomethasone is an inhaled steroid that is used to command patients on measure 2 asthma. A survey on the efficaciousness of beclomethasone was carried out to handle mild to chair asthma. The consequences show no important betterment in FEV1 in patients having salbutamol and beclomethasone compared to patients having merely salbutamol. However, consequences showed that intervention with beclomethasone and salbutamol reduced the admittance rate compared to salbutamol alone.22 A double-blind, randomized survey was carried out by handling 93 chronic asthma patients with no history of corticoid usage with beclomethasone.23 The consequences showed that beclomethasone aerosol increased FEV1 and FVC. In mild to chair asthma, dosage of inhaled corticoids used should fit the badness of the disease, and usage of high dosage inhaled steroids and cut downing it after that has no extra benefit.24 Inhaled steroids are more effectual when given as twice daily dosing than one time daily.25 However, small benefit is found for more frequent dosing.25 Therefore, the usage, dose and frequence of dosing used is appropriate.