Discuss about the Study of Ben Marshall Diagnosed With Severe Asthma.
Ben Marshall born on 05/03/1993 is diagnosed with severe asthma.
Social: He is university graduate and living with his parents and two younger siblings. He is very fit young adult male who used to play competitive football.
Medical history: He was diagnosed with asthma at very early stage of life at the age of 7 years. Since, then he was suffering through asthma. He was hospitalised twice due to severe symptoms of asthma. He was last admitted to the hospital two years back. During this hospitalisation, his pulmonary function tests were carried out. His observed FEV1/PEFR was 80 % predicted. His observed PEFR variability was 30 %.
Hospital presentation: He was presented to the hospital with severe dyspnoea and no loss of consciousness.
Medication: He was prescribed salbutamol inhaler.
Current health status: His resting respiratory rate is 34 breaths per minute. He is having tightness of chest and dry cough. He is using accessory muscles due to shallowness in breathing. His peak expiratory flow rate is below 140 ml and SpO2 93% on 4L O2. On auscultation, he is exhibiting diffuse wheezing. His resting pulse rate is 128 beats per minute and blood pressure is 90/60 mmHg. It indicates that his both respiratory and cardiovascular parameters are abnormal. He is exhibiting cardio-pulmonary dysfunction. He has no chest pain, coma score and temperature are in the normal range. His urine output is 40mls/hour which is below average. His blood glucose level is 5.9 mmol/l which indicate he is a prediabetic. His oxygen saturation is below normal and carbon dioxide saturation is in the higher range. All these parameters indicate, he is having dyspnoea which is prominent symptom of asthma.
Asthma is a chronic allergic and inflammatory disease. Shortness of breath, coughing and wheezing are the prominent symptoms if Asthma. Physiological changes occur in asthma patients due to anatomical and pathological changes like bronchoconstriction, airway oedema, airway hyperresponsiveness and airway remodelling. Productive cough in asthma patients can act as body’s defence mechanism against extraneous matter. During productive cough, there is expulsion of phlegm harmful substances from the lungs (Bonini and Usmani 2015; Bausewein and Simon, 2013).
Physiological aspects of the respiratory system mainly depend on the factors like oxygen transfer across the alveolus and blood vessels. Function of respiration is to supply oxygen to different tissues and elimination of carbon dioxide from the blood back into the alveolus and from alveolus to the external environment through expiration (West, 2012). In asthma patients like Ben there is impairment in the normal physiological process of the respiratory system. As a result of impaired physiology of the respiratory system, there is impaired gaseous exchange. Alveolar and blood capillaries interface is the main site for the gaseous exchange. At this interface, oxygen enters the bloodstream and bind to haemoglobin present in the blood. This binding depends on the partial pressure of oxygen (PaO2). It indicates exact amount of oxygen present in the blood stream (Bateman et al., 2015). Exact amount of carbon dioxide present can be indicated by partial pressure of carbon dioxide (PaCO2). Normal PaO2 range should be between 75 to 100 mmHg. However, in Ben PaO2 value is less i.e. 70 mmHg. It indicates less amount of oxygen in the blood. Normal PaCO2 range should be between 35 to 45 mmHg (Krishnan et al., 2012). However, in Ben PaCO2 value is more i.e. 45 mmHg. Even though carbon dioxide value is in the normal range, it is extreme at higher end. Hence, it can be considered as the higher value. It indicates less amount of oxygen in the blood. With increase or decrease of PaO2, there is also increase or decrease in SpO2 which indicate peripheral capillary oxygen saturation. In Ben, observed SpO2 is 93 %. Normal SpO2 in adults should be between 94 to 99 %. During normal respiration, SpO2 remains normal; however, during respiratory impairment, SpO2 get reduced. Depression of the respiratory system can occur due to weakness of the respiratory muscles. Peak expiratory flow rate (PEFR) is the maximal rate expiration after the full inspiration. There is a correlation between the PEFR and forced expiratory volume in one second (FEV1). In patients with asthma, PEFR get reduced due to the constriction of the airways (Hillman et al., 2014; Shiner & Steier, 2012).
On auscultation, diffuse and auditory inspiratory and expiratory wheezes are observed in Ben. It indicates asthma in Ben. Wheezing is the whistling sound due to the exhaled air. Main reason for the occurrence of wheezing sound in asthma patients is mainly due to the forceful flow of air through the constricted and narrow airways. In Asthma patients, narrowing of the airways mainly occurs due to inflammation and mucus deposition (Kim et al., 2012). Narrowing of airways also lead to breathing insufficiency and dyspnoea. Due to dyspnoea, there would be less oxygen saturation. To compensate deficiency of oxygen, lung need to perform breathing at faster rate (Mims, 2015). Hence, there is increase in the respiratory rate in Ben.
In normal adults, respiratory rate should be between 12 – 20 breaths per minute. However, due to dyspnoea, there is increase in the respiratory rate in Ben. Increase in the respiratory rate can lead to increase in the pulse rate because respiratory rate increases due to dyspnoea. To compensate deficiency of oxygen heart need to pump at the faster rate. It can lead to increase in pulse rate. Normal pule rate in the adults is between 60 to 100 beats per minute. However, in case of Ben it has been observed that pulse rate increases upto 128 beats per minute due to dyspnoea. Increase in the respiratory rate influence baroreceptor reflux which can influence blood pressure. Increase in the pulse rate indicates, more frequent beating of the heart per minute. Due to this, blood vessels get dilated to allow flow of more amount of blood to flow through the blood vessels. Due to dilatation of these blood vessels, blood exerts less pressure against the walls of the blood vessels. It leads to low blood pressure in Ben. His blood pressure was recorded as 90/60 mmHg. However, normal blood pressure should be 120/80 mmHg. In asthma patients, there can be elevated jugular venous pressure (JVP) due to increased inspiration. Inspiration increases due to increased respiratory rate in patients with asthma. As a result of insufficient supply of oxygen to different tissues and organs, there can be fatigue development in patients with asthma (Olin and Wechsler, 2014).
Long term fatigue can lead to coma in patients with asthma. His GCS coma scale score is 15. It indicates in terms of coma, he is normal. Arterial blood gas (ABG) test indicates balance of oxygen and carbon dioxide present in the blood. In patients with severe dyspnoea like Ben, there can be increase in carbon dioxide levels and decrease in the oxygen levels. Therefore, there can be shift in the Ph to either acidic or basic side. Normal ABG in the adults should be between 7.34–7.44 (Patadia et al., 2014; Byrne et al., 2014). In Ben, observed ABG is 7.35. It indicates his ABG is normal.
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Subjective information |
After 20 minutes of jog, Ben developed severe shortness of breath and tightness of chest. He was transported to hospital with the help of ambulance. He is 25-year-old and fit young adult. He also used to play competitive football. He complained about severe dyspnoea and no Loss of consciousness. He was diagnosed with asthma at the age of 7 and prior to this he was hospitalised for the symptoms of asthma. Last time, he was admitted to hospital two years ago. |
Objective assessment:
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Voice Breath sounds – Clear voice |
Indicates air movement. Airway obstruction can be complete or incomplete. Head-tilt and chin-lift can be used to open the airways. Stethoscope need to be used for the lung auscultation (Kinkade & Long, 2016). |
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34 respiratory rate. Lung auscultation – Diffuse wheezes, auditory inspiratory and expiratory wheeze Pulse oximetry – 93 % |
Raised respiratory symptoms are very common in Asthma patients. Ben has dyspnoea as result of shortness of breath which results in the reduced lung capacity and impairment in breathing. Increased respiratory rate due to oxygen deficiency and noisy breathing (Kinkade & Long, 2016). |
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Pulse rate – 128 bpm Blood pressure – 90/60 |
Due to increase in the pulse rate and blood pressure, Ben is centrally warm and perfused. Reduced perfusion can be detected by the observing Color changes, sweating, and a decreased level of consciousness. |
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Level of consciousness – AVPU • Alert • Voice responsive • Pain responsive Unresponsive – No loss of consciousness. Pupillary light reflexes – + 3 |
As a result of insufficient supply of oxygen to different tissues and organs, there can be fatigue development in patients with asthma. Long term fatigue can lead to coma in patients with asthma (Olin and Wechsler, 2014). Ben responds to external stimuli. Orientation in Ben is maintained. |
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ABG – Metabolic acidosis and respiratory alkalosis with probable respiratory compensation. PaO2 – 70 mmHg PaCO2 – 45 mmHg |
It mainly occurs due to reduced oxygen saturation and increased carbon dioxide saturation. Due to deficiency of oxygen, lung starts breathing at faster rate. In this test pH and acid content can be measured which indicate oxygen and carbon dioxide level in the blood (Byrne et al., 2014). |
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Temperature – 36.7 Chest examination – No chest pain. |
In asthma patients, if there is less change in the size and shape of the diaphragm. There would not be any chest pain (Ware, 2014). |
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Observation and fluid chart Presence of drains and tubes – Presence of catheterisation Output – 40 ml |
Observe patient for complain of thirst because alteration in the fluid intake can lead to alteration thirst. |
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Blood glucose level – 5.9 Symptoms due to increased blood glucose level – No consciousness. |
Observe patient for complain of thirst. Orientation of Ben is maintained. |
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Chest X ray – Normal, hyper-inflated with flattening of diaphragm |
Temperature can be determined by feeling the skin and using the thermometer. Chest region become hyperinflated due to accumulation of fluid (Ware, 2014) |
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Pulmonary function test FEV < 40 % ; FVC < 60 % ; FEV1 < 45% ; FEV1/FVC > 80% |
Spirometer can be used to perform pulmonary function test which can be useful in identifying respiratory system impairment. In asthma patients, there can be obstruction to the inhaled and exhaled air due to obstruction of airways and pulmonary oedema. Forced expiratory volume 1 (FEV1) can be helpful in determining volume of exhaled air at the end of first second after forced expiration. FEV1 more than 80 % can be considered as the normal value. Forced vital capacity (FVC) can be helpful in determining vital capacity after maximally forced expiratory effort. FCV more than 80 % can be considered as normal value. FEV1/FVC indicates percentage of FVC expired in one second. Less than 70 % is considered as normal for FEV1/FVC (Shiner & Steier, 2012) |
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Use of accessory muscles |
Utilization of accessory muscles of respiration like intercostal and sternocleidomastoid muscles reflects more work for breathing. Utilization of accessory muscles at rest is indication of severe respiratory impairment (Chesnutt, & Prendergast, 2017) |
Assessment information: Ben is diagnosed with asthma with sever dyspnoea.
Conclusion :
In this essay, case of Mr. Ben was discussed. He was associated with asthma since his childhood. His current data also indicate dyspnoea which is a prominent symptom of asthma. He is being treated with salbutamol inhaler. However, from the current assessment it is evident that by using salbutamol inhaler, his condition didn’t improve considerably. Salbutamol exhibits its action by acting as bronchodilator. It is not exhibiting desired effect in Ben because there might be more pathological remodelling of lung due to chronic condition of asthma in him. It is evident that his respiratory parameters like respiratory rate, oxygen and carbon dioxide partial pressure, oxygen saturation, ABG and lung function tests exhibited dysfunction. His cardiovascular parameters like pulse rate and blood pressure are abnormal. It reflects his cardiovascular system dysfunction. Overall, he is having cardo-pulmonary abnormality. Accurate assessment can be helpful in providing exact intervention for the people. Hence, for the assessments of health condition of Ben validated methods like SOA and A-G assessment were used. These tests assessed health condition of Ben comprehensively. This comprehensive assessment can be used in corelating influence of these abnormal vital parameters on each other. Hence, improvement in one of the parameters can lead to the deterioration of another parameter. This comprehensive assessment of the patient can be helpful in monitoring multiple parameters. It can be helpful in providing holistic care to the patient.
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References:
Bateman, E.D., Reddel, H.K., van Zyl-Smit, R.N., and Agusti, A. (2015). The asthma-COPD overlap syndrome: towards a revised taxonomy of chronic airways diseases? Lancet Respiratory Medicine, 3(9), 719-28.
Bausewein, C., and Simon, S.T. (2013). Shortness of breath and cough in patients in palliative care. Deutsches Ärzteblatt International, 110(33-34), 563-71.
Bonini, M., and Usmani, O.S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Therapeutic Advances in Respiratory Disease, 9(6), 281-93.
Byrne, A.L., Bennett, M., Chatterji, R., Symons, R., Pace, N.L., and Thomas PS. (2014). Peripheral venous and arterial blood gas analysis in adults: are they comparable? A systematic review and meta-analysis. Respirology, 19(2), 168-175.
Hillman, D., Singh, B., McArdle, N., and Eastwood, P. (2014). Relationships between ventilatory impairment, sleep hypoventilation and type 2 respiratory failure. Respirology, 19(8), 1106-16.
Kinkade, S., and Long, N.A. (2016). Acute Bronchitis. American Family Physician, 94(7), 560-565.
Kim, K., Byun, M., Lee, W., Cynn, H., Kwon, O., and Yi, C. (2012). Effects of breathing maneuver and sitting posture on muscle activity in inspiratory accessory muscles in patients with chronic obstructive pulmonary disease. Multidisciplinary Respiratory Medicine, 7(1), 9. doi. 10.1186/2049-6958-7-9.
Krishnan, J.A, Lemanske, R.F. Jr., Canino, G.J., Elward, K.S., Kattan, M., Matsui, E.C., Mitchell, H., Sutherland, E.R., and Minnicozzi, M. (2012). Asthma outcomes: symptoms. Journal of Allergy and Clinical Immunology, 129(3), S124-35.
Mims, J.W. (2015). Asthma: definitions and pathophysiology. International Forum of Allergy & Rhinology, 5(l), S2-6.
Olin, J.T, and Wechsler, M.E. (2014). Asthma: pathogenesis and novel drugs for treatment. British Medical Journal, 349, g5517. doi: 10.1136/bmj.g5517.
Shiner, R.J., and Steier, J. (2012). Lung Function Tests Made Easy. Elsevier Health Sciences.
Ware, L.B. (2014). Acute Respiratory Distress Syndrome, An Issue of Clinics in Chest Medicine. Elsevier Health Sciences.
West, J.B. (2012). Respiratory Physiology: The Essentials. Lippincott Williams & Wilkins.
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