A “ DIFFERENT ” CASE

OF BRONCHIAL

ASTHMA

Prof. RAMASAMY.S

Prof. CHITRAMBALAM.P

Dr. PRASANNA KARTHIK( ASST.)

Dr. SARAVANAN.S (2nd YEAR M.D)

HIS(S)TORY

29 year old male , Manager by profession from

Avadi , Chennai

Breathlessness since 1 month

Cough with sputum production since a week

HIS(S)TORY

Patient was apparently normal a month back

Breathlessness on exertion( MMRC GRADE 1)

since 1 month , insidious in onset , gradually

progressive

Productive cough since 1 week with scanty

whitish non foul smelling sputum

Had wheezing predominantly at night

All the above symptoms increased in severity for

the past 1 week and not adequately relieved by

medications

HIS(S)TORY

No h/o hemoptysis and chest pain

No h/o loss of weight, loss of appetite , night

sweats

No h/o Halitosis, pedal edema, puffiness of face

PAST HISTORY

Known case of Bronchial asthma since 3 years of age – had occasional episodes of wheezing relieved by SOS medications.

Not on any regular prophylactic drugs.

Not a known case of T2DM, SHT, EPILEPSY, JAUNDICE,

PERSONAL HISTORY

Mixed diet

Normal Bowel and Bladder habits

Non Alcoholic , Non Smoker , no social

addictions

FAMILY HSTORY

No history of similar complaints in the family

members

GENERAL EXAMINATION

Well built and Well nourished

Not Anemic , Jaundiced , Clubbing or Cyanosed.

Dyspnoeic at rest.

VITALS

PULSE: 116 bpm, regular in rhythm and normal

volume

BP :100/80 mm Hg RUL, Supine

No orthostatic hypotension

Respiratory rate 24/min

Oxygen saturations: 93% at room air

SYSTEMIC EXAMINATION

INSPECTION:

Upper respiratory tract : Normal

Trachea appears to be in mid line

Apical impulse seen at 5th ICS

Normal chest wall symmetry

PALPATION:

Position of trachea: Midline

Position of apical impulse : ½ inch medial to M.C.L

in the 5th I.C.S

Normal chest wall movements

No intercostal tenderness

PERCUSSION:

Resonant in all the areas of the chest

AUSCULTATION:

Normal vesicular breath sounds with bi-lateral

rhonchi

OTHER SYSTEMS

CVS: S1 , S2 heard in all areas, no murmurs

ABDOMEN: Soft, no organomegaly

CNS: NFND

INVESTIGATIONS

HEMATOLOGY:

C.B.C: 15,500/MM3

D.C : N 80% L 16% E 4%

HB: 12 g/dl

PLATELETS: 3.2 lakhs/mm3

BIO-CHEMISTRY:

RBS: 112 mg%

Urea: 56 mg%

Creat: 0.8 mg%

CHEST X-RAY

CHEST XRAY

Trachea: Mid line

C:T Ratio: 40%

Angles : Free

Lung Fields : Clear

Right Lower Lobe Bronchus seemed to be

Clogged – giving rise to a suspicion of

“GLOVED FINGER” appearance

Hence, proceeded to estimate Serum Ig-E ,

HRCT CHEST and Sputum for Fungal spores.

Urine routines: Unremarkable

ECHOCARDIOGRAPHY : NORMAL

SERUM IG-E: 680 IU/ML , RAISED ( 0.5 – 290

IU/ML)

Sputum culture: No organisms isolated

Sputum for Fungal Spores : Negative

HRCT THORAX

HRCT REPORT

MODERATE PNEUMO-MEDIASTINUM( no

cause is visualised , probably spontaneous

pneumo-mediastinum due to asthma)

Minimal surgical Emphysema of neck

No bullae or Pneumothorax

MANAGEMENT

Tab. Levofloxacin 500 mg OD

Tab. Levocitrizine 5 mg h/s

Tab. Montelukast 10 mg h/s

Nebulise : Duolin bd

O2 therapy and Rest

HRCT after 2 weeks

REPEAT CT THORAX REPORT

Thin Linear streak of air seen in the prevascular

space involving the para-aortic and sub-aortic

region

Rest of the mediastinum shows no features of

pneumomediastinum

No subcutaneous emphysema seen in the deep

cervical spaces of neck

PNEUMO MEDIASTINUM

MEDIASTINAL CONNECTIONS

The mediastinum communicates with the sub-

mandibular space, retropharyngeal space and

vascular sheaths within the neck

It can also communicate with Retro peritoneum

via sternocostal attachments to the Diaphragm, as

well as the periaortic and perioesophageal fascial

planes

PULMONARY CAUSES

1. Rupture of alveolus with air dissection along

peribronchial vascular sheaths into the hilum

and mediastinum

2. Ruptured bleb with peripheral extensions

3. Sudden rise in intra pulmonary pressure:

a) Asthma

b) Forceful coughing

c) Artificial ventilation

d) Vomiting, Crying( in children)

TRAUMA

Rupture of trachea or main bronchus , usually via

accidental trauma

Trauma to the neck

BOERHAAVE’S syndrome

BAROTRAUMA

PRESENTATION

May complain of retro sternal chest pain radiating down

the both arms that is exacerbated by respiration and

swallowing

DYSPNOEA- in association with Asthma, Tension

Pneumothorax

FEVER- due to cytokine release with air leak

Dysphagia, Dysphonia, Neck swelling and Torticollis

PHYSICAL EXAMINATION

Sub cutaneous air

Oxygen saturations

Associated Pneumothorax

HAMMAN’S SIGN:

“CRUNCHING” sound heard over the apex of the heart

with every cardiac cycle in left lateral decubitus position

DIAGNOSTIC PROCEDURES

X-RAY CHEST

CT CHEST

Chest tube ( pneumothorax)

Bronchoscopy if Tracheo-bronchial perforation is suspected

Oesophagoscopy if an oesophageal perforation is suspected

MANAGEMENT

Usually no treatment is required , but the

mediastinal air will be absorbed faster if the patient

inspires high concentrations of oxygen

Percutaneous placement of mediastinal drains:

If the Mediastinal structures are compressed

MECHANICAL VENTLATION with low pressure or

Tidal volumes

FOLLOW UP

Patients should avoid strenuous physical activity

like weight lifting , scuba diving until resolution of

symptoms , for upto 6 months

MESSAGE……

Bronchial asthma not responding to conventional

therapy

Revise your diagnosis

Suspect ABPA

Rule out other Endo Bronchial Obstructive

pathologies

Remember the possibility of

“PNEUMO-MEDIASTINUM”