《医学英语》课件：Asthma Tx in three different ages

1、N Engl J Med 2012;366:827-34. Copyright 2012 Massachusetts Medical Society.,Introduction,people have suffered from asthma for millennia. The word “asthma” originated from the Greek meaning short of breath.,Our understanding of asthma evolved dramatically over the past two centuries. The article is d

2、edicated to our progress made in treating asthma as well as to NEJM 200 anniversaries. A series of fictional case reports of the same patient Mrs.A. Smith In three different ways of case description Office notes/Letter/E-mail,CASE #1,YEAR OF 1828,Year of 1828,Boston,MA,约翰 昆西 亚当斯 John Quincy Adams,HO

3、ME VISIT,A 35yrs old woman Just move her family to Boston with her husband, four children, a cook, two maids, and a footman. Shes with a complaint of repeated shortness of breath.,The History of Her Illness,A musical noise was heard in her chest, and she must labor to draw and expel a full breath In

4、hale the steam coming from the spout of a kettle that her cook keeps always at the ready She recovers within one or two days. Once or twice a year as severe fit, which may last for a week in bed She has suffered such fits of laborious breathing since her childhood, more common in the spring She rout

5、inely calls for coach even for a short journey Symptoms arise at night and she has to gasp for air,HISTORY,Recurrence after giving birth When she is not suffering from laborious breathing, her strength is good Difficulty of respiration is accompanied by itchy eyes, runny nose and cough No hemoptysis

6、, No consumption and No rheumatic fever Her mother and two sons suffered from the same problem.,P.E.,Observation: Nothing far out of the ordinary. Her speech was full and normal. Palpation: The movements of her chest were full. No swelling of her liver or her legs. Auscultation: stethoscope to exami

7、ne her chest, hear the musical sounds termed “wheezes”.,Diagnosis and treatment,Diagnosis based on her typical history and physical findings that match the book named “Treatise of the Asthma” by Sir John Floyer Rx:smoking the leaf of Datura stramonium,NEJM Comments,In 1800s, term “Asthma” known as e

8、pisodic dyspnea due to bronchial contraction. Physician primarily needs to exclude TB and cardiac diseases Effective treatments was quite limited at that time Burning Datura stramonium was probably the best. Inhalation of the fumes of hydrocyanic acid or inflation of the lungs with a bellows N Engl

9、J Med Surg 1820;9:193-197,CASE #2,YEAR OF 1928,YEAR OF 1928,BOSTON,MA,Letter to the referral physician,A 35yrs old woman Having “asthma attacks” since her early childhood Sudden onset of dyspnea frequent in the spring and fall. An attack lasts for a few days, and stops if a subcutaneous injection of

10、 adrenaline was given The attacks seemed more frequent recently Her mother carried a diagnosis of asthma, as do two of her children,P.E.,At a time having acute asthmatic symptoms: Showed normal body temperature, blood pressure, and pulse. No rashes. Nasal passages showed inflammation and edema but n

11、o polyps. Respirations were 24 and slightly labored. Diminished tactile fremitus. Expiratory wheezing was audible in all lung fields. Cardiac exam was normal. No clubbing, cyanosis, or edema.,Lab tests and X ray,Chest radiograph showed hyperinflation of the lungs.No findings of tuberculosis and card

12、iac silhouette normal. Blood smear showed 14% of eosinophils (5%) Sputum smear showed all the polymorphonuclear leukocytes were eosinophils Skin testing had positive reactions to extracts of ragweed and horse dander.,Diagnosis and treatment,Your dx of asthma is correct based on her medical history o

13、r the physical examination and laboratory findings The positive skin tests make the case as extrinsic asthma. Treatment is difficult. Rx: 1.Adrenaline injections for acute attacks 2.Oral ephedrine may help with asthmatic episodes 3.Removing the patient from exposure to the allergic proteins,NEJM Com

14、ments,The differential diagnosis of asthma was well established (heart diz and PNA) The term “asthma” to refer to episodic dyspnea widely used Eosinophils in the blood and sputum were known to be characteristic of asthma. Skin tests for allergies had been developed to identify specific offending pro

15、teins. The issues that plague us today was concerned Ephedrine/Adrenaline/theophylline/aerosol inhaler been widely adopted in 1940s,CASE #3,YEAR OF 2012,YEAR OF 2012,BOSTON,MA,E-Mail Message to Ms. Smith,A 35y/o F Present w/ asthma since childhood Several times of ER visit Hx of Tx: Teenage inhaled

16、Vanceril 2puff Bid 10 yrs ago switch to inhaled Qvar + Singulair Past 10 yrs Advair and symbicort, no apparent improvement Switch back to inhaled Qvar 80ug/puff,2puff Bid + Singulair 10mg every nite (current Tx ),Hx and Labs,Asthma symptoms are still present Nocturnal attacks exist two three per mon

17、th Rescue albuterol inhaler used Total IgE level was 75 IU per milliliter. Positive skin tests were for house-dust mites and ragweed Nonsedating antihistamine and oral prednisone given during exacerbations 24-hour esophageal pH monitoring found normal Environment is secured,P.E. and PFT,No ALOC, VS

18、BP 110/75 PR 77 RR 25 T 98.5F Sat 98%，No abnormalities were noted in HEENT. Chest examination was normal except for the presence of scattered expiratory wheezes, no abnormalities in your extremities. Neurologic exam was normal as well. Spirometry,Dx and med. advices,First, oral theophylline could be

19、 added to your regimen. Second, Singulair could be replaced with Zyflo CR (zileuton). inhibitor of 5-lipoxygenase Third, Xolair (omalizumab) could be added to your regimen,NEJM Comments,1.Spirometry, invented in the 1840s, refined in early 1950s, used in the diagnosis and treatment of asthma. 2. Glucocorticoids were identified as an effective and useful asthma treatment in the early 1950s and inhaled form were made subsequently 3. Our understanding of the Asthma immunobiology beyond the view of an i