Clinical Case 1: Chronic Bronchitis

Pathology: Chronic bronchitis is characterised by chronic inflammation of the bronchial tubes, leading to excessive mucus production, impaired mucociliary clearance, and narrowed airways. Histologically, there is goblet cell hyperplasia, submucosal gland hypertrophy, and infiltration of inflammatory cells.

Development: A 58-year-old male with a 30-pack-year smoking history presents with a productive cough lasting over 3 months each year for the past 2 years. He complains of morning sputum and frequent respiratory infections. Spirometry reveals an FEV1/FVC ratio < 70%, confirming airflow limitation.

Line of Treatment:

1.⁠ ⁠Short-acting beta-agonists (SABA): Salbutamol – for immediate symptom relief.

2.⁠ ⁠Long-acting muscarinic antagonists (LAMA): Tiotropium – reduces exacerbations and improves lung function.

3.⁠ ⁠Inhaled corticosteroids (ICS): Fluticasone – reduces airway inflammation in those with frequent exacerbations.

4.⁠ ⁠Phosphodiesterase-4 inhibitors: Roflumilast – particularly useful in chronic bronchitis with frequent exacerbations.

 

Management:

Smoking cessation

Vaccination (influenza, pneumococcal)

Pulmonary rehabilitation

Nutritional and psychosocial support

Precautions:

Avoid exposure to pollutants and irritants

Maintain good hydration to loosen mucus

Monitor for signs of infection

Living with Chronic Bronchitis: Patients should adhere to medication, maintain a healthy lifestyle, attend follow-up visits, and use breathing techniques to manage symptoms effectively.

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Clinical Case 2: Emphysema

Pathology: Emphysema involves destruction of alveolar walls and capillary beds, resulting in enlarged air spaces and reduced surface area for gas exchange. This causes air trapping, hyperinflation, and reduced elastic recoil.

Development: A 65-year-old female with a history of heavy smoking reports progressive shortness of breath and minimal sputum production. Imaging reveals hyperinflated lungs with flattened diaphragms. DLCO is decreased, suggesting impaired gas exchange.

Line of Treatment:

1.⁠ ⁠LABA: Salmeterol – improves airflow and reduces dyspnea.

2.⁠ ⁠LAMA: Glycopyrronium – bronchodilation and reduction in hyperinflation.

3.⁠ ⁠ICS/LABA combination: Budesonide/formoterol – for patients with exacerbations.

4.⁠ ⁠Oxygen therapy: For chronic hypoxemia.

 

Management:

Smoking cessation

Regular pulmonary rehabilitation

Nutrition counseling

Consideration for lung volume reduction surgery in select patients

Precautions:

Avoid respiratory infections

Use oxygen carefully and monitor SpO2

Avoid sedatives that depress respiration

Living with Emphysema: Energy conservation techniques, portable oxygen, regular exercise, and emotional support are key to improving quality of life.

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Clinical Case 3: Small Airway Disease

Pathology: This condition features inflammation and fibrosis in the bronchioles, leading to narrowed airways and airflow obstruction. It may precede or coexist with other COPD phenotypes.

Development: A 52-year-old non-smoker with occupational exposure to chemical fumes presents with wheezing, mild dyspnea, and cough. HRCT shows thickened airway walls and air trapping.

Line of Treatment:

1.⁠ ⁠SABA: Levalbuterol – for relief during episodes.

2.⁠ ⁠LABA: Formoterol – for maintenance.

3.⁠ ⁠ICS: Mometasone – to reduce airway inflammation.

4.⁠ ⁠Macrolides: Azithromycin – anti-inflammatory and infection prophylaxis.

 

Management:

Avoid occupational exposures

Routine spirometry monitoring

Bronchial hygiene therapy

Precautions:

Wear protective masks in high-risk environments

Immediate attention to respiratory symptoms

Living with Small Airway Disease: Patients should prioritize trigger avoidance, maintain medication adherence, and engage in light physical activity.

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Clinical Case 4: Alpha-1 Antitrypsin Deficiency-Related COPD

Pathology: This genetic disorder leads to deficient alpha-1 antitrypsin, a protease inhibitor, resulting in unchecked neutrophil elastase activity and early-onset emphysema, particularly in lower lobes.

Development: A 38-year-old male with no smoking history but with a family history of COPD presents with progressive dyspnea and occasional cough. Genetic testing confirms alpha-1 antitrypsin deficiency. CT chest shows panacinar emphysema predominantly in lower lobes.

Line of Treatment:

1.⁠ ⁠Augmentation therapy: Alpha-1 proteinase inhibitor (e.g., Prolastin) – slows disease progression.

2.⁠ ⁠Bronchodilators: Tiotropium and salmeterol – for symptom control.

3.⁠ ⁠ICS: Fluticasone – to manage inflammation.

4.⁠ ⁠Pulmonary rehabilitation and vaccination.

 

Management:

Lifelong augmentation therapy if indicated

Avoid smoking and secondhand smoke

Monitor liver function (risk of hepatic involvement)

Precautions:

Regular monitoring of lung and liver function

Genetic counselling for family members

Living with Alpha-1 Antitrypsin Deficiency: Early diagnosis and treatment can greatly improve prognosis. Regular exercise, adherence to therapy, and emotional support are vital for optimal living.

 

Here’s a detailed academic discussion of three clinical cases of asthma, each representing a different presentation—status asthmaticus, chronic bronchial asthma, and acute asthma attack. Each case includes the cause, pathology, drug treatment, and precautions to be taken by the patient.

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Case 1: Status Asthmaticus

Patient Profile:
A 28-year-old male with a history of poorly controlled asthma presents to the Emergency Department with severe dyspnea, wheezing, and use of accessory respiratory muscles. He is unresponsive to repeated doses of short-acting β2-agonists.

Cause:

Often precipitated by poor adherence to controller medication, viral infections, exposure to allergens, or nonsteroidal anti-inflammatory drug (NSAID) use.

Pathology:

Status asthmaticus is a life-threatening condition characterized by severe, refractory bronchospasm, mucus plugging, and progressive hypoxemia. It represents the extreme end of the asthma spectrum, where the usual bronchodilator response is absent. Airway edema, mucus hypersecretion, and persistent inflammation result in air trapping and hypercapnia, potentially progressing to respiratory failure.

Drug Treatment:

Oxygen Therapy: High-flow oxygen to maintain SpO₂ ≥ 94%.

Systemic Corticosteroids: IV hydrocortisone 100 mg stat, followed by 100 mg Q6H.

Inhaled β2-agonists: Nebulized salbutamol 2.5–5 mg every 20 minutes for 1 hour.

Anticholinergics: Nebulized ipratropium bromide 0.5 mg every 20 minutes.

IV Magnesium Sulfate: 2 g IV infusion over 20 minutes if bronchospasm is severe.

Mechanical Ventilation: If patient develops fatigue, altered mental status, or rising CO₂.

Precautions:

Strict avoidance of known triggers.

Regular use of controller therapy (ICS or ICS+LABA).

Asthma action plan and proper inhaler technique.

Emergency alert system in place.

Regular follow-up with a pulmonologist.

 

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Case 2: Chronic Bronchial Asthma

Patient Profile:
A 45-year-old female with a history of seasonal allergies and chronic asthma reports persistent wheezing, daily coughing, and nocturnal symptoms occurring more than twice a week.

Cause:

Chronic exposure to environmental allergens, dust mites, and poorly managed allergic rhinitis. May also be exacerbated by occupational exposure or smoking.

Pathology:

Chronic bronchial asthma is marked by persistent airway inflammation leading to airway remodeling. Long-term exposure to allergens and recurrent episodes lead to goblet cell hyperplasia, subepithelial fibrosis, and smooth muscle hypertrophy. This results in persistent airflow limitation and bronchial hyperresponsiveness, with variable reversibility.

Drug Treatment:

Inhaled Corticosteroids (ICS): Budesonide 400–800 mcg/day.

Long-acting β2-agonists (LABA): Formoterol (12 mcg BID) with ICS (MART regimen).

Leukotriene Receptor Antagonists (LTRAs): Montelukast 10 mg daily.

Nasal corticosteroids for coexisting allergic rhinitis.

Annual Influenza and Pneumococcal vaccination.

Precautions:

Daily use of controller medication.

Avoid household allergens (use air purifiers, wash bedding in hot water, etc.).

Smoking cessation if applicable.

Adherence to routine pulmonary function testing and monitoring PEFR.

Exercise under guidance to maintain pulmonary fitness.

 

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Case 3: Acute Attack of Asthma

Patient Profile:
A 16-year-old male presents to the clinic with acute onset of wheezing, breathlessness, and chest tightness after a soccer match on a cold, windy day.

Cause:

Exercise-induced bronchoconstriction possibly combined with exposure to cold air and pollen. Patient has a known history of mild intermittent asthma but was not on any prophylactic treatment.

Pathology:

Acute asthma attacks are caused by transient bronchial smooth muscle constriction, leading to airflow limitation. Mast cell degranulation and release of histamines and leukotrienes cause acute inflammation and mucus secretion. Air trapping leads to decreased expiratory airflow and hyperinflation.

Drug Treatment:

Short-acting β2-agonist (SABA): Salbutamol 2 puffs via MDI with spacer every 4–6 hours PRN.

Low-dose Inhaled Corticosteroids: If symptoms recur frequently (e.g., Beclomethasone 200 mcg BID).

Oral corticosteroids (short course): Prednisolone 20–40 mg for 3–5 days in moderate attacks.

Antihistamines or LTRAs for allergic contributors.

Precautions:

Pre-exercise SABA use for known exercise-induced asthma.

Avoid cold air exposure; consider using a mask.

Begin controller therapy if attacks are frequent.

Regular monitoring and patient education on asthma warning signs.

Maintain a rescue inhaler at all times.

 

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Conclusion

Asthma is a multifaceted disease with varying clinical presentations. Effective management requires identifying triggers, understanding the pathophysiological basis, and implementing appropriate pharmacologic and non-pharmacologic strategies. Patient education and preventive measures are key to reducing morbidity and improving long-term outcomes.

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