Italian Journal of Pediatrics

Running head: CASE STUDY
CASE STUDY
Name of the Student
Name of the University
Author Note

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CASE STUDY
PATHOPHYSIOLOGY OF ASTHMA
Asthma is a kind of chronic respiratory disease, which causes inflammations in the
respiratory tract and tightens the smooth muscles of the respiratory airways. Asthma can be
classified into two types such as allergic asthma and non-allergic asthma (Sinyor & Perez,
2019). Bronchoconstriction is a common symptom is both the cases. The condition is
triggered by environmental particles such as smokes in the air, pollens causing the pathway,
which carries the oxygen into the lungs, narrow, which leads to difficulty in breathing
condition as a result of mucus secretion from the airways. It is a kind of allergic disorder also
known as hypersentivity type1 which is a kind of autoimmune response of body the body.
The vascular abnormality such as inflammation reactions like angiogenesis, vasodilation and
plasma exudation leads to the narrowing of airways. Increased blood flow is vital for
eradicating the inflammatory mediators from the airways, which is significant in exercise-
induced asthma. The normal function is preserved by autonomic nervous system where the
parasympathetic nerve is largely activated by the stimuli and produces impulse which is
further carried by the vagal nerves in to the brain which is further carried into the airways
(Mims, 2015). The efferent nerve discharges the acetylcholine which produces the inositol
triphosphate causing in beginning of bronchoconstriction along with restriction of muscles in
the airways of the lungs. The inflammation take place due to the huffed allergens. The
immune system discharges interleukin4 encouraging disparity of the helper T cells. The T
cells discharges antibodies in reaction to this allergens and strains to resolve the condition.
The inflammation effects the cells of the airways to proliferate and mounting thicker mucus
cells along with beginning of cell-mediated reaction of immune system. These thicker cells
are more predisposed to bronchospasm. The stimuli can be of various types such as air
pollutions, hormonal changes, exercise induced irritation, obesity, psychological disorder,

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food allergies and industrial compounds. Asthma can also occur due gastrointestinal disorder
and sleeping disorder (Lambrecht & Hammad, 2015.
SIGNS AND SYMPTOMS OF ASTHMA
Asthma is a chronic pulmonary disorder that results in the inflammation of the
airways and creation of unwarranted amount of mucus. It makes difficulty in breathing and
causes breathing shortness, wheezing and coughing. The signs vary from individual to
individual (Globe et al., 2015). The most common signs and symptoms of this allergic
reaction are difficulty in sleeping due to breathing shortness, wheezing and coughing
(Sullivan et al., 2016). Pain or tightness in the chest, whistling sound during exhalation,
which is more common in children who are suffering from asthma and also sudden acts of
infection due to less immune capacity of the body. The breathing difficulty occurs during
chronic asthma condition of the body and requires instant cure and medications. The
exercise-induced asthma is a condition which is triggered due to strenuous exercises and that
causes narrowing of the lungs airways pathway that is also known as bronchoconstriction.
Exercises also considered as the triggering effect of asthma (Del Giacco et al., 2015). This
condition is more common among children, which lead to escaping of action, coughing,
wheezing, breathing symptoms fatigue and also low performance in athletic sports.
The patient in the case study has a history of asthma along with complaint of
respiratory tract infection. The patient had a sign and symptom like unresolved coughing,
breathing shortness and wheezing. The children have a symptom of exercise-induced asthma,
which lead the child withdrawing sports activity. The child had an asthma attack which lead
to the sudden rise of heart rate and respiratory rate. The heart rate increases due to compact
pumping effectiveness of the left side of the heart, which lead to the accumulation of the fluid
in the lungs, called pulmonary oedema. This accumulation lead to wheezing and coughing

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rising the body pressure high. The respiratory increases in the body due to low supply of
oxygen in the lungs because of squat PaCO2 leading to bronchospasm caused by
hyperventilation and leading to hyperinflation. The spo2 level of the body indicates the
condition of acute exacerbation categorized by tachypnea and reduced saturation level. It also
leads to anaemia in the body. The breathing shortness happens due to swelling of muscles and
also mucus build up in the lungs airways as a result the lung fails to hold up much air. The
whistling sound takes place when the air tries to pass from the inflamed narrow pathway
leading to breathing difficulty. Respiratory tract infections are also common in asthma due to
lower immunity of the body (Quirt et al., 2018).
MEDICATIONS AND MECHANISMS OF ACTION
Salbutamol is a drug used in the treatment of asthma patient. The brand name of the
drug is Ventolin, which belongs to the bronchodilators. The patient was given oral
prednisolone, which is used in the curing of allergic reaction such as asthma or respiratory
tract infections. Ipratropium is also used in the treatment of asthma.
Salbutamol are used to exposed up the enormous and medium lungs airways and thus
helping in the treatment of asthma, bronchoconstriction, chronic pulmonary disease. The drug
is also used in the treatment of high potassium level of the blood. It is used as an inhaler,
which helps in reducing the condition maximum after 15minutes of inhalation. It is a kind of
beta agonist used in relaxation of the airway muscles. The butyl group of the drug is highly
reactive with the beta receptors which are predominant receptors of the smooth muscles of
the bronchus (Ullmann, Caggiano & Cutrera, 2015). The receptors activates and secretes
adenylyl cyclase which transforms the adenosine triphosphate to cyclic adenosine
monophosphate activating the signalling cascade which ultimately initiates the inhibition of
the inflammatory cells to stop the production of cytokines and also the production of myosin

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phosphorylation which are essential for the muscular contraction (Halwani et al., 2017). The
drug ultimately increases the channel sensitivity towards both the potassium and sodium and
ultimately helps in achieving the hyperpolarisation state and also relaxation of the muscles.
The drug has few side effects including redness in skin, rash, itching, swelling of faces, eyes
and throat, headaches, increased heart rate and blood pressure. The drug needs to be stored in
room temperature.
Prednisolone is a corticosteroid drug used in the treatment of breathing problems,
allergic reaction, it is also known as anti-inflammatory drug. The prednisone is transformed
into prednisolone after administration. Prednisolone binds to the glucocorticoid receptors of
the cells to inhibit the inflammation of the cells and suppresses the mediators that causes
inflammation (Alangari, 2014). The drug has its fast absorption in the body. the drug has
many side effects such as nausea, stomach discomfort, abdominal pain, muscle weakness,
pain muscle, osteoporosis, feeling of dehydration, high blood pressure, acne, rashes in the
skin, impairment of adrenal functions, porphyria, blood clots, headache, chest pain and
mental issues.
Ipratropium is known as acetylcholine antagonist drug which acts by the help of
cholinergic muscarinic receptor of the body. The production of cyclic guanosine
monophosphate is decreased due to the blocking of muscarinic receptor (Saab & Aboeed,
2019). This decreases the smooth muscle contraction of the lungs airways leading to dilation
of the muscle. The drug produces parasympathetic response when administered from the
nasal pathway and which leads to the less amount of water secretion from the mucosal glands
and ultimately improving the condition of allergic and non-allergic asthma. The drug has
many side effects such as arrhythmia, angioedema, visual impairment, chest pain,
tachycardia, dyspnea, constipation, insomnia, tremor, headache, cough, vomiting and
irritation.

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Medications related to the case study
The patient in the case study was prescribed a dose of salbutamol 100ug 12puffs as
this drug is useful in giving the patient instant relief from asthma attack. It helps in resolving
the symptoms like coughing and wheezing (Johnson & Bound, 2019). It is also used in the
treatment of exercise induced asthma and also to cure allergic responses. The drug starts its
action within a span of 4 to 6hours after administration. Oral Prednisolone 1mg/kg is used to
reduce the inflammation by depressing the immune reaction of the body. It belongs to the
group of corticosteroid drug and is helpful in reducing allergic reaction. The drug is used in
the treatment of asthma attack as well as reducing the respiratory tract infection. The patient
was given ipratropium 8puffs to improve the allergic reaction of the body which acts by
activation of beta-agonist for shorter period. The administration can be of various types but in
this case it is done by intranasal route. The patient was also given salbutamol and ipratropium
simultaneously, because Salbutamol belongs to a cluster of medicines called short-acting beta
2 agonists. The drug works by acting on receptors in the lungs called beta 2 receptors.
As ipratropium wedges the receptors, it discontinues the mechanism of acetylcholine and
permits the airways to uncluttered, constructing the pathway free from stimuli and easier to
breathe. The two drugs are mixed together in an inhaler or puffer and together used to treat
breathing problem. The drug acts by making the breathing condition and reliefs from chest
pain, tightness and wheezing. These both are bronchodilators which helps in relieving the
breathing problem (Donohue et al., 2016). The inhaler is helpful because it delivers the drug
completely into the lungs or the airways and relaxing the body from the sudden asthma
attack. These two are bronchodilators as well as relievers which relives from the breathing
issues.
Pharmacokinetics of the drugs

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The ipratropium drugs can be administered by both oral and nasal. The nasal pathway
is more effective because the dose is readily absorbed into the systemic circulation with the
help of nasal mucosa (Gosens & Gross, 2018). The oral drug is not readily absorbed into the
systemic circulation and the effectiveness of the dose is visible after 4 to 5hours after
administration. It is used in case of acute exacerbations which the patient was suffering after
admission in the hospital. The drug Salbutamol reaches the peak of its effect after 3 hours of
administration by inhalation. It is metabolised by the liver and is converted to salbutamol 4’O
sulfate, the dose is excreted by the kidney in form of metabolites. This drugs are capable of
crossing the blood brain barriers and the concentration was found to be more then plasma
concentration (Jiang et al., 2016). The prednisolone drug is rapidly absorbed by the body and
reaches its peak after 1 to 3 hours after administration. These drug has a mechanism of dose
wise kinetics which is dependent upon the clearance of the drug by the binding proteins. The
drug interaction is dependent upon the activation of enzymes as well as agents such as
rifampicin, phenytoin and corticosteroids. In this case, the patient was suffering from asthma
and also sudden asthma attack after admission which was confirmed by the signs and
symptoms such as high heart rate, shortness of breathing, difficulty in speaking, high
respiratory rate. The prescribed such belongs to steroid, anti-inflammatory and
bronchodilators useful for treating the disease.

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References
Alangari, A. A. (2014). Corticosteroids in the treatment of acute asthma. Annals of thoracic
medicine, 9(4), 187.
Del Giacco, S. R., Firinu, D., Bjermer, L., & Carlsen, K. H. (2015). Exercise and asthma: an
overview. European clinical respiratory journal, 2, 27984.
https://doi.org/10.3402/ecrj.v2.27984
Donohue, J. F., Wise, R., Busse, W. W., Garfinkel, S., Zubek, V. B., Ghafouri, M., ... &
Bleecker, E. R. (2016). Efficacy and safety of ipratropium bromide/albuterol
compared with albuterol in patients with moderate-to-severe asthma: a randomized
controlled trial. BMC pulmonary medicine, 16(1), 65.
Globe, G., Martin, M., Schatz, M., Wiklund, I., Lin, J., von Maltzahn, R., & Mattera, M. S.
(2015). Symptoms and markers of symptom severity in asthma--content validity of
the asthma symptom diary. Health and quality of life outcomes, 13, 21.
https://doi.org/10.1186/s12955-015-0217-5
Gosens, R., & Gross, N. (2018). The mode of action of anticholinergics in asthma. European
Respiratory Journal, 52(4), 1701247.
Halwani, R., Sultana, A., Vazquez-Tello, A., Jamhawi, A., Al-Masri, A. A., & Al-Muhsen, S.
(2017). Th-17 regulatory cytokines IL-21, IL-23, and IL-6 enhance neutrophil
production of IL-17 cytokines during asthma. Journal of Asthma, 54(9), 893-904.
Jiang, B., Ruan, Z., Chen, J., Lou, H., Shao, R., Jin, F., & Shen, H. (2016). Pharmacokinetic
properties and bioequivalence of orally inhaled salbutamol in healthy Chinese
volunteers. Drug development and industrial pharmacy, 42(9), 1476-1481.

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Johnson, D. B., & Bounds, C. G. (2019). Albuterol. In StatPearls [Internet]. StatPearls
Publishing.
Lambrecht, B. N., & Hammad, H. (2015). The immunology of asthma. Nature
immunology, 16(1), 45.
Mims, J. W. (2015, September). Asthma: definitions and pathophysiology. In International
forum of allergy & rhinology (Vol. 5, No. S1, pp. S2-S6).
Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, asthma,
and clinical immunology : official journal of the Canadian Society of Allergy and
Clinical Immunology, 14(Suppl 2), 50. https://doi.org/10.1186/s13223-018-0279-0
Saab, H., & Aboeed, A. (2019). Ipratropium. In StatPearls [Internet]. StatPearls Publishing.
Sinyor, B., & Perez, L. C. (2019). Pathophysiology Of Asthma. In StatPearls [Internet].
StatPearls Publishing.
Sullivan, A., Hunt, E., MacSharry, J., & Murphy, D. M. (2016). The microbiome and the
pathophysiology of asthma. Respiratory research, 17(1), 163.
Ullmann, N., Caggiano, S., & Cutrera, R. (2015). Salbutamol and around. Italian Journal of
Pediatrics, 41(Suppl 2), A74. https://doi.org/10.1186/1824-7288-41-S2-A74