Asthma

Question 1

category of life threatening asthma attack

Answer 1

PEFR < 33% best or predicted

Oxygen sats < 92%

‘Normal’ pC02 (4.6-6.0 kPa)

PaO2 <8 kPa

Silent chest, cyanosis or feeble respiratory effort

Bradycardia,

dysrhythmia or hypotension

Exhaustion, confusion or coma

Question 2

category of severe asthma attack

Answer 2

PEFR 33 - 50% best or predicted

Can’t complete sentences

RR > 25/min

Pulse > 110 bpm

Question 3

category of moderate asthma attack

Answer 3

PEFR 50-75% best or predicted

Speech normal
RR < 25 / min

Pulse < 110 bpm

Question 4

A fourth category, ‘Near-fatal asthma’

Answer 4

raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.

Question 5

when cxr recommended?

Answer 5

chest x-ray is not routinely recommended, unless:
life-threatening asthma
suspected pneumothorax
failure to respond to treatment

Question 6

Mx of acute asthma attack?

Answer 6

oxygen
15L of supplemental via to maintain a SpO₂ 94-98%.

nebulisers

corticosteroid
all patients should be given 40-50mg of prednisolone orally (PO) daily,

Question 7

bedside investigations?

Answer 7

PEF expressed as a % of the patient’s previous best value is most useful clinically.

In the absence of this, PEF as a % of predicted is a rough guide and can be helped to determine severity

An arterial blood gas would be important for my work up. Patients with SpO2 <92% or other features of life-threatening asthma require ABG measurement. Finally, a chest x-ray

Question 8

criteria that would prompt you to discuss this patient with ITU?

Answer 8

with acute severe or life-threatening asthma, who is failing to respond to therapy, as evidenced by:

deteriorating PEF
persisting or worsening hypoxia
hypercapnia
ABG analysis showing decreasing pH or increasing H+
exhaustion, feeble respiration
drowsiness, confusion, altered conscious state
respiratory arrest.

Question 9

When considering a cardiac arrest in a patient with asthma it is important to consider the following:

Answer 9

I would make sure high flow oxygen continues to be administered – hypoxaemia is likely the cause of the arrest

Ventilate with respiratory rate (8-10 min) and sufficient tidal volume to cause the chest to rise

Aim to intubate early once your anaesthetic team arrive

I would check for reversible causes of CPR, particularly a tension pneumothorax

Disconnect from positive pressure ventilation if this has been started

Consider ECPR in accordance with local protocols if initial resuscitation efforts are unsuccessful

Question 10

5H and 5T

Answer 10

hypoxia
hypotension
hydrogen ion - acidosis
hypothermia
hypo/hyperkalemia

tension pneumothorax
tamponade
toxins
thrombosis - PE or MI

Question 11

How would you manage asthmatic patient long term?

Answer 11

managed on a short course of oral prednisolone

make sure during admission they can stay off nebulisers for 24 hrs before sarge

PEF is >75% of best.

The patient should be started on an inhaled Corticosteroid (if not on one already). This dose should be titrated up to response. A short acting Beta-2 agonist is required for symptomatic control.
SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)

SABA + low-dose ICS + long-acting beta agonist (LABA)

SABA +/- LTRA
Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS

Patient education is always important prior to discharge and should include observation of inhaler technique and PEF record keeping.

Follow up should be arranged with the patient’s GP – ideally this should happen in 48 hours!

Finally, in this particular patient smoking cessation is very important!