Asthma Flashcards
Not to hate asthma
What are three important questions to ask asthma patients?
In the last month/week have you had DIFFICULTY SLEEPING due to your asthma?
Have you had your usual asthma symptoms DURING THE DAY?
Has your asthma interfered with your usual DAILY ACTIVITIES?
Name 5 conditions in which you can hear wheeze.
Pulmonary Disease COPD Eosinophilic Lung Disease Foreign Body Aspiration Cardiac Failure
What advice should you give re asthma and exercise?
Always have your inhaler on you.
Take an additional dose of the blue inhaler if exercise is known to precipitate asthma.
Try to avoid exercising in the cold/around known allergies.
Why should you advise people with asthma to get the flu jab?
Although people with asthma are not more likely to get the flu, it can be more serious for people with asthma. This is because the have swollen and sensitive airways. The flu can cause further inflammation, triggering asthma attacks and worse asthma symptoms. It can also lead to pneumonia and other acute resp diseases.
What is asthma?
It is a reversible narrowing of the peripheral airways
What other vaccination is recommended in asthma?
Pneumococcal disease
Define PEFR?
Peak Expiratory Flow Rate is the maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration.
Which measurements do you need to predict peak flow?
Height, age, gender
How long do you record PEFR for diagnosis?
2-4weeks
2x daily
Occupational asthma - 2-4hourly, several weeks
How many doses does a salbutamol inhaler contain?
200
How should you expect patients with asthma to feel if they have well-controlled asthma?
They should go about their lives as normal with no expectation of symptoms
What does dyspnoea mean?
shortness of breath
What is the forced vital capacity? (FVC)
How much air can the patient breath out of their lungs at force. The difference between TLC and Residual Volume
What is FEV1?
The amount of air the patient can forcefully exhale within 1 second. A measure of how wide and strong their airways are
What should the FEV1:FVC ratio be?
80%
How do you measure PEFR from a volume/time graph?
Flow = volume/time so the max slope of FVC curve is equal to the PEFR
What is the TLC?
Equivalent to the amount of air a patient can hold in their lungs
What is the flow/volume loop?
It is a graph that shows the association with flow of air and volume of lungs
What is MVV?
The maximal voluntary ventilation - the amount of air the patient can inhale and exhale within one minute
What is obstructive lung disease?
Lung disease in which the airways are obstructed, for example by a narrowing e.g. in asthma
What is restrictive lung disease?
Diseases that restricts lung expansion
What is COPD?
Chronic obstructive pulmonary disease (COPD) is the name used to describe a number of conditions including emphysema and chronic bronchitis.
What is emphysema
The alveoli/air sacs are enlarged and damaged, reducing the surface area for gas exchange
What is chronic bronchitis?
Chronic inflammation of the lungs, frequently complicated by infections.
What are the FVC, FEV1 and FEV1/FVC ratio values of obstructive lung disease?
FVC: Normal or decreased (severe)
FEV1: Normal or decreased (severe)
FEV1/FVC ration: Decreased <70%
What are the FVC, FEV1 and FEV1/FVC ratio values of restrictive lung disease?
FVC: Normal or decreased (severe)
FEV1: Decreased
FEV1/FVC ration: Normal or Increased >70%
If an FEV1/FVC ratio is low, and the FVC is normal, which kind of lung disease would you suspect?
Obstructive
If an FEV1/FVC ratio is high and the FVC is high, which kind of lung disease do you suspect?
Normal lung mechanics
If the FEV1:FVC ration is high and the FVC is low, which kind of lung disease do you suspect?
Restriction
If you see a flow/volume loop that is ‘shrunk’, which kind of lung disease is that?
Restrictive - the air mechanics is still the same, there just isn’t as much of it.
What are the types of upper airway obstruction?
Extrathoracic - vocal cord paralysis, tracheomalacia, tumour
Intrathoracic - tumour, tracheomalacia
Fixed - tracheal stenosis, goitre, tumour
What are the stages of COPD?
- FEV1 = ≥80%
- 50% ≤ FEV1 <80%
- 30% ≤ FEV1 <50%
- FEV1 <30%
How do you document observations that you suspect could be due to domestic violence?
You record them in the medical notes, noting down facts i.e the exact site and dimensions of the bruising and quote the explanations given by the patient (Body map diagrams can be used if appropriate). Your observations of the patient’s demeanour are part of your examination and so should be documented accordingly.
What medication should be given upon a severe exacerbation of asthma?
- Salbutamol, nebulised: 1 puff every 5 mins or 6 puffs at once in spacer.
- Ipratropium bromide, nebulised
- Oxygen high flow
- IV hydrocortisone if needed
- Sit patient upright
What is SBAR?
Situation: I am (name), (X) nurse on ward (X)
I am calling about (patient X)
I am calling because I am concerned that…
(e.g. BP is low/high, pulse is XX, temperature high)
Background: Patient (X) was admitted on (XX date) with…
(e.g. MI/chest infection)
They have had (X operation/procedure/investigation)
Patient (X)’s condition has changed in the last (XX mins)
Their last set of obs were (XX)
Patient (X)’s normal condition is…
(e.g. alert/drowsy/confused, pain free)
Assessment: I think the problem is (XXX)
And I have… (e.g. given O2/analgesia, stopped the infusion)
OR
I am not sure what the problem is but patient (X) is
deteriorating
OR
I don’t know what’s wrong but I am really worried
Recommendation: I need you to…
Come to see the patient in the next (XX mins)
AND
Is there anything I need to do in the mean time?
(e.g. stop the fluid/repeat the obs)
What are the support agencies for adults?
Social Services
Police adult safeguarding
Women’s Refuge
What do you do in an asthma attack?
Assessment - Peak Flow, RR and O2 Sats
Give Steroids and O2
Nebulised salbutamol
If peak flow is 33-50% then give ipratropium and inform senior.
Can also give magnesium.
If peak flow is under 33% and sats <92 then get a PXR and call ITU
If blood gases are rising, then give aminophylline.
Do pregnant women have the same lung physiology?
No. Lung function changes partly because progesterone increases and partly because the enlarging uterus interferes with lung expansion. Progesterone causes the brain to lower CO2 levels, so tidal and minute volume and RR increase,= ++pH. O2 consumption increases by about 20% to meet the increased metabolic needs of the foetus, placenta, and several maternal organs. Inspiratory and expiratory reserve, residual volume and capacity, and PaCO2 decrease. Vital capacity and PaO2 do not change. Thoracic circumference increases by about 10 cm.
What are the features of acute severe asthma upon assessment?
Peak flow 33-50%
RR >25
HR >110
Inability to complete sentences in one breath
What is salbutamol?
beta 2 agonist
What is ipratromium?
Antimuscarinic
What is beclometasone?
Corticosteroid
What is budesonide?
Corticosteroid
What do you get upon examination of bad asthma attack?
wheeze, slurring words, high rr, silent chest, sat forward, frightened
What do you see upon exam of pulmonary oedema?
peripheral oedema, dull percussion, pink frothy sputum, sat upright, out of breath, drowning, raised jvp
What do you see upon exam of tension pneumothorax?
deviated trachea, pleuritic pain, hyper resonance percussion, wonky expansion, increased problematic breath
What do you see upon examination of massive haemthorax?
low bp, haemoptesis, dull percussion, white, wonky expansion, reduced breath sounds
With what do you treat a pulmonary oedema?
Loop diuretic
With what do you treat tension pneumothorax?
Venflon 2ics Mc
Chest drain narrow bore 5ics ma
With what do you treat a massive haemthorax?
Chest drain (wide bore)
Why is normal CO2 abnormal in asthma attack?
Not even ventilating anymore, so they will have low paO2
Which immediate treatment do you give acute asthma attack?
5mg nebulised oxygen driven salbutamol as much as poss
Nebulised 0.5mg ipratropium every 6 hours
Prednisolone 40-50mg daily tablet or IV hydrocortisone 100mg
IV magnesium 2mg 20 minutes
What are the side effects of b2 agonist?
Tremor, hypokalaemia, tachycardia,
What are the side effects of magnesium?
Not really many, maybe phlebitis
What are side effects of corticosteroids?
Adrenal suppression, osteoporosis,hyperglycaemia, weight gain
How to corticosteroids work?
Enter target cells, bind to glucocorticoid receptors in cytoplasm, transport to nucleus and inhibit T cell activation so reduce inflammation
Why do we do a cxr before icu with asthma?
To check no pneumothorax.
What do you think about when discharging?
Clinical, treatment, education/self-management, follow up
What does the patient need to show, clinically, in order to leave after an asthma attack?
PEFR +70% same in day and night
Normal stats
No resp distress
Be monitored for 24 hrs
What treatment do we need to give patient upon discharge?
Inhaler technique and compliance (if feeling well may stop using preventer inhaler)
Use asthma nurses
Steroids
What education/self managing do we need to give this patient?
Inhaler technique, possible flare up causes
Asthma plan
Smoking!
What follow up appointments do they need?
Asthma nurse in two days and outpatient clinic in 4 weeks
1in 6 are back in 4 wks
Clinically what is asthma?
Recurrent episodes of dyspnoea, cough and wheeze.
Which three factors of pathophysiology cause asthma?
Narrowing of the airways:
- Bronchial muscle contraction
- Mucosal swelling/inflammation
- Increased mucus production
What are the symptoms of asthma?
Intermittent SOB
Wheeze
Cough (nocturnal)
Sputum
Other atopic disease in PMH or FH.
What can precipitate symptoms of asthma?
Exercise Allergens Cold air Smoking +passive Infection Aspirin Beta Blocker NSAIDs Pollution Emotion
When are asthma symptoms worse in the daytime?
Early morning or late night (diurnal)
What are signs of an asthma attack?
Tachypnoea
Audible wheeze
Accessory muscle use
Hyper-resonant percussion
What are obs of a severe attack?
Pulse >110bpm
RR >25
PEF 33-50% predicted
What are the obs of a life-threatening attack?
SpO2 <92% Silent chest Cyanosis Poor resp effort Arrhythmia Exhaustion Altered concious level Hypotension Pao2 <8 Normal PaCO2
What is the treatment for a severe asthma attack?
Oxygen to maintain 94-98% Salbutamol nebs 5mg/20min Ipratropium bromide neb 0.5mg/4-6hrs 100mg hydrocortisone IV/6hrs IV Magnesium sulphate 1.2-2g over 15 minutes
What are differentials of asthma attack?
Pulmonary oedema COPD Obstruction of airway (foreign body/tumour) SVC obstruction Pneumothorax PE Bronchiectasis
How do you diagnose asthma?
You suspect it strongly if FEV1/FVC <0.7 then see if it responds to salbutamol with spirometry.
How do you manage chronic asthma pharmacologically?
- Salbutamol PRN
- Beclometasone/budesonide 200-800mcg/day (1x100BD)
- Salmeterol 50mcg/12hr (combination therapy)
- If no response to LABA, stop it. Montelukast 10mg OD, theophylline 250-500mg/5hrs at night.
- Prednisolone 30mg OD
- Refer to someone else
What lifestyle advice is given in chronic asthma?
Quit smoking Avoid precipitants Lose weight Check inhaler technique Monitor with PEF Educate Write plan if emergency
At which points do you move down the chronic asthma management steps?
Consider moving down if control is good for more that three months
What are differentials of lots of bruises?
Caused by drugs - steroids/blood thinners
Depression
Domestic Violence
Sports
What is the classification of moderate/severe/life-threatening asthma attack according to PEFR?
50%+ = moderate 33-50% = severe <33% = life-threatening
What non-pharmaceutical things can you do when treating an acute asthma attack?
Sit upright
Document treatment
Insert cannula
When discharging a patient from hospital who had an asthma attack, what do you tell them to book?
A GP appointment within 48 hours
Do you manage asthma differently in pregnancy?
No, but continuously monitor foetus
What treatment does a wheeze indicate?
Bronchodilator bc wheeze is the result of airway obstruction
Which drugs do you not give in asthma?
Beta blockers
Ibuprofen
Aspirin
