Asthma Flashcards
What is asthma
Chronic type 1 hyper-responsiveness of airway
Leading to inflammation and obstruction
Inflammation - mucous / muscle hypertrophy and contraction
Variable - 20% peak flow
Reversible - bronchodilator
Responds to treatment
What are types of onset of asthma
Infant Childhood Adult Exertional Occupational
What causes asthma
Genetics FH atopic tendency Atopy - hay fever / eczema / allergy Occupation - smoke LBW Obesity Environment - smoke / pollution
What triggers asthma
Cold air Exercise Smoke Allergen Virus - URTI
How does asthma present
Wheeze SOB - trapped Dry nocturnal exertional cough Diurnal - typically worse at night Tight chest as muscles contract Worse at night
What are signs of asthma
Hypercapnia Hypoxia Cyanosis Tachycardia Accessory muscle Resp distress Hyperinflated lungs Clubbing - chronic hypoxia
When is it NOT asthma
<18 months = VIW Productive cough Stridor (hard inspiratory) Asymmetrical signs / unilateral Dull percussion Crepitations No response to RX
How do you Dx asthma
No investigation in children
What can you do to aid Dx
Trial of ICS
LTRA <5
How do you monitor
Peak flow if >5
If child comes into hospital what tests do you do
Pulse oximetry
Peak flow if >5
ABG if life threatening but VBG will work
Bloods - FBC, U+E as salbutamol = hypoK, lactate+CRP if think sepsis
CXR if suspect pneumonia / pneumothorax
Why is normal CO2 worrying
Hyperventilating so should be low
What are goals of Rx
Minimal Sx
Minimal reliever
No attacks
No limitations
How do you measure control
SABA / week
Absence from school
Nocturnal Sx / week
Exertional Sx / week
What are general measures
Remove trigger
Stop tobacco exposure
What do you do if asthma Dx / suspected
SABA as required
When do you step up
If SABA
>3 week
Nocturnal
Oral steroid
What do you add
8 week trial of Low dose ICS (even if <5 according to NICE)
If Sx resolved but came back after stopped ICS = offer low dose ICS + SABA
If Sx did not resolve consider other Dx
LTRA <5
What do you do if still not controlled
Add LTRA if not controlled after 4-8 weeks Stop if one hasn't worked REFER Add LABA to ICS Increase to medium dose if inadequate Add MART
What are additional
REFER High dose ICS Theophylline Daily steroid Biologics
If still not responding what should you query / before you add on therapies
Inhaler technique Dry CI <8 MDI with spare = gold Psychological Compliance Dx
What are complications
Pneumothorax due to increased trapped alveolar pressure
What are doses of ICS
Low = 200 High = 400
SE of ICS
Oral candidiasis
Height and weight
Adrenal insufficiency
What is MART
Maintenance AND reliever
Combined ICS and LABA
What do you do for children 5-16
Treat as adult
What is important in the Hx of acute asthma attack / wheezy child
Onset Trigger Any infection that could trigger Specific Sx Any Rx tried Any admissions to hospital or ITU PMH - atopy / infections / asthma / eczema DH - inhalers? Immunisation FH SH - parental smoke Birth / vaccination Hx
How do you examine
A - speaking B - distress / sats / RR. /ausculate C - CRT / BP / HR D - consciousness / pupils / temp / BG E - rash / ENT / abdo
What is a moderate attack
SpO2 >92
PEF >50
What is a severe attack
SpO2 <92 PEF 33-50 No sentences HR >125 RR >30 Accessory neck muscle
What is lifethreatening
SpO2 <92 PEF <33 Resp acidosis Silent chest as airways so small no air Cyanosis Poor resp effort Normal CO2 Exhaustion Hypotension Confusion
What is fatal
Raised PaCO2
What do you do in mild asthma attack
SABA + spacer - 1 puff every 30s up to 10 puffs
+- prednisolone
How do you treat moderate asthma attack
SABA via nebuliser + prednisolone Add ipatropium bromide (SAMA) Oxygen if low sats Magnesium sulphate Oral steroids early
How do you treat severe asthma
Peak flow <33%
Can’t complete sentence
IV salbutamol IV magnesium sulphate IV aminophylline with anti-emetic IV hydrocortisone Steroids High flow Oxygen Intubate and ventilate if exhausted Chest drain if pneumothorax
How do you give steroid
IN ALL ATTACK Maintenance = inhaled Acute = oral 10mg <5 40mg >5 3 days or until recover Repeat if vomit
What do you need to do if steroid >14 days
Taper down
When do you discharge
Stable 3-4 hours inhaled SABA
PEF >75%
Sats >94%
What must you do before
Check inhaler technique Asthma management plan Primary care follow up 1 week Asthma clinic 1 month Continue oral steroid
Ddx cough
Congenital laryngomalacia CF Foegin body Pertussi Croup Pneumonia TB Ciliary dyskinesia Bronchiolitis Habitual cough
Ddx wheeze
VIW Bronchiolitis / LRTI Anaphylaxis FB - monophonic as only in one area GORD HF CF TB Aspiration Tracheo-bronchomalacia Ciliary dyskinesia
What causes viral induced wheeze
Viral illness
RSV = common
Persistent / recurrent wheeze but well in between attacks
What is multi-trigger wheeze
If not caused by virus
How does it present and what makes it more likely than asthma
Hx viral illness Wheeze Resp distress Cough SOB Cyanosis If <3 years old, no Hx of atopy and occurs with viral illness
What does VIW not have
Crackles in chest
NOT LRTI
What is RF
Atopy
Previous Hx
Passive smoke
How do you treat VIW
None if mild
SABA (10 puff)
Inhaled steroid -bexamethasone if recurrent
When do you give oral pred
If admitted
What may you consider given if recurrent/ multi-trigger
Preventor
ICS or LTRA
What should you encourage parents to do
Stop smoking
SE of SABA
Tachy
Tremor
Flushing
Headache
Lifestyle advice
Asthma action plan Vaccination Advise on triggers Weight loss and smoking cessation Inhaler technique and peak flow
WIW
More likely develop asthma
