Asthma

Question 1

What is asthma?

Answer 1

Chronic inflammatory d/o of the airways, associated with hyperresponsiveness and reversible airflow limitation.

Question 2

Name common triggers of exacerbations

Answer 2

Viral infection, environmental allergens or irritants.

Question 3

What are the hallmarks of an asthma exacerbation?

Answer 3

SOB, cough, wheeze, chest tightness, decrease in expiratory airflow

Question 4

What is the DDx for asthma exacerbation? (SOB/wheeze)

Answer 4

COPD, CHF, upper airway obst, PNA, ACS, PE

Question 5

Risk factors for severe asthma (13)

Answer 5

1) poor asthma control.
2) Hx of ICU/hospital admits.
3) Previous need for mechanical ventilation.
4) Multiple ER visits for asthma.
5) Hx prior hyperCO2 attacks.
6) Poor compliance w/ meds
7) XS reliance on short-acting dilators.
8) Underuse ICS
9) Hx need for oral steroids
10) Monotherapy with long acting beta-adrenergic (e.g. salmeterol)
11) Smoking
12) +co-morbidities

Question 6

What signs of physical are suggestive asthma exacerbation?

Answer 6

Accessory muscle use, tachycardia, tachypnea, difficulty speaking due to SOB/fatigue, altered LOC, quiet chest, diaphoresis, inability to lie flat, pulsus paradoxus, PEF <30% predicted or FEV1 <25% predicted after tx, O2 sat<90%, cyanosis.

Question 7

What investigations should you order for asthma exacerbation?

Answer 7

PEF to determine severity and help guide therapy.
Consider CXR, EKG/cardiac w/u.
ABG if deteriorating (pCO2 will indicate severity/fatigue)

Question 8

What are the hallmarks of MILD asthma?

Answer 8

Exertional SOB/cough +/- nocturnal symptoms.
Increased use of B2 agonist w/ good response.
FEV1 or PEF >60% predicted.
O2 sat >95%

Question 9

What are the hallmarks of moderate asthma?

Answer 9

SOB at rest, cough, congestion, chest tightness, nocturnal symptoms.
Partial relief from B2 agonist or requiring more than q4 hrs.
FEV1 or PEF 40-50% predicted.
O2 sat >95%.

Question 10

What are the hallmarks of severe asthma?

Answer 10

labored respirations, tachycardia, agitation/diaphoresis, difficulty speaking, no relief from b2 agonists.
FEV1 or PEF <40% predicted or unable to do.
O2 sat 90-95%

Question 11

Potentially fatal

Answer 11

Exhausted, confused, diaphoretic, cyanotic. 
Failing HR. 
Silent chest. 
Decreased resp effort. 
FEV1 or PEF- unable to do. 
O2 <90%

Question 12

Key components of asthma exacerbation tx

Answer 12

1) Oxygen (titrate to at least 92%)
2) ventolin
3) Atrovent
4) Steroids
5) Mg
6) NIPPV (BiPAP)

Question 13

Describe how you give bronchodilators in asthma exacerbation.

Answer 13

MDI and nebulizers equally effective.
Ventolin: 4-8 puffs q14-20 min via spacer x3. Can increase to 1 puff q30-60s up to 20 puffs if severe.
Alt = nebulizer 5.0 mg q15-20 min x3 or continuous as needed.

Atrovent: MDI 4-8 puffs q15-20 min x3, increase to 1 puff q30-60s (up to 20 puffs) prn. Nebulizer 250-500 mcg q15-20 min x3 or continuous prn.

Inhaled bronchodilators = effective and safer than parenteral route.

Question 14

When should you consider IV salbutamol or IV/SC epinephrine for asthma exacerbation?

Answer 14

When response to inhaled bronchodilators is poor or pt is moribund. Do not use routinely. Alternatively, tube pt and deliver agents through ET tube.

Question 15

Describe the role of steroids in asthma exacerbation and doses you would give.

Answer 15

1) Give for moderate/severe asthma.
2) Slow onset so give promptly.
3) No evidence that IV is better than PO
4) Start with pred 50 or methylpred 125
5) Consider adding high dose ICS if severe (500 mcg q10min x1 hr) though additional benefit not clear.

Question 16

When should you give MgSO4 and how much should you give?

Answer 16

Give if poor response to first line tx and severe airflow limitation.
Run 2g bolus IV over 20 min.

Question 17

Which induction agent should you consider in the case of asthma exacerbation?

Answer 17

Ketamine due to its bronchodilator effects.

Question 18

Which patients are at increased risk for asthma exacerbation relapse? (8)

Answer 18

1) previous near death episode.
2) Frequent ED visits.
3) Frequent hospitalization
4) Steroid dependence or recent use.
5) ‘Flash’ attacks
6) prolonged duration of recent exacerbation.
7) Poor compliance or understanding of self mgmt
8) Prolonged use of high dose beta agonists.

Question 19

What discharge instructions should you give pts leaving the ED after asthma exacerbation?

Answer 19

1) Ventolin 2-4 puffs q4 hrs then prn once symptoms controlled.
2) return if using ventolin more than q1-2 hrs.
3) oral steroids for pts with moderate to severe attack: prednisone 30-60 mg/d for 7-14 days (don’t need to taper)
4) Asthma plan to prevent and manage future exacerbations.
5) Review role of meds, talk about trigger avoidance.
6) F/u with community care provider.