Case 1 - Asthma Flashcards
What are the classifications of asthma attack?
- Mild
- Moderate
- Severe
- Life threatening
- Near fatal
Mild asthma attack
PEFR still >75%
No features of moderate asthma
Moderate asthma attack
PEFR between 50-75%
No features of severe asthma
Severe asthma attack
- PEFR 33-50%
- Cannot speak full sentences
- HR >110
- RR >25
- No features of life threatening attack
Life threatening asthma attack
- PEFR <33%
- Sats <92% or paO2 <8kpa
- Normal paCO2
- Cyanosis
- Silent chest
- Altered consciousness
- Poor respiratory effort
- Arrhytmia
Near fatal asthma attack
- Raised paCO2
- Mechanical ventilation with increased inflation pressures
Differentials for asthma attack
- Acute bronchitis
- PE
- Pneumonia
- Cardiac causes?
- Vocal cord dysfunction
- GORD
- Allergy
- Foreign body
What is controlled O2?
- Avoiding unecessary oxygenation of pt - can sometimes do harm
- O2 is a drug and should only be given when necessary using target sats eg 94-98% target if non CO2 retainer
What O2 sats do we do ABG?
If below 92%
Treatment for asthma attack - just mild/moderate
- 2.5-5mg nebulised Salbutamol
- 40mg oral prednisolone STAT - 0.5mg/kg (IV hydrocortisone if PO not possible) but no time difference between the two
Added management for asthma attack if pt has severe attack
- Nebulised ipratropium bromide 500 micrograms
- Back to back nebulised salbutamol - repeat in 15 mins if no improvement
Added management if asthma attack is life threatening/near fatal
- ICU/anaesthetist assessment
- Urgent portable CXR
- IV aminophylline?
- IV salbutamol - unless side effects
- IV magnesium?
Other causes of raised eosinophils?
- Asthma/COPD - airway inflammation
- Hayfever/allergy
- Parasites
- Allergic bronchopulmonary aspergillosis (fungal hypersensitivity in chronic lung problems)
- Recurrent abx usage eg in CF
- Vasculitis
- Lymphoma
- SLE
What criteria do pts have to meet to be discharged after asthma attack?
- PEFR >75% best/predicted
- No nebuliser usage for 24hrs
- Asthma nurse review inhaler technique and adherance
- 5 days oral predisolone
- GP f/u in 2/7
- Respiratory clinic f/u
What advice should be given to pt following discharge from hospital as an outpatient?
- Confirm diagnosis of asthma as outpatient
- Avoid triggers - identify using skin prick?
- Adherance - eg put meds next to toothbrush, alarms etc
- PEFR and inhaler technique
- Action plan - self management plan
What is a self management plan for pt following asthma attack?
- Plan for what pt should do if becomes unwell again
- Can be made using PEFR readings
- Depending on how severe will either direct to GP or hospital
Things that can provoke asthma
- Smoking
- URTI - viral usually
- Allergen - eg pollen, dust, pets
- Exercise - inc cold air
- Occupation
- Pollution
- Drugs - beta blockers, aspirin, eye drops
- Food and drink - dairy, alcohol, orange juice
- Stress
- In severe asthma consider inhaled heroin, psychosocial effects?
How common is asthma?
1 in 12 adults
1 in 11 children
What is asthma?
- Chronic inflammation
- Reversible - in some pts it isn’t completely
- Spontaneous reversal or treated
- Mucus plugging
Stepwise management of chronic asthma (BTS guidelines)
- SABA - eg salbutamol
- ICS
- LAMA - if no response consider removing LAMA and increasing ICS
- LTRA, theophylline
- 4th drug - LTRA, theophylline or B2 agonist tablets
- Steroid tablets - get specialist advice
Only move to next step if no response to previous - usin salbutamol >3/7
Asthma pathophysiology
- Airway epithelial damage - shedding and subepithelial fibrosis, BM thickened
- Inflammatory reaction - eosinophils, T lymphocytes, mast cells –> histamine, leukotrienes and PGs released
- Cytokines amplify inflammation response
- Increased goblet cells, smooth muscle hyperplasia and hypertophy
- Mucus plugging in fatal and severe
Overall acute asthma management
- A-E
- Aim SpO2 94-98%
- ABG if sats <92%
- 5mg nebs salbutamol (can rpt after 15 mins)
- 40mg oral prednisolone STAT
