FN: Acute Severe Asthma

Question 1

Presentation

Answer 1

Acute breathessness and wheeze

Question 2

History

Answer 2

1. Precipitant: infection, travel, excercise
2. Usually and recent treatment
3. Previous attacks and severity: ICU?
4. Best PEFR?

Question 3

Investigations

Answer 3

1. PEFR
2. ABG
3. FBC, U + E, CRP, blood cultures

Question 4

ABG’s show

Answer 4

PaO2 usually normal or slightly reduced
PaCO2 reduced
If PaCO3 increased: send to ITU for ventilation

Question 5

Assesment severe any one of the following

Answer 5

1. PEFR 25
2. HR>110
3. Cant complete sentence in one breath

Question 6

Life threatening: any one of

Answer 6

1. PEFR 4.6 kPa, PaO2<8kPa
2. cyanosis
3. Hypotension
4. Exhaustion, confusion
5. Silent chest, poor respiratory effort
6. Tachy-/brady/arrhythmias

Question 7

Differential

Answer 7

Pneumothorax
Acute exacerbation of COPD
Pulmonary oedema

Question 8

Admission criteria

Answer 8

1. Life-threatening attack
2. Feature of severe attack persisting despite initial treatment
3. May discharge if PEFR>75% 1h after intial Rx

Question 9

Discharge when

Answer 9

1. Been stable on discharge meds for 24hr

2. PEFR>75% with diurnal variability <20%

Question 10

Discharge Plan

Answer 10

1. TAME pt.
2. PO steroids for 5d
3. GP appointment w/i 1 wk
4. Resp clinic appointment w/i 1 mo

Question 11

Management

Answer 11

1. O2, Nebs and steroids
2. If life threatening:inform ITU, MgSO4 IVI, nebulised salbutamol
3. If improving
4. IV treatment if no improvement in 15-30mins
5. Monitoring

Question 12

O2, Nebs and steroids

Answer 12

1. Sit-up
2. 100% O2 via non-rebreathe mask (aim for 94-98%)
3. Nebulised salbutamol (5mg) and ipratropium (0.5mg)
4. hydrocortisone 100mg IV or pred 50mg PO (or both)
5. Write “no sedation” on drug chart

Question 13

If life threatening

Answer 13

1. Inform ITU
2. MgSO4 2g IVI over 20 min
3. Nebulised salbutamol every 15min (monitoring ECG)

Question 14

If improving

Answer 14

1. Monitoring: SpO2 @ 92-94%, PEFR
2. Continue pred 50mg OD for 5 days
3. Nebulised salbutamol every 4hrs

Question 15

IV treatment if no improvement in 15-30 min:

Answer 15

1. Nebulised salbutamol every 15min (monitor ECG)
2. Continue ipratropium 0.5mg 4-6 hrly
3. MgSO4 2g IVI over 20 min
4. Salbutamol IVI 2-30ug/min
5. Consider aminophylline
   a. Load:5mg/kg IVI over 20min: unless already on theophylline
   b. Continue:0.5mg/kg/hr
   c. Monitor levels
6. ITU transfer for invasive ventilation

Question 16

Monitoring

Answer 16

1. PEFR every 15-30min: pre- and post beta agonist
2. SpO2: keep >92%
3. ABG if initial PaCO2 normal or increased