Respiratory - Acute and Chronic Asthma Flashcards
How does an acute exacerbation of asthma present?
Progressively worsening SOB
Signs of respiratory distress
Tachypnoea
Expiratory wheeze throughout chest
Chest sounds tight on auscultation with reduced air entry
What can a silent chest be a sign of?
Airways so tight not possible for child to move enough air to create a wheeze
Can also be associated with reduced respiratory effort due to fatigue
Life-threatening
What are the different signs in moderate, severe and life threatening asthma exacerbations?
Moderate
Peak flow > 50% predicted
Normal speech
Severe
Peak flow < 50% predicted
Saturations < 92%
Unable to complete sentences in one breath
Respriatory distress signs
Respiratory rate
> 40 in 1-5 year olds
> 30 in > 5 year olds
Heart rate
> 140 in 1-5 year olds
> 125 in > 5 years
Life threatening
Peak flow < 33% predicted
Saturations < 92%
Exhausation and poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered conscioussness/ confusion
What is used to manage acute viral induced wheeze or asthma?
Supplementary oxygen (if under 94% sats)
Bronchodilators
Steroids- to reduce airway inflammation
Antibiotics
What steroids can be used to reduce airway inflammation?
Prednisolone (oral)
Hydrocortisone (IV)
How are bronchodilators stepped us as needed?
- Inhaled or nebulised salbutamol (B2)
- Inhaled or nebulised ipratropium bromide (anti-muscarinic)
- IV magnesium sulphate
- IV aminophylline
How are mild cases of acute asthma exacerbations managed?
Outpatient with regular salbutamol inhalers via a spacer
4-6 puffs every 4 hours
What is the stepwise approach for treating moderate to severe cases of asthma exacerbations?
- Salbutamol inhalers via spacer, 10 puffs every 2 hours
- Nebulisers with salbutamol / ipratropium bromide
- Oral prednisolone
- IV hydrocortisone
- IV magnesium sulphate
- IV salbuatmol
- IV aminophylline
Call anaesthetist and ITU, may need intubation and ventilation if no control by this point
What are the signs of respiratory distress?
Tracheal tug
Subcostal recessions
Hypoxia
Tachypnoea
Wheeze on auscultation
What needs to be monitored when giving high doses of salbutamol?
Serum potassium
As potassium is absorbed from the blood into cells
What side effects can acute salbutamol use cause?
Tachycardia
Tremor
What step down regime of inhaled salbutamol is used?
10 puffs 2 hours
10 puffs 4 hourly
6 puffs 4 hourly
4 puffs 6 hourly
When can discharge for acute asthma exacerbations be considered?
When the child is well on 6 puffs 4 hourly of salbutamol
What other steps should be considered when discharging after an asthma exacerbation?
- Finish the course of steroids if started
- Provide safety-net information about when to return to hospital or seek help
- Provide individualised asthma action plan
What presentation suggests a diagnosis of asthma?
- Episodic symptoms with intermittent exacerbations
- Diurnal variability, worse at night and early morning
- Dry cough with wheeze and SOB
- Typical triggers
- History of atopic conditions
- Family history of atopic conditions
- Bilateral widespread polyphonic wheeze
- Symptoms improve with bronchodilators
What presentation indicates a diagnosis other than asthma?
- Wheeze only related to coughs and colds
- Isolated or productive cough
- Normal investigations
- No response to treatment
- Unilateral wheeze suggesting focal lesion, inhaled foreign body or infection
What are the typical triggers of asthma?
Dust
Animals
Cold air
Exercise
Smoke
Food allergens
How is low to high probability asthma diagnosed?
Based on history and examination
Children not diagnosed until 2-3 years old
When low chance of asthma and child symptomatic, refer to specialist for diagnosis
With high chance, trial of treatment implemented and if symptoms improve diagnosis can be made
What investigations are used for immediate probability asthma diagnosed?
Spirometry with reversibility testing (children over 5)
Direct bronchial challenge test with histamine or methacholine
Fractional exhaled nitric oxide FeNO
Peak flow variability, keep diary for 2 to 4 weeks
What are the principles of using the stepwise ladder?
Start at the most appropriate step for severity of symptoms
Review at regular intervals
Step up or down ladder based on symptoms
Aim for no symptoms or exacerbations on lowest dose
Always check inhaler technique and adherence at each review
What medical therapy is used in under 5s?
- Start a short-acting beta-2 agonist as needed (salbutamol)
- Add low dose corticosteroid inhaler or LTR antagonist (oral montelukast)
- Add the other option from step 2
- Specialist referral
What medical therapy is used in 5-12 year olds?
- Start short-acting beta-2 agonist as needed
- Add regular low dose corticosteroid inhaler
- Add long-acting beta-2 agonist e.g. salmeterol, continue salmeterol if patient has a good response
- Titrate up corticosteroid to medium dose, consider adding LRTA or oral theophylline
- Increase dose of ICS to high dose
- Referral to specialist, may need daily oral steroids
What medical therapy is used for over 12s?
- Start a SABA
- Add low dose ICS
- Add a LABA
- Titrate up corticosteroid inhaler to medium dose, consider oral LTRA, oral theophylline or inhaled LAMA
- Titrate inhaled corticosteroid to high dose, add additional treatments
- Add oral steroids at lowest dose, specialist
Can inhaled steroids affect growth?
Can slightly reduce growth and cause a small reduce in final adult height up to 1cm when used long-term
Dose-dependent
Medications act to prevent poorly controlled asthma and attacks that could lead to higher doses of steroids
Poorly controlled asthma can lead to more of an impact on growth
Regular asthma reviews to ensure they are growing well and on minimal dose
Why is inhaler technique so important?
Better the technique, more medication reaches the lungs
Poor technique causes medication in the mouth or back of throat, reducing effectiveness and leading to oral thrush
What should be used to increase effectiveness of inhalers?
Spacer device
How often should spacers be cleaned?
Once a month
Avoid scrubbing and allow them to air dry to avoid creating static
Static can interact with mist and prevent the medication being inhaled
What is the typical salbutamol inhaler called?
Metered dosed inhaler (MDI)
