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AIP: Shortness of breath > Severe asthma > Flashcards

Severe asthma Flashcards

1
Q

In which patients is acute asthma nearly always seen in?

A

patients with a history of asthma

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2
Q

What are 6 examples of specific triggers for acute asthma?

A
  1. URTI
  2. Housemite
  3. Pollen
  4. Animal
  5. Aspirin
  6. Beta-blockers
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3
Q

What are 5 examples of non-specific triggers for acute asthma?

A
  1. Cold air
  2. Exercise
  3. Atmospheric pollutants
  4. Stress
  5. Emotion
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4
Q

What is the significant morbidity and mortality of asthma related to?

A

underestimation of severity

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5
Q

What are 3 aspects to the pathophysiology of an acute asthma exacerbation?

A
  1. increased work of breathing - increased airway resistance and decreased pulmonary compliance, results in hypercapnic respiratory failure
  2. V/Q mismatch - from airway narrowing and closure - leads to impaired gas exchange and increased work of breathing to compensate
  3. adverse cardiorespiratory interactions - increase venous return because of high intrapleural pressures, but also increased afterload causing pulsus paradoxus
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6
Q

What are 3 characteristics of the airway in an acute asthma exacerbation?

A
  1. Reversible obstruction
  2. Inflammation
  3. Mucous formation
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7
Q

What are 5 features in the history of an acute exacerbation of asthma?

A
  1. Shortness of breath
  2. Cough
  3. Wheeze
  4. Chest tightness
  5. Status asthmaticus - failing to respond to nebulised bronchodilators
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8
Q

What is meant by status asthmaticus?

A

failing to respond to nebulised bronchodilators

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9
Q

What is hyperacute, fulminating asthma?

A

onset over <3 hours

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10
Q

What are 5 questions to ask about in the background history for an episode of acute asthma?

A
  1. Previous intubations
  2. Previous control
  3. Multiple admissions
  4. Poor psychological circumstances
  5. Poor response to treatments
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11
Q

What are the 3 groups into which acute asthma exacerbations are classified?

A
  1. Moderate asthma
  2. Severe asthma
  3. Life-threatening asthma
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12
Q

What are 5 features of a moderate exacerbation of asthma?

A
  1. PEFR 50-75% best or predicted
  2. Speech normal
  3. RR <25 / min
  4. Pulse <110 bpm
  5. No features of severe asthma
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13
Q

What are 4 features of a severe asthma exacerbation?

A
  1. PEFR 33-50%
  2. RR > 25
  3. HR > 110
  4. Inability to complete sentence in one breath
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14
Q

What are 9 markers of life-threatening asthma exacerbation?

A
  1. PEFR <33% best or predicted
  2. Oxygen sats < 92%
  3. Silent chest
  4. Cyanosis
  5. Feeble respiratory effort
  6. Bradycardia, dysrhythmia
  7. Hypotension
  8. Exhaustion, confusion or coma
  9. Normal CO2
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15
Q

Why is a normal pCO2 in an acute asthma attack a worrying sign?

A

indicates exhaustion

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16
Q

What is a fourth category of acute severe asthma that is now recognised?

A

near-fatal asthma

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17
Q

What are the 2 key features defining near-fatal asthma?

A
  1. Raised pCO2
  2. Requiring mechanical ventilation with raised inflation pressures
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18
Q

When should an ABG be performed in acute exacerbations of asthma?

A

oxygen saturations <92%

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19
Q

When is a chest x-ray indicated in acute severe asthma?

A

not routinely recommended unless:

  1. Life-threatening asthma
  2. Suspected pneumothorax
  3. Failure to respond to treatment
20
Q

What will an ABG initially show in acute severe asthma?

A

respiratory alkalosis (blowing off acid CO2)

21
Q

What will an ABG show later in an acute asthma exacerbation? How does this come about?

A

metabolic lactic acidosis from salbutamol/adrenaline (beta adrenergic stimulation) - increased glycolysis and increased pyruvate + lactate production

22
Q

What are 2 electrolytes to monitor in an acute asthma exacerbation?

A
  1. K+
  2. Mg2+
23
Q

What are 7 criteria for referral to intensive care in an acute asthma exacerbation? (2 main, 5 sub)

A
  1. Requiring ventilatory support
  2. With acute severe or life-threatening asthma who is failing to respond to therapy, as evidenced by:
    • deteriorating peak flow reading
    • persisting or worsening hypoxia
    • hypercapnia
    • exhaustion, feeble respiration
    • respiratory arrest
24
Q

What is a normal PCO2?

A

4.6-6.0

25
Q

What are the first 5 steps of management of an acute asthma exacerbation?

A
  1. Sit up
  2. 100% O2 (15L non-rebreathe) aiming fro 94-98%
  3. Nebulised salbutamol 5mg back to back
  4. Hydrocortisone 100mg IV or prednisolone 50mg PO
  5. Ipratropium 0.5mg (500 micrograms)
26
Q

What should you aim for the oxygen sats for in an acute asthma exacerbation?

A

94-98%

27
Q

What is the dose of nebulised salbutamol and how should it be given?

A

salbutamol nebulisers 5mg each

can do up to 5 back to back (prescribe at least 2 initially with 15 min or so apart)

28
Q

How should ipratropium nebulisers be given in an acute asthma exacerbation?

A
  • 0.5mg given as mixed nebs with salbutamol
  • only need to give them once rather than with each back to back salbutamol
  • can give max QDS
29
Q

What steroids can be given in an acute asthma exacerbation?

A
  • usually IV hydrocortisone 100mg
    • given stat 100mg then 50mg max QDS
  • or prednisolone 50mg PO continued for at least 5 days or until patient recovers from the attack
30
Q

How can salbutamol be given in patients without features of life-threatening or near-fatal asthma?

A

standard presurised metered-dose inhaler (pMDR) or oxygen-driven nebuliser

31
Q

What should be done about a patient’s normal asthma medication during an acute attack?

A

continue their normal medication routine, including inhaled corticosteroids

32
Q

If asthma attack is life-threatening, what are 3 next steps to take in the acute management?

A
  1. Inform intensive care team
  2. IV aminophylline following consultation with senior staff
  3. Magnesium sulfate 2g IV over 20 minutes
  4. Nebulised salbutamol every 15 minutes
33
Q

Which team should you let know about a life-threatening acute asthma exacerbation?

A

intensive care team

34
Q

When should aminophylline be administered and how?

A

following consultation with senior medical staff

5mg/kg IV loading dose over 20 min, followed by 0.5mg/kg/hr IV maintenance dose

35
Q

When should you not use IV aminophylline to treat an asthma exacerbation?

A

if the patient usually takes theophylline already

36
Q

How is magnesium given in an acute exacerbation of asthma?

A

IV magnesium sulphate 2g over 20 minutes

37
Q

When should ipratropium be given in asthma attacks?

A

patients with severe or life-threatening asthma

38
Q

How frequently should salbutamol nebulisers be given in a patient who is not responding?

A

5mg every 15 min

39
Q

How often should ipratropium nebs be given in patients with severe or life-threatening asthma?

A

0.5mg every 4-6 hours

40
Q

What are 4 considerations of management for patients who fail to respond to the OSHITME steps of management?

A
  1. Senior critical care support needed
  2. Treat in appropriate ITU/HDU setting
  3. Intubation and ventilation
  4. Extracorporeal membrane oxygenation (ECMO)
41
Q

What are 3 aspects of monitoring of patients with acute asthma exacerbation?

A
  1. Peak flow every 15-30 minutes pre- and post- salbutamol
  2. SpO2: keep >94-98%
  3. Consecutive ABG measurements
42
Q

What is the preferred induction agent if rapid sequence intubation is performed for asthmatics and why?

A

ketamine due to bronchodilation (propofol can cause hypotension but is alternative)

43
Q

What are 3 criteria for discharge following an acute asthma exacerbation?

A
  1. Beens table on discharge medication - i.e. no nebulisers or oxygen for 12-24 hours
  2. Inhaler technique checked and recorded
  3. PEF >75% of best or predicted
44
Q

What are 4 complications of an acute asthma exacerbation?

A
  1. Pneumothorax
  2. Respiratory failure
  3. Respiratory arrest
  4. Cardiac arrest
45
Q

What are the likely steps to the A-E assessment of an acute asthma exacerbation?

A
  • History + get obs going: AMPLE history, ask about triggers, previous admissions, ITU/intubation previously
  • if low O2 on obs during history - get 15L oxygen non-rebreathe going (target sats 94-98)
  • A: if patient talking, move on, otherwise manoeuvres/ adjuncts
  • B: look at sats, resp rate (if >25 severe), if sats <92 life-threatening. chest expansion, listen - wheeze?, percuss, tracheal deviation
    • get medications prescribed: salbutamol and ipratropium nebs (back to back salbutamol)
  • C: HR (>110 severe), BP (hypotension suggests life-threatening, cap refill
    • do ABG
    • get IV access - put in cannula
    • take bloods: FBC, U+Es, LFTs
    • start IV hydrocortisone 100mg
  • D: blood glucose, AVPU, pupils, temperature
    • sepsis 6 if high temp?
  • E: expose, abdo exam
46
Q

Up to how many back to back 5mg salbutamol nebs can be given?

A

5

AIP: Shortness of breath (12 decks)

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