Flashcards in Asthma Deck (28):
What is asthma?
chronic inflammatory disease of the airways characterised by reversible airways obstruction and bronchospasm
In children < 12mo, what other DDx should you consider besides asthma?
How would you define when someone has poorly controlled asthma?
- > 3 uses of reliever/week
- > 3 night time wakenings/month
What are some triggers for asthma?
• Pollutants, tobacco smoke, occupational fumes
• URTIs - concurrent viral infection
- MOST common
• Changes in weather - cold
• Emotion, anxiety
• Food, additives
• Medication (aspirin, beta blockers)
What are the most important parameters in the examination of asthma? What are less important ones? What are not reliable ones?
- general appearance/mental stat
- initial SaO2 in air
- ability to talk
- Wheeze intensity
- pulsus paradoxus
- peak expiratory flow rate
If asymmetry is found on auscultation in asthma, what might be the cause, but what might another DDx be?
- Asthma - mucous plugging
- Other ddx: foreign body
How might you differentiate between mild, mod, severe and critical asthma attack?
- Normal mental state
- can finish whole sentences in one breath
- subtle change in WOB, wheeze/normal auscultation
- no tachy
- inc WOB, with tachy
- some limitation of talking
- few words in one breath
- mod-severe WOB, wheeze can be loud/little - not indicator of severity
- can't vocalise
- Maximal WOB, silent chest, cyanotic, exhausted
- Marked tachy
Risk factors for asthma attack
- Previous ICU admission
- Poor compliance to asthma therapy
- Poorly controlled - significant interval symptoms
What might you see on derm exam for an asthma patient?
- atopic dermatitis (eczema)
- ‘allergic shiners’ (darkness and swelling under eyes caused by sinus congestion)
What signs on resp auscultation and percussion might you find with asthma?
○ Hyperresonance on percussion (airway oedema)
○ auscultation of chest
• Reduced breath sounds (airway oedema)
• Expiratory, polyphonic wheeze
(or silent chest)
Outline the interventions for an acute asthma attack, in order for severity.
1. Salbutamol: MDI/spacer, 6-12 puffs, wait 20 mins
2. Oral pred: 2mg/kg, 60mg max initially
3. Ipratropium: MDI/spacer, wait 20 mins - 1 hour only
4. IV Mg sulfate
5. IV aminophylline (if deteriorating): loading dose then continuous/6h dose
6. Consider IV pred
• O2 (when <92%), aim 92-96%
• Escalate care
○ Inc. adrenaline
○ ICU for resp support: positive pressure ventilation (CPAP, BiPAP), intubation
CPAP vs BiPAP
- CPAP helps oxygenate, continuous pressure to keep open
- BiPAP helps ventilation, pushes and pulls pressure
How many puffs of salbutamol in an asthma attack? Ipatropium?
- Salbutamol: 6 puffs if < 6 years old, 12 puffs if > 6 years old
- Ipratropium (Atrovent 20mcg/puff) dose: 4 puffs if < 6 years old, 8 puffs if >6 years old
SEs of aminophylline
N/V, arrhythmias, convulsions
Signs of salbutamol toxicity
Tremor, tachycardia, tachypnoea, metabolic acidosis, high lactate
First aid for asthma: instructions
- DRS ABC
- 4 x 4 x 4: 4 puffs, in between each puff take 4 breaths, then wait 4 mins for improvement
- Do second round
- If not improvement on second round, call ambo
D/C after asthma attack - asthma d/c pack
1. Review medications
2. Check inhaler technique
3. Family education
4. Follow up plan/communicate with GP
5. Written action plan
CLD for asthma
- 3-4hourly use of salbutamol
Ix to aid diagnosis of asthma, and requirements
- Major Ix is spirometry
○ For > 6 yo (or those who can perform it): FEV1 before and 10-15mins after bronchodilator
○ Minimum requirement of asthma in CHILDREN: 12% improvement in FEV1 with bronchodilator (salbutamol) only (not double req as adults)
- Other Ix include:
○ Bronchial provocation tests
○ Cardiopulmonary exercise test
- CXR generally not required
- ABG and spirometry not required in acute asthma in children
For long-term mx of asthma, what is the progression of medications used?
1. SABA - reliever (salbutamol/ventolin)
2. + ICS - preventer
3. If <12yo (general rule): If not ICS, then montelukast i.e. singulair tablet/cromone (preventers too) ... then only LABA
3. If >12yo (general rule): try + LABA, then switch ICS -> montelukast/cromone
4. Increase ICS dose
Outline the major LABA/ICS combos (and compare)
- Symbicort (budesonide, eformoterol)
○ 2 min onset - acts as reliever too
- Seretide (fluticasone, salmeterol)
○20 min onset - need ventolin too
What is montelukast?
Leukotriene receptor antagonist
When should you consider preventer use?
- Wheezing attacks less than 6/52 apart
- Attacks becoming more frequent and severe
- Increasing interval Sx
What should you counsel re:
- preventer use
- spacer vs MDI
- ICS use
- Preventers must be used every day
- Spacer always more effective
- rinse mouth (and use every day)
OSCE: inhaler technique:-
- General things to do
- Common mistakes
- Check pts technique by getting them to show you, not just ask
- Then show them, don't just tell
- Inhalers, common mistakes:
○ Must check dose counter
○ Failing to shake inhaler
○ Inability to seal lips - need tight seal (without biting)
○ Wrong position - not tilted, upright
○ Failing to exhale fully before inhaling, then inhaling weakly and slowly
○ Not holding their breath for long enough
○ exhaling into the device mouthpiece before or after inhaling
○ Using past expiry date
Correct spacer technique
1. Put together the spacer following the instructions that came with it.
2. Remove the protective cap from the puffer.
3. Shake the puffer well and insert (place) it firmly into the end of the spacer.
4. Place mouthpiece in mouth between teeth + create tight seal/make sure mask covers mouth and nose, creating tight seal
5. Hold level - not tilted
6. Breathe out gently.
7. Press the puffer ONCE to release a dose of the medicine into the spacer. Do not remove the puffer.
8. Breathe in very slowly until you have taken a deep breath. You will hear a whistle sound if you are breathing in too fast. Hold your breath for a few seconds, then breathe out slowly and deeply through your mouth. Breathe in and out 4 or 5 times (do not remove in between each breath - there is a 2 way valve system which will prevent any of the medication from escaping from the chamber).
9. If a second dose is needed, shake the puffer again and repeat steps 4-7. You can shake the puffer while it is still attached/connected to the spacer.
How to care for a spacer: instructions.
• The spacer should be cleaned once a week.
• Take the spacer apart and wash it in warm water containing a little dishwashing detergent or mild soap.
• DO NOT RINSE.
• Allow the spacer to drip dry. Do not wipe the spacer dry with a tea towel or kitchen paper but allow it to air dry. This can be done overnight.
• Put the spacer back together.
• Do not allow anyone else to use your spacer.