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Flashcards in Asthma Exacaerbation Deck (42):



When assessing asthma attack severity, what signs would indicate that someone was suffering from a life threatening asthma attack?

Any one of

  • PEFR < 33%
  • SpO2 < 92%
  • PaO2 < 8kPa
  • HR > 130
  • Poor respiratory effort - exhaustion
  • Can't speak
  • Normal or High PaCO2
  • Other signs - Silent chest, cyanosis, bradycardia/arrhythmia, hypotension, confusion, coma




In an acute asthma attack, what are the objective measurements used to determine severity?


  • Ability to speak
  • HR
  • RR
  • PEFR
  • Oxygen saturations
  • Arterial blood gases




What causes death in asthma attacks?



Cardiac arrest 2o to hypoxia and acidosis - REVERSAL OF HYPOXIA IS PARAMOUNT






When assessing asthma attack severity, what signs would indicate a moderate asthma attack?

  1. Increasing symptoms
  2. PEFR >50-70% predicted/best
  3. No features of severe attack
    1. SpO2 >/= 92%
    2. Able to speak
    3. HR < 110
    4. RR < 25
    5. PaO2 > 8kPa




When assessing asthma attack severity, what signs would indicate that someone is suffering from a severe asthma attack?

Defined as any one of:

  1. PEFR 30-50% predicted/best
  2. RR >/= 25
  3. SpO2 >/=92%
  4. HR >/= 110
  5. Cannot complete sentences
  6. PaO2 > 8kPa




What would bradycardia in a life threatening asthma attack potentially indicate?



Cardiac arrest may be imminent




What are signs that would indicate that someone is having a near fatal asthma attack?



Life threatening signs + Raised PCO2 +/- need for mechanical ventilation with raised inflation pressures




What are risk factors for fatal or near fatal asthma attacks?


  • Previous near fatal attacks
  • Three or more classes of asthma medication
  • Repeated A&E attendances
  • High ß2 agonist use
  • Background difficult asthma




How would you initially manage someone who is admitted to hospital with an acute asthma attack?


  • Airway - ensure no obstruction
  • Breathing - give high flow O2
  • Circulation - IV access




How would you monitor someone in hospital having an acute asthma attack?


  • PEFR on arrival, 15-30 mins after, then regularly thereafter
  • O2 saturations
  • ABG (if SpO2 < 92%) - pH and PCO2
  • Observations - HR and RR especially
  • Blood glucose
  • Other bloods - FBC, U+E's, cultures
  • CXR 




When would you consider doing an ABG in an acute asthma attack?



SpO2 <92%




Why would you do a CXR in someone having an acute asthma attack?



Check for infection or pneumothorax




When monitoring someones PCO2, what are important things to bear in mind with regards to CO2 retention in an asthma attack?


CO2 retention, following administration of high flow oxygen, is not a problem in moderate or severe acute asthma attack. Therefore, a high CO2 indicates a life-threatening attack and should precipitate urgent ITU review for invasive ventilatory support




In the initial stages of an asthma attack, what can happen to the PCO2?



Can go low due to the patient hyperventilating - therefore blowing off CO2




What can a change from a low PCO2 to a normal PCO2 in somone having an acute asthma attack indicate?



The patient is tiring - initially hyperventilating, but now starting to retain CO2




How would you treat a mild/moderate asthma attack?


  • Oral prednisolone for 7 days - 0.5mg/kg/day
  • SABA reliever - up to 2 hrly
  • Assess within 24 hrs
  • Advise medical help if deteriorating




If you were treating someone in A&E for moderate asthma attack, when would you consider discharging them?



PEF > 75% predicted/best




How would you manage someone with acute severe asthma?


  • High flow oxygen - aim sats 94-98% (unless COPD aswell...)
  • Salbutamol - 5mg nebulised
  • Steroids - Hydrocortisone (100mg IV) or prednisolone (40-50mg PO) or both




If you were managing who was demonstrating life-threatening features of acute asthma, how would you manage them?

Inform ICU/seniors

  • SABA nebulisers - every 15 minutes
  • Steroids - Hydrocortisone (100mg IV) or prednisolone (40-50mg PO) or both
  • Add ipratroprium nebulisers - if initial ß2 agonist response is poor
  • If no response - single dose MgSO4 1.2-2g over 20 minutes

Investigations - ECG, ABG, CXR




When would you consider giving IV magnesium sulphate in acute asthma?



Immediately if very severe attack and if poor response to inital therapies




When would you consider giving IV aminophylline?



If poor response to initial therapy in acute severe or life-threatening attack




What is important to remember when thinking about when to give corticosteroids in an acute asthma attack?



The earlier in the attack it is given, the better the outcome




When would you use IV salbutamol?



When inhaled/nebulised therapy cannot be used reliably




What is the risk of using ß2 agonists with steroids?







When would you consider moving someone to ITU if they were having an asthma attack?


  • Worseing PEF despite treatment
  • Worsening hypoxia
  • Hypercapnia/rising PCO2
  • Falling pH
  • Exhaustion
  • Drowsiness/confusion
  • Respiratory arrest




When would you consider discharging someone who is recovering from an acute severe asthma attack?


  • Reduced ß2 agonist dose
  • Off nebulised drugs and on inhalers > 24 hrs
  • PEF >/= 75% predicted/best
  • Minimal PEF dirunal variation





If someone who you are treating for life threatening asthma shows signs of improvement within 15-30 minutes of treating them, how would you manage them?


  • Nebulised salbutamol ever 4 hours
  • Prednisolone - 40-50 mg PO OD 5-7 days
  • Monitor peak flow
  • Aim sats 94-98%




Under what circumstances would you consider admitting someone with acute asthma to hospital?


  • Features of life threatening/near fatal asthma
  • Features of severe attack after initial treatment




What severity of acute asthma should corticosteroids be given?



Should be given in all cases of acute asthma




How do antimuscarinic agents work?

Muscarinic antagoinists competitively inhibit cholinergic receptors on bronchial smooth muscle. They block the action of acetylcholine on the nerve endings therefore inhibiting the parasympathetic effect. This results in dilatation of the airways.




When would you consider giving ipratropium bromide?

Add nebulised to ß2 agonist for severe or life threatening asthma, or those with poor ß2 response





What class of drug does ipratroprium bromide fall under?







What are the adverse side effects of antimuscarinic medications?


  • Dilated pupils
  • Blurred vision
  • Dry mouth
  • Nausea
  • Constipation
  • Headache
  • Urinary retention / difficulty micturating
  • Tachycardia
  • Hypotension




What is the mnemonic you can use to determine if someone has life threatening asthma?

33, 92 CHEST

  • 33 - PEFR <33% predicted
  • 92 - Sats <92%
  • Cyanosis
  • Hypotension
  • Exhaustion
  • Silent chest
  • Tachycardia




What mnemonic can you use when thinking about the treatment of acute asthma?


  • Oxygen
  • Salbutamol (2.5-5mg) nebulised
  • Hydrocortisone (100mg) IV/Prednisolone (40mg) PO
  • Ipratroprium bromide (500mcg) nebulised
  • Theophylline infusion (1g in 1L saline 0.5ml/kg/h)
  • Magnesium sulphate (2g IV over 20 minutes)
  • Escalate care




What dose of salbutamol nebulisers would you give in an acute asthma attack, and at what rate?


2.5-5mg back to back nebulisers at 5-10 mg/hour




What dose of IV hydrocortisone would you give in an acute asthma attack, and at what frequency?


100mg - 6 hourly infusions




What dose of oral prednisolone would you give someone with an acute asthma attack, and how often would you give it?


40mg Orally - once daily




Why can you give oral prednisolone at longer intervals than IV hydrocortisone?



Prednisolone has a longer half life




What dose of ipratropium Bromide Nebuliser would you give someone having an acute asthma attack?


0.5 mg (500mcg) nebulisers - 4-6 hourly




If you were going to use theophylline as treatment for asthma, what dose would you use and what rate would you give it at?



1g in 1L saline - 0.5ml/kg/hr




If you were going to use IV magnesium sulphate to treat acute asthma attack, what dose would you use and what rate would you give it at?



2g over 20 minutes - one off dose before theophylline