Beruflich Dokumente
Kultur Dokumente
Bronchial hyperreactivity due to airway inflammation results in at least 2 of the following 4 symptoms of dysnpea, wheezing and cough and chest tightness and respiratory signs of prolonged expiratory phase, rhonchi,
crepitations and reduced air entry.
Severity
Mild Moderate Severe Respiratory arrest imminent
Breathlessness While walking While talking While at rest Feeble respiratory effort
Speech Speaks in sentences Speaks in phrases Speaks in words Hardly able to talk
Mental state Usu. agitated Usu. agitated Usu. agitated Drowsy or confused
RR Increased Increased > 30 breaths/min Decreased
Use of accessory muscles - + ++ Paradoxical thoracoabdominal
Wheeze Moderate, often only end Loud, throughout expiratory Usually loud throughout inspiration No wheeze i.e. silent chest
expiratory and expiration
HR < 100 100 - 120 > 120 Bradycardia
O2 sat > 95% 91 – 95% < 91% Clinical cyanosis
PEF after initial bronchodilator or % > 80% 60 – 80% < 60% or response lasting < 2hrs
predicted or % personal best
Control
Controlled Partly controlled Uncontrolled
Daytime symptoms < 2x/wk > 2x/wk > 3 features of partly controlled asthma
Nocturnal symptoms/awakening None Any
Limitation of activities None Any
Need for reliever/rescue treatment <2x/wk >2x/wk
Lung f(x) = PEF rate/FEV1 Normal < 80% predicted or personal best
Exacerbations None > 1/yr 1 in any wk
Investigations
Not indicated in most cases and guided by clinical assessment
CXR indicated in patients not responding to intial therapy – TRO pneumothorax, pneumonia, congestive cardiac failure
ABG in severe asthmatic exacerbations – looking for hypercarbia (ominous sign!) and hypoxia
FBC and RP – looking for hyperK+ due to nebulised salbutamol whichs stimulates K+ entry into cells
Management
If symptoms of life-threatening asthma are PRESENT: (if absent, skip supportive management and go straight to pharmacological therapy
Supportive
ABCs – secure airway, administer supplemental oxygen, IV access 500ml crystalloid over 3 – 4 hrs
Monitor with ECG, pulse oximetry, vital signs
Triggers
Classify into infective (usually viral with possibly superimposed bacterial, pneumonia) and non-infective
Non-infective:
Phenotypes
Allergic
Non-allergic are less able to repsond to ICS
Late onset (e.g. in a 50y/o aunty with no previously known asthma) also be less able to respond to ICS hence need higher doses
Asthma with fixed airlow limitation (due to recurrent exacerbations with fixed airway remodelling)
Assessing asthma
Asthma control
o Symptom control (does not correspond to future risk, symptoms are very variable)
Use GINA table for long case
In Sg, we use the ACT
o Future risk
Previous intubation or ICU
Severe exacerbation in the past year
Inadequate ICS use
High use of reliever
Major pscyh or socioeconomic problems
Smoking/ exposure
Pregnancy
Low FEV1
o Severity is not control (assessed retrospectively)
IMPORTANT when examiner asks you what if treatment at Step 2 fails – don’t jump to say step up to Step 3!
Adult Long Case will ask you to differentiate between asthma and COPD
GINA has a table to differentiate (more likely to be…)
Also note Asthma copd overlap – not a single disease, treat as per asthma (treat early w steroids)
Inhaler technique
Remove cap, shake canister
Kiv spray into air to make sure it works
Breathe out first – empty lungs first to take in as much as possible
Seal lips around mouthpiec
Deep breath in while simultanoeusly pressing
Hold breath for iCS
Gently exhale
Wait for 30s before nex
Rinse mouth after ICS
If patient’s technique v poor, suggest spacer – requires priming (was w warm soapy water, spray 10 puffs whent dry to prime)