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Asthma (Primary Survey: (Breathing (RR, SpO2, Provide oxygen via facemask,…
Asthma
Primary Survey:
Circulation: HR, BP, cap refill, 2x IV cannula, bloods (FBC, UEC, VBG/ABG)
Breathing
RR, SpO2
Provide oxygen via facemask
Nebulised salbutamol +/- ipatropium bromide
Disability: GCS/AVPU, pupils, BGL
Airway: is the airway patent?
Exposure: temp
DRS: assess ability to respond in sentences/words/struggling to speak --> indicates severity
Investigations:
Acute exacerbation
ABG if severe exacerbation
CXR if focal signs or if severe exacerbation
Sputum culture (if suspecting infection)
Diagnosis
CXR
May be normal; hyperinflation
PEF
Variability of 20% in serial measurements or diurnal variation (normal <15-20%)
Spirometry
Bronchodilator reversibility > 12%
FEV1/FVC < 1
Tests to consider: FBC (eosinophilia), allergy testing, bronchoprovacation test
Acute Management:
Mild/moderate
4-12 puffs of salbutamol via MDI and spacer, repeat every 20 minutes x3
Severe (SaO2 < 94%, accessory muscle use, unable to complete sentences)
12 puffs of salbutamol via MDI and spacer, repeat as needed w/ minimum of above
If unable to use spacer: 5mg salbutamol nebulised
Life-threatening (SaO2 < 90%, exhaustion, reduced LOC)
2x 5mg nebulised salbutamol
Maintain O2 > 92% (adult), > 95% (paeds)
ICU/HDU admission
Consider need for ipatropium bromide, IV magnesium sulfate, IV salbutamol, NIPPV
Corticosteroids
Given regardless of severity, within 1 hour of presentation
oral prednisone OR IV hydrocortisone
Long Term Management:
Add long term inhaled steroid (fluticasone) PLUS above
Add a long term bronchodilator (salmetarol) PLUS above
Short acting bronchodilator (salbutamol) PRN
Titrate doses of above medications upwards
At each step evaluate ICE: Inhaler technique, compliance and environment
Other medications:
Muscuranic agonisits (short acting e.f. ipratropium bromide and long acting e.g. tiotropium bromide): act on M1, 2 & 3 receptors to bronchodilate and reduces mucus secretion
Xanthine e.g. aminophylline, theophylline: increase muco-ciliary clearance and central respiratory drive
Mast cell stabiliser e.g. cromoglycate
Leukotrine antagonist e.g. monteleukast
Monoclonal antibody IgE e.g. omalizumab
Pathophysiology:
Trigger --> activation of Th2 mediated immune response --> accumulation of plasma cells, mast cells and eosinophils --> inflammatory molecules (e.g. histamine, prostaglandins, leukotrines) drive bronchial hyper-responsiveness, bronchoconstriction, increased mucus production and decreased muco-ciliary clearance
Overtime: damage to epithelium and submucosa --> activation of myofibroblasts --> remodelling of collagen matrix --> muscle hypertrophy --> further narrowing of airway
Definition:
A chronic inflammatory obstructive airways disease, characterised by inflammation, hyper-responsiveness and reversible airflow obstruction
Clinical Features:
Presents with intermittent episodic clinical syndrome of cough, wheeze, chest tightness and SOB.
O/E: Expiratory wheeze, hyper-inflation, signs of allergic rhinitis (sneezing, runny nose, dark circles under eyes)
Risk Factors: Atopy, FHx, smoking, abnormal lung function, female, obesity, only child, late day care, pets in childhood
Triggers: Time of day (at night or early morning), cold air, exercise, dust, pollen, virus