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Definition

Asthma is a chronic inflammatory condition of the airways that is characterized by variable and recurring symptoms, bronchial
hyper-responsiveness and airflow limitation that is often reversible with the use of bronchodilators.
What in the history to elicit
Complaint:
Asymptomatic, nocturnal cough, cardinal features of acute exacerbation: i) cough ii) SOB iii) wheezing iv) chest tightness;
briefly take a history of presenting complaint
Assess severity of exacerbation: i) speaking in words, phrases, sentences ii) SOB at rest, talking or walking iii) able to lie
down, sit up or hunched forward
Any attempted treatment at home: rescue therapy (how many puffs) and whether followed written asthma action plan
Any triggers: URTI, dust/pets/pollen, smoke/construction, cold/stress/emotion/exercise, NSAIDs/beta blockers, non-
compliance
Cause
Exclude other causes of acute onset cough/SOB/chest-tightness/wheezing: ASK IF SYMPTOMS ARE SIMILAR TO THE
PREVIOUS ATTACK
- Pneumonia fever/chills/rigors/sputum production/recent travel/contact hx
- Pneumothorax sudden onset pleuritic chest pain, trauma
- Cardiac Wheeze history of CCF, PND, orthopnea, LL swelling, chest pain/palpitations/N/V
- Exclude foreign body ingestion in a child
Establish patient has a formal diagnosis of asthma: ask if symptoms are similar to previous episodes
Course (Control and Severity)
When was asthma diagnosed: childhood (think more extrinsic), adulthood (think more intrinsic)
How was it diagnosed initial presenting symptoms (ask about any childhood history of recurrent wheeze/bronchiolitis),
personal history of atopy (eczema, AR, conjunctivitis), family history of atopy, investigations spirometry, skin prick test (to
look for allergens)
What is control like:
- Frequency of exacerbations: >1x/year, >1x/week, none
- Daytime symptoms: <2x/week, >2x/week
- Use of bronchodilators: <2x/week, >2x/week
- Night-time symptoms: present, none
- Limitation in activity: present, none
- PEF or FEV1: <80% predicted/personal best, normal
- Asthma control test: how often do you have SOB/wake up at night/use your reliever/keep you from work or school;
how would you rate your asthma control (<20 = poor control in last 4 weeks)
What is severity like: how often requires A&E visits/admission for exacerbation, any ICU stay, any intubations before,
describe a typical exacerbation: tempo, typical management, rate of recovery
What is current management: allergen avoidance, relievers, preventors: dose, administration route, compliance, adverse
effects, technique, before exercise, any recent changes in medications, asthma action plan
Complications
Acute: as above respiratory failure requiring intubation and ICU, pneumothorax
Chronic: Limitation of physical exercise, lack of sleep due to nocturnal cough, impact on work/school
Medications: skin atrophy/bruising, thrush, osteoporosis, cataracts, diabetes mellitus, HTN
Care
Any smoking (if teenager and smoking, ask for more information how they obtain cigarettes, parents aware, tried to stop,
peer company who also smoke, does smoking worsen asthma), any second hand smoke
Vaccinations influenza, pneumococcal, recommended vaccines according to Singapore schedule
Home environment: carpets/rugs, how often wash bed-sheet/pillow-cases/clean house, construction/upgrading
Impact on work, child, family (especially finances); support groups

P/E: confirm diagnosis, assess severity & evaluate complications (respiratory failure, pneumothorax, secondary LRTI)
Ability to speak in words/phrases/sentences
Breathless on walking/talking/at rest; Ability to lie down/sit up/hunch forward
Respiratory rate: increased >30 decreased
HR: <100 100-120 >120 bradycardia
SpO2: >95% 91-95% <91% clinically cyanosed
Mental status: alert agitated obtunded
Use of accessory muscles of respiration
Wheeze: moderate, only end-expiratory loud, throughout exp loud through insp and exp absence of wheeze (silent)
PEF after bronchodilator: >80% of pred/best 60-80% <60%
Risk factors
Smoking in the family
Atopy allergic rhinitis, conjunctivitis, eczema: personal history and family history
Triggers: Exercise induced, Recent infection (URTI), New construction sites near home, Pets in the family, *Any change in
environment recently*
Complications
Of disease Of medications
Acute: Status asthmaticus (acute exacerbation of asthma that Beta agonists Inhaled corticosteroids
does not respond to standard treatments bronchodilators or Tremors, hypokalemia Oral candidiasis
steroids) airway compromise, Previous hospitalization and
ICU stay needing intubation (respiratory failure) Monoclonal antibodies Systemic steroids
(immunotherapy) Cushings syndrome
Chronic: Limitation of physical activity, work, affecting sleep, Expensive osteoporosis, skin
growth issues atrophy/bruising, HTN, DM

How to diagnose
Through history and Lung Function Test/PEF
Spirometry: Improvement of >12% in FEV1 after bronchodilators (latest GINA)
Peak Expiratory Flow: Improvement of >20% after use of bronchodilators or diurnal variation of >20%
Metacholine or histamine challenge test if LFT/PEF normal, but patient has consistent symptoms and signs
Skin prick tests or specific IgE tests can help identify risk factors that cause asthma
How to manage
Multidisciplinary approach respiratory physician/ allergist, asthma care nurse

Acute Management in Adult:


Maintain SpO2 >/= 95% (nasal prongs, face mask): inform senior if have to increase O2 beyond low-flow NP 2-3L
Intensive bronchodilator therapy
Nebs salbutamol:ipratropium bromide:N/S (1ml:2ml:1ml stat and every 4-6 hourly depending on severity. Up to 3 stat nebs
can be given to break bronchospasm if no contraindications. Beware of higher frequency of nebs in elderly) Note: 1ml of
salbutamol = 5mg
If neb not available, MDI with spacer: 4 puffs salbutamol (0.1mg/puff) + 4 puffs atrovent (20mg) q15 minutes for 1 hour to
be repeated 2-4hrly cycles
Steroids (Mod-Severe attack): Oral prednisolone 30mg STAT OM, IV hydrocortisone 100mg STAT Q6hrly (if unable to
tolerate orally)
Reassess patient frequently PRN to monitor clinical response
KIV IV MgSO4 2g over 20 minutes
KIV short acting theophylline if not already on theophylline, if on theophylline have to measure serum concentrations 1st
KIV intubation if severe (if patient unwell, does not respond to treatment, impending respiratory arrest, mental
obtundation/AMS, hemodynamic instability inform senior)

Acute Management in Child:


Maintain SpO2 >/= 95% (nasal prongs, face mask): inform senior if have to increase O2 beyond low-flow NP 2-3L
Intensive bronchodilator therapy
Nebs salbutamol:ipratropium bromide:N/S (0.03ml/kg) + ipratropium bromide (1ml for all >1yo, 0.5ml for <1yo) dilute to 4ml
with N/S every 4-6hrly depending on severity. Up to 3 stat Nebs can be given to break bronchospasm if no contraindications
If nebs not available, MDI with spacer: 0.3puffs/kg (max 10 puffs, pause 30 seconds between puffs), q4-6hrly according to
severity
Steroids (Mod-Severe attack): Oral prednisolone 1mg/kg STAT OM, IV hydrocortisone 5mg/kg/dose Q6hrly (if unable to
tolerate orally)
Reassess patient frequently PRN to monitor clinical response
KIV IV MgSO4 25mg/kg in 100ml N/S over 20 min
KIV IV aminophylline (phosphodiesterase inhibitor: increases cAMP) 5mg/kg if not previously on theophylline and no C.I.
KIV intubation

Chronic Management:
Patient education about disease, treatment, compliance especially inhaler/spacer technique, pre-exercise reliever, written
asthma action plan
Allergen avoidance: pollutants/dust/pet fur, trigger-avoidance
Smoking cessation
Immunization: influenza, pneumococcal
Pharmacological therapy:
o Step 1: Short-acting inhaled beta-agonist as required
o Step 2: + Low-dose steroid inhaler (fluticasone, budesonide)
o Step 3: Long-acting beta-agonist (symbicort = formoterol + budesonide; seretide = salmeterol +
fluticasone) and low-dose ICS OR change to high-dose ICS
Symbicort Dry powder inhaler, rapid onset of action (within 5 minutes)
Seretide Dry power / Evohaler, onset of action (30 min)
o Step 4: Increase steroid inhaler further +/- leukotriene receptor antagonist / theophyllines
o Step 5: Oral steroids +/- anti-IgE treatment (only under care of a respiratory physician)
Step up therapy if uncontrolled, if controlled, maintain for 3/12, step down therapy gradually
Monitor for complications of treatment

Salbutamol (ventolin); Fluticasone evohaler/accuhaler (flixotide); Budesonide turbuhaler (pulmicort)

Symbicort turbuhaler: budesonide + fometerol = short onset 5 minutes

Seretide evohaler / dry powder (accuhaler): fluticasone +


salmeterol = longer onset 30 minutes

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