Asthma

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

Pathophysiology of cardiac arrest in asthma

1. Hypoxemia
2. Obstructive shock (Tension pneumothorax secondary to volume trauma or barotrauma)
3. High pressure from Auto PEEP causes increases work of breathing
 Pharmacological
 Bronchodilators – continuous inhaled salbutamol with ipratropium via nebulisation every 20min for 1 hr
 1ml (5mg) salbutamol with 2ml ipratropium bromide and 2ml NS to make up to 5ml (121, 122 – variations in mixing w NS)
alternatively, 4 to 8 puff of salbutamol by metered dose inhaler or 2.5 to 5mg of salbutamol via nebs over 20min;
+ ipratropium 4 – puffs via MDI or 0.5mg via nebs over 20 min if severe
Paediatric dosing:
- 0.03ml/kg salbutamol diluted in 2ml of saline; repeat twice
 Steroids – 0.5 – 1mg/kg prednisolone PO (typically comes up to 30/40mg)
o Effect usually kicks in 4 – 6 hours later so give early (same principle applies for ipatropium, also thus don’t need to give ipatropium again in repeat nebs as previous one will be kicking
in now)
o No difference between IV and PO as effect is transcriptional i.e. works on DNA
 Reassess after 60 to 90min of treatment
 If mild to moderate exacerbation, continue SABA q 1hr
 If severe,
 Repeat nebs 2 – 3 times with salbutamol and ipratropium; pred or IV hydrocortisone 200 – 400mg +/-
 IV 1 – 2g MgSO4 over 30min * watch for hypotension (affects Calcium)
o Relaxes bronchial smooth muscle to increase pulmonary function (use as part of combined therapy)
 Adrenaline (use with caution if at all in elderly, IHD or severe HTN)
 Terbutaline (which is more beta 2 selective)
Disposition
 Decide the disposition within 4hrs of presentation and after 1 – 3 hrs of treatment , Do ABG in cases where you are worried if patient is going into Type 2 RF
o In asthma, you expect the hyperventilating patient to have a low CO2
o Thus, if CO2 is normal, patient is tiring out already so A NORMAL ABG IN AN ASTHMATIC IS NOT A GOOD SIGN
 Good response (PEF at least 70%, 90% O2 sat., no distress): Discharge
 Partial response (PEF 40 – 69%): Admit to ward
 Poor response (PEF < 40%): Admit to ICU

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)

Things that don’t fit

 Isolated cough without other respi symptoms
o Medication-induced cough, GERD, chronic upper airway cough syndrome (Post nasal drip)
 Paresthesia, giddiness/lightheadedness (associated with breathlessness)
o Hyperventilation/anxiety
 Chronic sputum production
o COPD, bronchiectasis
 Inspiratory wheeze
o Vocal cord dysfunction

Diagnosing airway obstruction

 Spirometry (FEV1/FVC < 0.7, as per COPD guidelines, 0.75 to 0.8 as per asthma GINA guidelines

Diagnosing airflow variability

  Increase in FEV1 post BD by 12% AND 200ml
o Or variability after 4 weeks of steroid treatment
o Or variability documented between clinic/hospital visits (less reliable)
 PEF (ask patient to do twice a day or many times and take highest and subtract lowest – average dirunal variability of PEF by > 10%)
 Provocation tests
o Basically reverse of the other 2 tests to make patient worse
o Either by exercise or metacholine which is a non-selective muscarininc receptor antagonist in the parasympathetic
o Sensitive but not specific (good to rule out but not to rule in i.e. other disease e.g. copd, cf can also cause)

When is ideal to test variability?

 Before start of treatment
 However of course don’t delay treatment for this

What if already been treated before?

 Either step up or step down ICS (Refer to GINA guidelines chart)

What if no variability in airflow?

 Medicated alr e.g. SABA 4hrs ago, LABA 12 hrs ago
 Really no variability? (another diagnosis)
 SEVERE asthma with fixed airflow limitation

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)

 Treatment (compliance, technique, WAAP, SE)

o Aims:
 Good symptom control
 Reduce future risk
 Reduce fixed airflow limitation
 Minimise SE
o Pharmacologically via stepwise approach
 Controllers vs relievers
 Bronchodilaters vs Corticosteroids
 LTRA (Less effective than ICS)
 Tiotropium (LAMA add in stage 4)
Google search Respi inhalers! – SABA (salbutamol), LABA (erols e,g, salmeterol, expecept fenoterol – SABA), SAMA (Ipratropium), LAMA (iums except ipratropium), USA for brand name
  Step 4 – SMART therapy (Symbicort Maintenance and Reliever Therapy), symbicort – budesonide and formoterol (ICS, LABA combinated but can be used for reliever and controller –
Formoterol is a FAST but long-acting
 Vaccinations (influenza, pneumococcal – in asthma only evidence for influenza but for COPD both)
o Non-pharmacological
 Disease education
 Smoking cessation
 Inhaler technique
 Trigger avoidance
 WAAP
How to initiate if 1st presentation

What if treatment is not working

 Compliance
 Technique
 Diagnosis
 Comorbids
 Triggers

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)