Asthma

Image credit: Patient Care Technician

Asthma

Oct 11, 2015 0
General medicine,onthepods,respiratory

James talks to Associate Professor Keith Wong about the presentation and management of asthma on the wards.

Summary Writer:  Elizabeth Campbell

Editor:  James Edwards

Interviewee:  Keith Wong

About Keith Wong

Keith Wong is a staff specialist in the Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital. His research interests include interventions to optimise the management of sleep disorders, monitoring of asthma control, and inhaler delivery of medications in asthma.

Keith has research collaborations with the School of Pharmacy at the University of Sydney, the Woolcock Institute of Medical Research, and the Brain and Mind Research Centre. In addition, he is a researcher with the Sleep and Circadian Research Group at the Woolcock Institute of Medical Research. Keith is a Clinical Associate Professor for the Central Clinical School at the University of Sydney.

Asthma

With Associate Professor Keith Wong, Respiratory Physician at Royal Prince Alfred Hospital, New South Wales, Australia.

Introduction

Asthma is a common presentation to the emergency department, but it can also occur on the ward.

Case

A 29-year-old woman is admitted to the surgical ward following a fractured radius in a fall from a bicycle.  She is for surgery tomorrow.  You are called by the nurse at 10pm, as the patient is complaining of shortness of breath.  She is charted for salbutamol BD, which she has already used with little relief.

  • Considering the possible underlying diagnoses: the patient has been charted salbutamol so may have asthma. Other causes for dyspnoea could include allergic reactions to medication, or a pneumothorax caused in the fall. Given the patient’s young age, cardiac causes and pulmonary embolism are less likely
  • To determine how urgently this patient needs to be reviewed, ask questions to assess how unwell she is: What are the observations? Has she been febrile? How much oxygen is she receiving?
  • What has been given so far? A phone order for salbutamol may be appropriate. If the patient is hypoxic, ask for the nurse to commence supplemental oxygen
  • Initial approach:
    • Look from the end of the bed
    • ABC assessment: breath sounds, wheeze, respiratory rate, saturations, use of accessory muscles, signs of heart failure, blood pressure, oxygen saturations, and heart rate
  • History:
    • Current episode: how and when did it start? Were symptoms present prior to admission?  Were there infective symptoms?  What treatment has already been commenced (e.g. antibiotics, steroids, bronchodilators)?
    • Underlying disease: when was asthma diagnosed? Is there a history of atopy, or family history of asthma?
    • Asthma control: how frequently are bronchodilators needed? Do symptoms occur at night and wake her from sleep?  How frequently have exacerbations occurred?  Have there been emergency presentations or hospital admissions?  Has she required intensive care treatment?
    • Usual therapy and compliance: maintenance therapy, PRN medications
    • Smoking history
    • Important to consider other differentials
  • Examination:
    • Observations, temperature
    • Use of accessory muscles, check trachea is midline, chest wall bruising and tenderness
    • Auscultate for wheeze
    • Any response to therapy so far?
  • The need for investigations will depend on how well the patient has responded to the initial treatment
  • Chest x-ray: pneumothorax, infections
  • Spirometry is useful, but may be impractical at night. Important at some point during the admission to determine degree of obstruction
  • Peak flow: useful in day-to-day monitoring, but would require baseline measurements in order to determine if there has been deterioration in lung function
  • Arterial blood gases: not routinely required in a mild presentation, but important in more severe asthma presentations (e.g. drowsiness, increasing or very high oxygen requirements)
    • If you do an ABG, do not take the patient off oxygen
    • Normocapneoa (normal pCO2) can be a warning sign in severe asthma – we would expect a low pCO2 if the patient is breathing up
    • Hypercapneoa is a very late sign
  • Patient is speaking in sentences and doesn’t appear distressed: mild
  • Use of accessory muscles and speaking short sentences: more severe
  • Becoming drowsy, desaturating and looking unwell at the end of the bed: life-threatening
  • What is the best route for salbutamol? The general guidelines recommend a metered dose inhaler (6-12 puffs) with a spacer, rather than a nebuliser.  It is important the MDI is applied correctly, and this can be challenging if the patient is distressed
  • If the patient is unable to use the inhaler and spacer herself, shake the inhaler and deliver a dose via the spacer and ask the patient to take four tidal breaths. Repeat this 6-12 times.  This can be quicker than using a nebuliser
  • Repetition depends on the response: the patient may need repetition in 20 minutes, or hourly, or two-hourly
  • Is there a role foratrovent (ipratropium bromide)? Not routinely required, except if there is no response to salbutamol
  • Steroids: if necessary, oral steroid course may be required for 5-10 days, with no need for tapering. IV steroids would only be required if they needed to be NBM
  • Opportunity to review her asthma management during this admission, appropriate to review inhaler technique, discuss with asthma educator regarding symptom recognition, smoking cessation if necessary, consider starting a preventer
  • Implications for theatre and anaesthesia tomorrow; important to inform anaesthetist, give regular bronchodilators and continue oral steroids. If it was an elective procedure, it would be appropriate to postpone
  • An interim asthma management plan may be appropriate: simple advice on how and when to seek therapy
  • Ensure the patient is well (particularly at night and not hypoxic) before sending home
  • Ensure social supports are adequate
  • Important to consider starting a preventer while in hospital – and ensure the patient knows how to use the new device
  • Control needs to be reviewed with GP
  • If there has been a significant flare-up during admission, if there is any doubt in the diagnosis, or if there are risk factors for symptom recurrence (eg. frequent exacerbations, poor symptom recognition) a follow-up with a respiratory physician is appropriate
  • This is a severe asthma, and this patient can deteriorate rapidly
  • ABC assessment
  • Supplemental oxygen to maintain saturations above 90%, back-to-back bronchodilators
  • Very close observation: if not improving, may require ICU admission
  • Role of non-invasive ventilation? This would not be appropriate on the ward if there was elevated pCO2.  This patient is more likely to require ICU admission and intubation
  • Asthma is a very common disease that is treatable. Unfortunately, 400 people per year die from asthma, so we need to look out for it
  • If a patient has symptoms of asthma while in hospital, this is an opportunity to review his or her asthma management and ensure an adequate plan is in place
  • There are many resources available to help you treat acute asthma, as well as for GPs

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Tags: #allergic reactions,#asthma,#breathing,#dyspnoea,#inhalers,#pneumothorax,#respiratory medicine,#salbutamol,#shortness of breath,#spirometry

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