SABA examples
- Salbutamol
- Terbutaline
- Levalbuterol
- Perbuterol
- Albuterol
How do you treat an acute exacerbation?
Inhaled SABA along with ipratropium bromide (anticholinergic) provide best bronchodilation.
What is SBAR assessment?
Handover of patient care Situation Background Assessment Recommendation
Process for identifying a CXR
Rotation - spinous process should be at midpoint between 2 ends of clavicles
Inspiration - 5-7 ribs anteriorly, 8-10 posterior
Penetration - if can see the vertebral bodies
Airway - trachea
Breathing - lung fields, lung markings, hilum, lymph nodes, shadowing or spots
Cardiac - heart size (PA <50%), look at borders
Diaphragm - right side is higher due to liver, costophrenic angles, gastric air bubble under left, calcification indicates asbestos
E - medical intervention, look behind heart and if 2 lines like a sail could be left lobar collapse, bones
What is and how to treat mild asthma?
- Symptoms >2/week, 3-4/month for night symptoms
- FEV1 >80%
- SABA PRN and low dose ICS
What is and how to treat moderate asthma?
- Symptoms 7/week, 1+/week night symptoms
- FEV1 60-80%
- SABA PRN + medium dose ICS or low dose ICS and LABA
What is and how to treat severe asthma?
- Symptoms throughout everyday
- Symptoms through every night
- FEV1 <60%
Treatment:
1. SABA PRN + med dose ICS + LABA
2. SABA PRN + high dose ICS + LABA
3. SABA PRN + high dose ICS + LABA + oral corticosteroids
LABA examples
- Salmeterol
- Formoterol
NEVER give without an ICS and NEVER for acute exacerbations
Corticosteroid examples
Inhaled: - Fluticasone - Budenoside - Mometasone Oral or IV: - Methylprednisolone - Prednisolone - Prednisone
What are mast cell stabilizers?
e.g. cromolyn sodium
Good for exercise or cold-induced asthma. Inhibit the release of histamine by mast cells and inhibit activation of eosinophils.
What are leukotriene receptor antagonists?
e.g. montelucast
Binds and inhibits leukotriene receptors, preventing bronchospasm and mucus production
Name an anti-IgE drug
Omalizumab
When should patients be admitted with a severe asthma attack?
- all patients with life-threatening should be admitted in hospital
- patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment
- previous near-fatal asthma attack
- pregnancy
- an attack occurring despite already using oral corticosteroid and presentation at night
When do you use oxygen therapy?
- if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
- if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.
What vaccinations should be given to asthma patients?
- Flu vaccine annually
- One-off pneumococcal vaccine
Acute asthma exacerbation and B2 agonists
- First-line give high-dose inhaled B2 agonists
- IV B2 agonists for those where inhaled cannot be used reliably
- In severe or life-threatening asthma a nebuliser (oxygen driven) is recommended
- Can add nebulised ipratropium bromide with severe or life-threatening or with poor response to only B2 agonist
- IV magnesium sulfate if bad initial response
Acute asthma exacerbation and steroid therapy
Give to patients with any type of asthma attack. Continue prednisolone for 5 days after/until recovery.
Discharge after exacerbation
Prednisolone for at least 5 days
Assess inhaler techniques
Self-management - triggers and what to do
Follow-up appointment at GP within 2 days
Resp specialist follow-up for at least 1 year with severe asthma attack
Side effects of B2 agonists
Tremor
Tachycardia
Hypokalaemia
Restlessness
What is the initial management of an asthma exacerbation?
- Sit patient up
- Give high flow oxygen
- Nebulised B2 agonists every 15 mins
- Nebulised ipratropium (repeat every 4 hours)
- Steroids - prednisolone (40mg) or hydrocortisone (100mg)
- If not responding - magnesium (1.2-2g IV over 20 mins) or consider IV aminophylline or B2 agonists
