Asthma & Acute Breathlessness

Jenny Till

Respiratory Nurse Specialist

Cumbria PCT

Airways and lungs

Alveolar capillary bed

Asthma

“A disease characterised by variable dyspnoea due to widespread narrowing of the peripheral airways, varying in severity over short periods of time, either spontaneously or as a result of treatment.”

Asthma Triggers

Worsening Asthma Increased symptoms

Especially nocturnal symptoms Reliever medication less effective

Tend to use more frequently Exercise restrictions Very vulnerable to severe “attack” At risk of death: previous admission with

asthma or ongoing poorly controlled New presentation: consider inhaled FB

Signs of Severe Asthma Difficulty speaking Dyspnoea at rest > 25 breaths per min

Possible wheezePossible cough

Tachycardia at rest > 110 beats per min

Pulse oximetry < 96% at rest on air (PEFR < 50% of best / predicted)

Life Threatening Asthma

Poor respiratory effort / silent chestMay not appear distressed

Fatigue / exhaustion Agitation / reduced level of

consciousness Confusion Cyanosis Pulse oximetry < 92% at rest on air

Treatment of Acute Asthma High dose bronchodilators

2.5mg neb salbutamol or Spacer (up to 10 puffs salb)

Oral steroids40 – 50mg for 5 days

OxygenIf O2Sats <92%Aim to raise to at least 95%

Call for medical assessment

Treatment of Acute Asthma

Review every 15 minsRepeat bronchodilators if poor response (PEFR

50-75% pred)Salb 5mg & add ipratropium 500mcg (spacer 8

puffs ipratropium) Referral to hospital

Consider if PEFR < 75%, late in the day, previous severe attack

General concern or poor response to treatment

Follow up of patients

All should be followed up within 48 hoursEnsure patients not admitted have

clear instructions about when to call for help

Bronchodilator not lasting 4 hours, increased symptoms again, PEFR 50-70%

COPD

“Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.”(NICE 2004)

Airways and lungs

Emphysema: a result of the air sacs being “dissolved away”and also less Support for theairways

Alveoli

Alveolar capillary bed

Is it asthma or COPD?

UncommonCommonSignificant diurnal or day to day variation in symptoms

UncommonCommonNight time waking with breathlessness and / or wheeze

Persistent and progressiveVariableBreathlessness

CommonUncommonChronic productive cough

RareOftenSymptoms under 45 yrs

Nearly alwaysPossibleSmoker or ex-smoker

COPDAsthma

Assessment of acute COPD

Breathlessness at rest? Rapid deterioration / exhaustion? Cyanosis? Acute confusion? Worsening swollen ankles? Significant comorbidity?

Cardiac or diabetes Ability to cope at home? Pulse oximetry (< 90% usually admit)

Management of COPD exacerbation Salbutamol

2.5mg neb (4 – 8 puffs spacer) Oxygen (usually 24% – 28% - 40%)

Maintain sats between 90 – 93% Consider prednisolone (30mg 7-14 days) Consider antibiotics (usually amoxycillin) Consider an ECG

if suspecting cardiac comorbidity New home care service next year?

Acute Breathlessness Acute asthma Anaphylaxis Acute COPD Pneumonia Anxiety – hyperventilation Heart disease

Angina, MI, LVF / pulmonary oedema Pulmonary Embolism Pneumothorax

Spontaneous & post injury Inhaled foreign body / bronchial cancer Diabetic Ketoacidosis

SOS Admit to hospital

Severe chest pain Cyanosis Acute confusion Loss of consciousness Abnormal vital signs

Particularly severe breathlessnessOr exhaustion as a result

Information gathering

Precipitating factorsTime course

Presenting symptoms / signs Associated symptoms Allergies Medications

Chemist / herbal / illicit drugs General health

Presenting signs / symtoms

Onset & timing? Anything make it worse / better? Intermittent / persistent? Exercise tolerance

Normal & now Worse at night? Worse lying flat?

Equipment

Pulse Oximeter MDI & Spacer Oxygen

Oxygen Saturation (SaO2)

Oxygen carried in bloodstream bound to haemoglobin (& small amount in plasma)

1 Hb can carry 4 O2 = 100% saturated

Pulse oximeter measures the average % saturation of haemoglobin in sample

Pulse Oximetry

Measures light absorbed by haemoglobin in blood When oxygenated – red frequency When deoxygenated – blue frequency

Needs to record pulsatile blood flow to ensure arterial blood

Normal values = or > 97% Hypoxia = or < 96% Significant hypoxia < 92%

Pulse Oximetry – problems / limitations Poor perfusion

Vascular disease, vasoconstriction, (cold hands), irregular heart rhythms, severe shock –may give falsely low readings

Nail varnish – falsely low readings Carboxyhaemoglobin – very bright red – SpO2

readings will be falsely higher Anaemia – will give falsely high readings

Less haemoglobin, less O2 carried SpO2 cannot determine CO2 Levels or actual O2

levels