Respiratory Topics

1
Respiratory Topics

• Sarah Davey
• SpR Emergency Medicine
• Pinderfields General Hospital.

2
Objectives

• Review of acute asthma management using British
  Thoracic Society guidelines.
• Overview of COPD management including metered
  oxygen therapy.
• Role of Non-invasive Ventilation.
• Safe discharge and appropriate follow up.

3
ACUTE ASTHMA

• Illustrate management of acute asthma using case
  examples.
• 4 groups.

4
Case 1.

• 35yr male.
• Known asthma usually well controlled.
• On salbutamol and becotide.
• Normal PEF 420.
• Unwell for 3/7 with inc. SOB, dry cough and
  general malaise.
• HR 70bpm, RR 18, Sats 96 (air), PEF 320.

5
Mild Exacerbation.

• Increased symptoms.
• PEF gt 75 best/predicted.
• Give usual bronchodilator and observe.
• If PEF remains gt75 best discharge with
  appropriate follow up.
• If PEF deteriorates reassess as for moderate
  exacerbation.

6
Case 2.

• 37yr female.
• Known asthmatic on salbutamol and becotide.
• Well controlled PEF 420.
• Unwell for 3/7 with SOB, cough and general
  malaise.
• HR 100bpm, RR 22, sats. 94 (air), PEF 210.

7
Moderate exacerbation

• PEF gt 50-75 best/predicted.
• No features of acute severe asthma.
• Nebulised bronchodilator PEF pre and post.
• Observe.
• If PEF _at_ 1hr gt 75 best consider discharge with
  steroids and appropriate follow up.
• If PEF lt 75 best consider repeat Neb with
  reassessment as above.

8
Case 3.

• 22yr male.
• Known asthma.
• ? Current Tx. Predicted PEF 580
• Unwell 3/7, SOB, dry cough and malaise.
• HR 130bpm, RR 28, sats 94 (air), PEF 260

9
Severe Exacerbation.

• Any of
• - PEF 30-50 best.
• - Resp rate 25/min.
• - HR 110/min.
• - Inability to talk in sentences.
• Nebulised bronchodilator with review if not
  improvement further neb with prednisolone and
  further review.
• Consider discharge if symptoms settle and PEF gt
  75 best after 1hr.
• If PEF gt 50 best at 2hrs with no signs of severe
  asthma consider discharge with oral steroids and
  appropriate follow up.
• If patients develops worsening symptoms treat as
  life threatening.

10
Case 4.

• 28yr female.
• Known asthma taking salbutamol and serevent
  inhalers.
• 3/7 history of increased SOB, dry cough and
  malaise.
• HR 60bpm, RR 60, Sats 90 (15l), appears
  confused.

11
Life Threatening Exacerbation.

• Any of following in patient with severe asthma
• - PEF lt 33 best.
• - Sats lt 92.
• - PaO2 lt 8kPa.
• - normal PaCO2 4.6 -6.0 KPa.
• - Silent Chest.
• - Cyanosis.
• - Feeble Resp. effort.
• - Bradycardia/arrhythmia.
• - hypotension.
• - exhaustion.
• - Confusion or coma.

12
Life Threatening Treatment.

• Seek Senior / ICU help.
• Oxygen high flow.
• Nebulised Bronchodilators
• - salbutamol 5mg consider giving rpt bolus
  or
• continuous if poor
  initial
• response.
• - add ipratropium bromide (atrovent) 500mcg
• if acute severe or poor initial
  response.
• Steroid therapy prednisolone 40-50mg po or
• hydrocortisone 100mg IV.

13
Life Threatening Treatment Cont.

• Magnesium Sulphate consider if
• - Severe asthma without response to initial
  treatment with bronchodilators.
• - Life threatening or near fatal asthma.
• - 1.2 2.0g IV over 20m
• Aminophylline
• - unlikely to produce additional benefit.
• Antibiotics routine prescription not indicated.

14
Admission?

• Any feature of life threatening or near fatal
  asthma at presentation.
• Any feature of severe asthma after initial
  management.
• Patients where PER gt 75 best _at_ 1hr may be
  discharged unless
• - significant symptoms.
• - concerns re compliance.
• - lives alone.
• - prev near fatal or brittle asthma.
• - exac. Despite pre-prescribed adequate
  steroid therapy.
• - presentation at night.
• - Pregnancy.

15
ICU ?

• Severe/life threatening asthma failing to respond
  to treatment.
• Deteriorating PEF or hypoxia.
• Increased PaCO2.
• Fall in arterial pH.
• Exhaustion or feeble resp. effort.
• Drowsiness or confusion.
• Coma or resp. arrest.

16
Investigations.

• Mild/Moderate oxygen sats and PEF pre and post
  treatment.
• ABG if initial sats lt92.
• - Repeat only if initial Pao2 lt8kPa,
  initial PaCO2
• normal or raised.
• - Patient condition deteriorates
• CXR if suspect Pneumothorax, Pneumonia,
  Failure
• to response to treatment, features
• of life threatening asthma, requires
• ventilation.

17
Discharge

• PEF gt 75 best/predicted.
• Not met criteria for admission.
• Trained staff given appropriate education
• - inhaler technique checked.
• - PEF record keeping.
• - symptom based action plan.
• Ensure appropriate follow up
• - Inform GP of attendance within 24hrs.
• - Formal GP or asthma nurse follow up within 2
  
• working days.
• - Follow up with hospital asthma nurse or
  resp.
• consultant within 1 month.

18
Acute Exacerbation of COPD.

• Acute onset sustained worsening of symptoms
  beyond normal day to day variations.
• Symptoms include
• - Increased dyspnoea.
• - Increased sputum purulence and volume.
• - Increased cough.
• - Upper airway symptoms e.g. sore throat.
• - Increased wheeze.
• - Chest Tightness.
• - Reduced exercise tolerance and fatigue.
• - Confusion.

19
Causes of COPD Exacerbations.

• Infection
• - Bacterial inc. C. pneumoniae, H.
  influenzae,
• S. pneumoniae, M. catarrhalis,
• Staph. Aureus, P. aeruginosa.
• - Viral inc. Rhinovirus, Influenzae,
• parainfluenzae, Adenovirus, RSV.
• Pollutants Nitrogen Dioxide, particulates,
  Sulphur
• dioxide ozone.

20
Differential Diagnosis.

• Pneumonia.
• Pneumothorax.
• LVF/Pulmonary oedema.
• PE.
• Lung Carcinoma.
• Upper airway obstruction.
• Pleural effusion.
• Recurrent aspiration.

21
Assessment of Severity.

• Signs of severe exacerbation include
• - Marked dyspnoea.
• - Tachyopnoea.
• - Purse lip breathing.
• - Use of accessory muscles at rest.
• - Acute confusion.
• - NEW onset cyanosis.
• - NEW onset peripheral oedema.
• - Marked decline in activities of daily
  living.

22
Investigations.

• CXR
• ABG with documentation of O2 concentration.
• ECG
• FBC, UE,(Theophyline levels if taking normally).
• Sputum culture if purulent.
• Blood culture if pyrexial.

23
Treatment

• Metered O2 therapy.
• Inhaled Bronchodilators.
• Steroid Prednisolone 30mg od for 7-14days.
• Antibiotics.
• Theophylline.
• Non-Invasive Ventilation.

24
Metered O2 Therapy.

• Aim is to prevent life threatening hypoxia.
• Keep O2 sats gt90 without exacerbating
  hypercapnia or respiratory acidosis.
• Use Venturi system to control oxygen delivery.
• Caution some patients respiratory drive
  dependent upon their degree of hypoxia.
  Uncontrolled O2 therapy in these patients can
  lead to resp. depression, CO2 narcosis and resp.
  arrest.

25
Inhaled Bronchodilators

• Salbutamol and Atrovent commonly used.
• Nebulised therapy is not more effective than use
  of an MDI used with spacers and good technique!
• BUT more convenient for staff.
• - Allow larger doses over shorter
  time.
• - Require less pt. co-operation.
• - Independent of effort or breathing
  pattern.
• - Nebulised droplets may aid
  expectoration.
• NB if hypercapnia or acidosis should be air
  driven and any supplemental oxygen
  required should be delivered via nasal prongs.

26
Antibiotic Therapy.

• Given if increased production of purulent sputum,
  signs of consolidation on CXR or clinical signs
  of pneumonia.
• Good choices include an aminopenicillin, a
  macrolide or tetracycline.
• Follow local microbiology protocol.

27
Theophylline.

• Bronchodilator and increases respiratory drive.
• Use confined to those patients without adequate
  response to inhaled bronchodilators.
• NB omit loading dose if patient if taking long
  term.

28
Non-Invasive Ventilation

• Method of providing ventilatory support that does
  not require endotracheal intubation.
• Used as treatment of choice for persistent
  hypercapnic respiratory failure despite optimal
  medical management.
• Further consideration given later in day!

29
(No Transcript)
30
Discharge.

• In all patients ensure they understand their
  treatment plan. (pref. with written
  clarification).
• Ensure clear instructions given on what
  circumstances should trigger reattendance.
• Clear and appropriate follow up.

31
Questions??
32
Summary.

• Use available guidelines to guide assessment and
  treatment of both COPD and asthma patients.
• Seek senior help early.
• If considering discharge ensure done safely.