asthma & acute breathlessness jenny till respiratory nurse specialist cumbria pct
TRANSCRIPT
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