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Asthma TCD 2 ZainabAjaj 3rdyearteaching@gmail.com Aetiology Presentation, diagnosis and management of Asthma What we will cover Acute Asthma today Practice questions OSCEsAetiology ● Characterizedbychronicinflammationoftheairways. ● Severalmechanismsleadtothisairwayobstructionincluding; -Bronchialmusclecontraction -Inflammatorycellinfiltration(particularlyeosinophils) -Increasedmucusproduction ● Acuteexacerbationsofchronicasthmapresentwithworseningsymptomsand areoftentriggeredbyenvironmentalfactors ● Inasthma,thereisreversibleairwayobstruction,eitherspontaneouslyorwith treatment(bronchodilators)Presentation Important areas to cover in history: Episodic symptoms Shortness of • (eczema, hay fever or allergies?)py breath (SOB) • Triggers: cold air, exercise, infection, allergens (dust, pollen), pets, emotions, NSAIDs • Occupation: exposure to dust, Chest tightness Dry cough chemicals. If symptoms remit at weekends or holidays? • Exercise: quantify exercise tolerance • Disturbed sleep: helps to assess Bilateral asthma severity widespread Diurnal variability? “polyphonic” wheezeInvestigations ● Bedside:PEFRisimportanttomonitorresponsetotreatment,helpstoassessthe severityofanacuteattackandcandemonstratediurnalvariation(>20%variability intwicedailyreadings). ● Laboratory:BasicbloodsincludingWCC&CRPtolookforinfection.More specialisttestse.g.eosinophilcountandtotalIgE.Sputumsampleiftheyhavea productivecough. ● Imaging:ChestX-rayusuallynormal(mayshowhyperinflation)butimportantinan acutesettingtoruleoutinfection,pneumothoraxorcollapse. ● Other:Spirometrywithbronchodilatorreversibilitytesting supportsdiagnosisof suspectedasthma.Fractionalexhalednitricoxide(FeNO)testmeasureslevelof exhalednitricoxide.Directbronchialchallengetestcarriedoutbyspecialists.Skin pricktesting(suggestsatopy).Spirometry ● Forcedexpiratoryvolumein1second(FEV1) measurestheabilityofairtofreelyflowoutofthe lungssoifthereisanairwayobstructionthiswillbereduced. ● Forcedvitalcapacity(FVC)measuresthetotalvolumeofairapersoncantakeintotheirlungssoif thereisrestrictiononthecapacityofaperson'slungsthiswillbereduced. ● Thesetwomeasurementsfromspirometryareusedtocreatearatiothattellsuswhetherthe patienthasarestrictiveorobstructivecondition. ● FEV1/FVCratio<70%indicatesanobstructivelungdisease ● IfFEV1andFVCareequallyreducedandFEV1/FVCratio>70%thisindicatesarestrictivelung disease. ● Asthmais obstructive ObstructiveDiseases RestrictiveDiseases 1. Asthma(reversible) 1. Interstitiallungfibrosis 2. COPD 2. Sarcoidosis 3. Bronchiectasis 3. ScoliosisDiagnosis TheBritishThoracicSociety(BTS)advisestogostraighttotreatmentifthere’sahighprobabilityof asthmabutNICEguidelinesondiagnosisspecificallyadvisenottomakeadiagnosisclinicallyand requirestesting.Firstlineinvestigations: ● Spirometry:FEV1/FVCratio<70%,thendobronchodilatorreversibility(BDR)test,with≥12% improvementinFEV1confirmingdiagnosisof asthma ● Fractionalexhalednitricoxidetest(FeNO)withFeNO≥40ppbinadultsandFeNO≥35ppbin childrenconfirmseosinophilicinflammationsuggestingasthma ● Ifthesearenegative,consider2-4weeksofpeakflowmonitoringwith>20%variabilityis+vefor asthma Long T erm Management MedicalManagement: Generalmeasures: ● Aimtoachievepatientcontrolover Stepupanddowntheladderbasedonseverityof managementincludinga symptomsandaimtoachievenosymptoms, personalisedasthmaactionplanand exacerbationsorlimitationsonactivityincluding encouragePEFRmonitoring exercise.BTSguidelinesforasthma: ● Teachandregularlycheckinhaler technique 1. Short-actingbeta-2agonist(SABA)e.g.salbutamol ● Removeanyidentifiedallergens forrelievertherapy ● Annualfluvaccine 2. Addlowdoseinhaledcorticosteroid(ICS) ● Smokingcessation(weakens 3. Addlong-actingbeta-2agonist(LABA)e.g effectivenessofsteroids) salmeterol.Onlycontinueifgoodresponse. ● Adviseonexerciseandweightloss 4. Considertrialofleukotrienereceptorantagonist ● Yearlyasthmareview (i.e.montelukast),oralbeta-2agonist(i.e.ora salbutamol),oraltheophylline. 5. TitrateICSuptoa“highdose”.Combineadditional treatmentsfromstep4.Refertospecialist.Acute AsthmaPresentation ● AcutesevereSOB ● Tachypnoea(fastrespiratoryrate) TopdifferentialsforacuteonsetSOB? ● Wheeze ● Useofaccessorymuscles ● Acuteexacerbationofasthma ● Hypoxia ● ACS-crushingcentralchestpain? nausea/sweating?cardiovascularrisk factors? Whatwillwedonexttodeterminethecause? ● Pneumothorax-pleuriticchestpain? riskfactorse.g.tall/thin,Marfan ● History-baseline&severity,exacerbationhistory, syndrome,COPD? ICUadmissions,normalPEFR,inhalercompliance ● Pneumonia-cough?chestpain?fever? ● Pulmonaryembolism-pleuriticchest ● ABCDEapproach ● Investigations pain?haemoptysis?riskfactorse.g.long - ABG(severity) haulflight,recentsurgery? - FBC,CRPandU&Es - CXR(excludepneumothorax)ABCDE Approach TheABCDEapproachhelpsustosystematicallyassesscriticallyunwellpatientsinmedicalemergencies. Itallowsustoidentifyandstabilisethemostlife-threateningproblemsfirst.Workthroughthesesteps andmakesuretore-assessregularly: ● Airways-canpatienttalk?Yes,moveon.No,checkforobstructioninsidemouth,head-tilt-chin-lift manoeuvre,Guedel,NPA ● Breathing-RR(12-20breathsperminuteisnormal),O2sats(94-98%normal),auscultate,ABG, PEFR,CXR. Oxygen(15Lnon-rebreathermask) ● Circulation-HR,BP(hypotensionlife-threatening).capillaryrefill,temperature,insertatleast1 wide-boreIVcannula,basicbloods,assessfluidbalance.IVfluids. ● Disability-consciousness(APVU),pupils,bloodglucose(DEFG-Don’tEverForgetGlucose) ● Exposure-inspectforinjuries,bleeds,rahes,calfswellingortenderness.Classifying Asthma Severity ● Mild(PEFR>75%predicted) ● Moderate(PEFR50-75%predicted) ● Severe(PEFR33-50%predicted): ABGsinacuteasthma ● Initially,patientshaverespiratory - Resprate>25 alkalosisduetotachypnoeacausing↓ - Heartrate>110 CO - Cannotcompletesentences 2 ● NormalpCO o2hypoxiaindicates ● Life-threatening(PEFR<33%predicted):33,92CHEST life-threateningasthmaaspatientis - 33:PEFR<33% tiring ● Respiratoryacidosis(highCO2)isa - 92:Sats<92% veryconcerningsignofanear-fatal - Cyanosis asthmaexacerbation. - Hypotension - Exhaustion - Silentchest - TachycardiaTreatment OSHITME! Monitor serum potassium Oxygen(maintainsatsof94-98%)-useoxygen-drivennebs when on salbutamol (causes it to be absorbed from blood into cells) Salbutamol5mgNEB-back-to-backnebsinitially Hydrocortisone100mgIV(orprednisolone40mgPO)-oraldaily(aseffectiveifcanswallow),IV6hourly Ipratropium500mcgNEB-6hourly(ifresponsepoor/severe/life-threatening) Theophylline(aminophyllineinfusion)-usuallyinICU(needU&Es,cardiacmonitoring) Magnesiumsulfate 2gIVover20mins -one-offdoseifsevere(beforetheophylline) Escalatecare(intubationandventilation)-involveICUifworseningdespitemaximaltherapy MonitorresponsetotreatmentusingsRR,PEFR,oxygensats,ABGresultsandauscultationFollow-up ● Optimiseasthmacontrolbeforedischarge-written“asthmaactionplan” ● Takeathoroughhistorytotryestablishcauseofattack ● Checkinhalertechnique ● Ensuretheytakesteroidsfor≥5days(40-50mgprednisolonePO) ● GPappointmentwithin2days ● Respiratoryclinicappointmentafter4weeksPractice QuestionsA19yearoldfemalepresentstotheirGPcomplainingofreducedexercisetolerance.Shereportsfeeling breathlessforthepast4weekswhilstplayingcricketmatchesoutsideandthisisaffectingherperformance. Shehadnobreathlessnessduringthesummerandexperiencesnobreathlessnessatrest,butdoesreportsome nocturnalcoughing.Herpastmedicalhistoryincludesseasonalallergicrhinitisandchildhoodeczemabutnil else.Sheusestheprogesteroneonlypillforcontraception. Whatisthesinglemostlikelydiagnosis? ● EosinophilicGranulomatosiswithPolyangiitis(eGPA) ● Pneumonia ● PulmonaryEmbolism(PE) ● Asthma ● AllergicRhinitisA19yearoldfemalepresentstotheirGPcomplainingofreducedexercisetolerance.Shereportsfeeling breathlessforthepast4weekswhilstplayingcricketmatchesoutsideandthisisaffectingherperformance. Shehadnobreathlessnessduringthesummerandexperiencesnobreathlessnessatrest,butdoesreportsome nocturnalcoughing.Herpastmedicalhistoryincludesseasonalallergicrhinitisandchildhoodeczemabutnil else.Sheusestheprogesteroneonlypillforcontraception. Whatisthesinglemostlikelydiagnosis? ● EosinophilicGranulomatosiswithPolyangiitis(eGPA) ● Pneumonia ● PulmonaryEmbolism(PE) ● Asthma ● AllergicRhinitisA15-year-oldgirlpresentstotheGP withaprevioushistoryofshortnessofbreathanddrycoughthat developswhenevershehasasportslesson. Sheusuallyusesablueinhalertorelievethesymptoms,howeveroverthepastthree weeksshehas beenwakingupfromepisodesofdyspnoeaandhermumisworriedthatsheismorewheezythanusual. Whatadditionalmedicationcanbeprescribedtocontrolhersymptoms? ● BeclometasoneInhaler ● SalmeterolInhaler ● Montelukast ● Theophylline ● OmalizumabA15-year-oldgirlpresentstotheGP withaprevioushistoryofshortnessofbreathanddrycoughthat developswhenevershehasasportslesson. Sheusuallyusesablueinhalertorelievethesymptoms,howeveroverthepastthree weeksshehas beenwakingupfromepisodesofdyspnoeaandhermumisworriedthatsheismorewheezythanusual. Whatadditionalmedicationcanbeprescribedtocontrolhersymptoms? ● BeclometasoneInhaler ● SalmeterolInhaler ● Montelukast ● Theophylline ● OmalizumabA33yearoldmalepatientpresentstoA&E havinganasthmaattack.HisobservationsandABGfollow: Heartrate(HR):105 Respiratoryrate(RR):28 Oxygensaturations(SATS):94%onroomair Bloodpressure(BP):135/90 Temperature:37' pH:7.31[7.35-7.45] PaO2:9.0kPa[9.5-14] PaCO2:6.7kPa[4.6-6] HCO3-:27mmol/l[22-30] BE:-0.1mmol/l[-2-+2] Howwouldyougradetheseverityofhisasthmaattack? ● Life-threatening ● Mild ● Moderate ● Severe ● NearfatalA33yearoldmalepatientpresentstoA&E havinganasthmaattack.HisobservationsandABGfollow: Heartrate(HR):105 Respiratoryrate(RR):28 Oxygensaturations(SATS):94%onroomair Bloodpressure(BP):135/90 Temperature:37' pH:7.31[7.35-7.45] PaO2:9.0kPa[9.5-14] PaCO2:6.7kPa[4.6-6] HCO3-:27mmol/l[22-30] BE:-0.1mmol/l[-2-+2] Howwouldyougradetheseverityofhisasthmaattack? ● Life-threatening ● Mild ● Moderate ● Severe ● NearfatalAn8-year-oldboywhoisaknownasthmaticpresentstoA&Ewitha3hourhistoryofdifficultybreathing. Onexamination,thereisadecreasedchestexpansionandawheezebilaterallyonauscultation.Hisheartrate is125,respiratoryrate35,BP110/80andO2sats86%onroomair.Heisunabletocompletehissentences. Whichofthefollowingfeaturesfromhisexaminationismostindicativeofalife-threateningasthmaattack? ● Bloodpressure110/80 ● Respiratoryrateof35 ● O2saturationsof86%. ● Heartrateof125 ● UnabletocompletesentencesinonebreathAn8-year-oldboywhoisaknownasthmaticpresentstoA&Ewitha3hourhistoryofdifficultybreathing. Onexamination,thereisadecreasedchestexpansionandawheezebilaterallyonauscultation.Hisheartrate is125,respiratoryrate35,BP110/80andO2sats86%onroomair.Heisunabletocompletehissentences. Whichofthefollowingfeaturesfromhisexaminationismostindicativeofalife-threateningasthmaattack? ● Bloodpressure110/80 ● Respiratoryrateof35 ● O2saturationsof86%. ● Heartrateof125 ● UnabletocompletesentencesinonebreathA24-year-oldfemalewithasthmapresentstoA&Ewithawheeze,chesttightnessanddifficultybreathing.A setofobservationsareperformed: ● SaO2:96% ● Respiratoryrate:24 ● Heartrate:96 ● Temperature:37.2 ● Bloodpressure:110/84 Sheisabletotalkandexplainsthatshehastakenatotalof10puffsfromhersalbutamolinhalerbutdoesnot feelanybetter.Treatmentwithintermittent5mgnebulisedsalbutamoldrivenbyairintheemergency departmentsuccessfullyrelieveshersymptoms. Whichadditionalmedicationshouldbeprescribedintheacutesetting? ● Prednisolone40mgPO ● Aminophylline250mgIV ● Ipratropiumbromide500microgramsneb ● Supplementaloxygentherapy ● Hydrocortisone100mgIVA24-year-oldfemalewithasthmapresentstoA&Ewithawheeze,chesttightnessanddifficultybreathing.A setofobservationsareperformed: ● SaO2:96% ● Respiratoryrate:24 ● Heartrate:96 ● Temperature:37.2 ● Bloodpressure:110/84 Sheisabletotalkandexplainsthatshehastakenatotalof10puffsfromhersalbutamolinhalerbutdoesnot feelanybetter.Treatmentwithintermittent5mgnebulisedsalbutamoldrivenbyairintheemergency departmentsuccessfullyrelieveshersymptoms. Whichadditionalmedicationshouldbeprescribedintheacutesetting? ● Prednisolone40mgPO ● Aminophylline250mgIV ● Ipratropiumbromide500microgramsneb ● Supplementaloxygentherapy ● Hydrocortisone100mgIVA19-year-oldmalepresentsinA&Eacutelyshortofbreathandwheezy.Hehasapastmedicalhistoryofasthma.On initialassessment,hisheartrateis115beats/minute,hisrespiratoryrateis25breaths/minuteandhissaturationsare 92%onroomair.Heisunabletocompleteafullsentenceinonebreath. Anarterialbloodgasonroomairshows: pH7.54(7.35-7.45) PaO29.1kPa(>10.6kPa) PaCO23.1kPa(4.7-6kPa) Baseexcess+2mmol/L HCO324mmol/L(23-30mmol/L) Whatisthemostappropriateinitialmanagementforthispatient? ● Urgentintubationandventilation ● Salbutamolnebulisers ● IVMagnesium ● IVHydrocortisone ● OxygenA19-year-oldmalepresentsinA&Eacutelyshortofbreathandwheezy.Hehasapastmedicalhistoryofasthma.On initialassessment,hisheartrateis115beats/minute,hisrespiratoryrateis25breaths/minuteandhissaturationsare 92%onroomair.Heisunabletocompleteafullsentenceinonebreath. Anarterialbloodgasonroomairshows: pH7.54(7.35-7.45) PaO29.1kPa(>10.6kPa) PaCO23.1kPa(4.7-6kPa) Baseexcess+2mmol/L HCO324mmol/L(23-30mmol/L) Whatisthemostappropriateinitialmanagementforthispatient? ● Urgentintubationandventilation ● Salbutamolnebulisers ● IVMagnesium ● IVHydrocortisone ● OxygenOSCEsRespiratory History Historyofpresentingcomplaint: ● SOB:severity?relievingfactors?exacerbatingfactors?asthma,pneumonia,COPD,PE,pneumothorax ● Cough:dry?(e.g.pulmonaryfibrosis,SEofACEinhibitors,asthma)productive?(e.g.pneumonia,COPD) ● Haemoptysis:lungcancer,TB,rarelyPE ● Wheeze:asthma,COPD ● Chestpain:pleuritic(worseoninspiration)?(e.g.PE,pneumonia,pneumothorax)suddenonset? (pneumothorax).SOCRATESusefultoexplorepain. ● Legswelling:DVT(PE) ● Systemicsymptoms:fever?(pneumonia),nightsweats(TB),fatigue(lungcancer,COPD,TB)andweightloss (lungcancer,TB) Pastmedicalhistory:atopy,respconditions,cardiacconditions,previouscancer Socialhistory:smoking-what?howmuch?howlong?(COPD,lungcancer),occupation(lungcancer) FamilyHistory:lungconditions,atopy Drughistory:regularmedication,allergies ALWAYSICE!!!Explanation Station Learnhowtoexplaineveryconditiontoapatientsinsimplelayman’sterms. Introduceyourself,buildrapport(takequickhistory),askpatientwhythey'rehere,assesstheirpriorknowledge(what theyknowaboutcondition),discusswhatyou’regoingtotalkabout(askiftheywanttodiscusssomethingspecific. Asthmaisarelativelysimpleconditiontoexplain; ● Normalanatomy/physiology:“Whenwebreathein,airtravelsfromourmouththroughasequenceoflargerto smallertubestoreachdeepintoourlungs.Thebodyabsorbstheoxygenintheairintoourbloodandusesitto powerourcells” ● Whatthedisease:“Asthmaisalongtermcondition,wherethesesmalltubesnarrowmakingitmoredifficultto breathe(henceSOB),alsolessoxygenisabsorbedintobloodsowebreathefastertotryandcompensate.The narrowingwindpipealsomeansairwhistleasitmovesthroughthem,wecallthiswheezing.Therearemany possibletriggersintheenvironmentthatcausethistohappene.g.coldair,exercise,allergiesetc” ● Problems/complications:SOB,wheezing.Acuteasthma. ● Management:“Themainaimoftreatingasthmaistominimisetheimpactithasonyourday-to-daylifebyhaving nosymptomsatdayornight.Wecandothisbygivingyouaninhalerthathelpstowidenyourwindpipetoallow moreairinandmakeiteasiertobreath. &thinkothernon-medicalmanagement Otherpotentialexplanations-peakflow,spacer,asthmamedication(checkingcompliance)Resources ● https://geekymedics.com/asthma/ ● https://geekymedics.com/acute-management-of-asthma/ ● https://geekymedics.com/explaining-a-diagnosis-of-asthma-osce-guide/ ● https://zerotofinals.com/medicine/respiratory/asthma/ ● https://zerotofinals.com/medicine/respiratory/lungfunctiontests/ ● https://zerotofinals.com/medicine/respiratory/acuteasthma/ ● https://oscestop.com/Common%20acute%20-%20SOB.pdf ● https://oscestop.com/Explaining.pdfThank you. Any questions? formalteachingprovidedbytheUniversity.dentsforstudentsandthesessioninnowayreplacesthe