Asthma RIPS

8/2/2019 Asthma RIPS

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Asthma

•MUHAMMAD SAALIMROLL # S08-54•AMANAT ALIROLL # S08-58



Chronic disease of the airways that maycause Wheezing Breathlessness

Chest tightness Nighttime or early morning coughing

Episodes are usually associated withwidespread, but variable, airflow obstruction

within the lung that is often reversible eitherspontaneously or with treatment.



Chronic inflammatory disorder of the airwaysin which many cells and cellular elements playa role. In susceptible individuals, thisinflammation causes recurrent episodes ofwheezing, breathlessness, chest tightness, andcoughing, particularly at night or in the earlymorning. These episodes are associated withwidespread but variable airflow obstruction

that is reversible either spontaneously, or withtreatment.



1. Intrinsic asthma

2. Extrinsic asthma

3. Nocturnal asthma

4. Bronchial asthma

5. Occupational asthma6. Silent asthma

7. Seasonal asthma Exercise induced

asthma



Genetic characteristics

Occupational exposures Environmental exposures



Three major changes:-Increase mucous production

air tubes clog up-Inflammation of air way cells

air tubes swell-Tightening of muscles around air tubes

Air tubes narrowing & hard to breathe



medical emergency

life-threatening episode of airway obstruction

an acute exacerbation of asthma that does not

respond to standard treatments ofbronchodilators and steroids.



Same symptoms as in normal asthma attack

Complications include cardiac and/or respiratoryarrest.

The lung failure means that oxygen can no longer beprovided, carbon dioxide can no longer beeliminated, which leads to acidosis.



PFT (Pulmonary Function Test) FEV (forced expiratory volume)

The volume of air that can be forced out taking a deebreath, an important measure of pulmonary function

3. PFR (Peak flow rate) FVC Forced Vital Capacity (FVC) is the volume

of air that can forcibly be blown out after

full inspiration, measured in liters.



PEF(PEF) is the maximal flow (or speed) achieved during themaximally forced expiration initiated at full inspiration, measuredin liters per minute.

Tidal volume (TV) Tidal volume (TV) is the specific volume of air drawn into, and

then expired out of, the lungs during normal tidal breathing. Total Lung Capacity (TLC) Total Lung Capacity (TLC) is the maximum volume of air present

in the lungs. Residual volume: Amount of air that stays in the lungs even after

max. expiration.

Step up: If uncontrolled at any severity level, oral steroids Step down: When stable for at least 3 months – reduce or stop oral steroids first.

http://en.wikipedia.org/wiki/Tidal_volume

http://en.wikipedia.org/wiki/Total_Lung_Capacity

http://en.wikipedia.org/wiki/Total_Lung_Capacity

http://en.wikipedia.org/wiki/Tidal_volume



Measurement Approximate Value

Males Females

Forced VitalCapacity (FVC)

4.8 L 3.7 L

Tidal volume

(Vt)

500 ml 390 ml

Total lung capacity(TLC)

6 L 4.7 L



Symptoms Coughing

Wheezing

Shortness of breath Chest tightness

Symptom Patterns

Severity

Family History



Troublesome cough, particularly at night Awakened by coughing

Coughing or wheezing after physical

activity Breathing problems during particular

seasons

Coughing, wheezing, or chest tightnessafter allergen exposure

Colds that last more than 10 days

Relief when medication is used



Wheezing sounds during normalbreathing

Hyperexpansion of the thorax

Increased nasal secretions or nasalpolyps

Atopic dermatitis, eczema, or otherallergic skin conditions



Peak expiratory flow (PEF)

Inexpensive

Patients can use at home

May be helpful for patients with severe diseaseto monitor their change from baseline everyday

Not recommended for all patients with mild or

moderate disease to use every day at home

Effort and technique dependent

Should not be used to make diagnosis of asthma



Allows patient to assess status of his/her asthma Persons who use peak flow meters should do so frequently

Many physicians require for all severe patients

Zone Reading Description



Zone Reading Description

Green 71-100%of normal

PFR

Asthma is under good control.

Yellow 50-70% of normal PFR

Indicates caution. It may meanrespiratory airways are narrowing

and additional medication may berequired

Red <50%

normal PFR

Indicates a medical emergency.

Severe airway narrowing may beoccurring and immediate actionneeds to be taken. This wouldusually involve contacting a doctoror hospital.



Spirometry

Recommended to do spirometry pre- and post- useof an albuterol MDI to establish reversibility ofairflow obstruction

> 12% reversibility or an increase in FEV1 of 200cc isconsidered significant

Obstructive pattern: reduced FEV1/FVC ratio

Restrictive pattern: reduced FVC with a normalFEV1/FVC ratio



Spirometry

Can be used to identify reversible airway obstructiondue to triggers

Can diagnose Exercise-induced asthma (EIA) orExercise-induced bronchospasm (EIB) by measuringFEV1/FVC before exercise and immediatelyfollowing exercise, then for 5-10 minute intervalsover the next 20-30 minutes looking for post-exercise

bronchoconstriction



Methacholine challenge

Most common bronchoprovocative test in US

Patients breathe in increasing amounts of

methacholine and perform spirometry after eachdose

Increased airway hyperresponsiveness is establishedwith a 20% or more decrease in FEV1 from baselineat a concentration < 8mg/dl

May miss some cases of exercise-induced asthma



Diagnostic trial of anti-inflammatorymedication (preferably corticosteroids) or aninhaled bronchodilator

Especially helpful in very young children unable tocooperate with other diagnostic testing

There is no one single test or measure that candefinitively be used to diagnose asthma in every

patient



Mild (no Mod (may need Severe (need



Mild (noadmission)

Mod (may needadmission)

Severe (needadmission)

Alteredconsciousness

No No Yes

Physicalexhaustion

No No Yes

Talks in Sentence Phrases Words

Pulsus

paradoxusNot palpable May be

palpablePalpable

Wheeze onascultation

Present Present Silent chest

Use of accessorymuscles

Absent Moderate Marked

SaO2 >93% 91-93% 90% & <

PFR >60% 40-60% <40%



Medications come in several forms.

Two major categories ofmedications are: Long-term control Quick relief



Taken daily over a long period of time

Used to reduce inflammation, relax airway

muscles, and improve symptoms and lungfunction

Inhaled corticosteroids

Long-acting beta2

-agonists

Leukotriene modifiers

Mast cell stablizer



Used in acute episodes

Generally short-actingbeta2agonists

Anticholinergic drug



Butekyo Method

Simple breathing technique

Studied in many clinical trials

No side effects

Brochial Thermoplasty

Deliver thermal energy to airway walls

Smoking

Weight Reduction



Achieve and maintain control of symptoms

Maintain normal activity levels, including

exercise Maintain pulmonary function as close to

normal levels as possible Prevent asthma exacerbations

Avoid adverse effects from asthmamedications

Prevent asthma mortality



Develop with a physician

Tailor to meet individual needs

Educate patients and families about allaspects of plan Recognizing symptoms

Medication benefits and side effects Proper use of inhalers and Peak Expiratory Flow

(PEF) meters



Describes medicinesto use and actions

to take



(ADULTS)



Peak flow >50-75% of predicted or best

No features of acute severe asthma

Increasing symptoms

Treat at home but response to t/m must beassessed before doctor leaves



Treatment:

High-flow oxygen if available

Salbutamol or terbutaline via large volume

spacer (4-6puffs each inhaled separately; doserepeated every 10-20min if necessary) ornebuliser

Monitor response 15-30min after nebulisation

Give oral prednisolone 40-50mg daily foratleast 5days and step up usual t/m.



Follow up:

Monitor symptoms and peak flow

Set up asthma action plan

Review in surgery within 48hrs



Cannot complete sentences in one breath

Pulse > 110 beats/min

Respiration > 25 breaths/min

Peak flow 33-50% of predicted or best

Seriously consider hospital admission if morethan one of above features present.



Treatment:

High flow oxygen if available

Salbutamol or terbutaline via large volumespacer (4-6puffs each inhaled separately; doserepeated every 10-20min if necessary) or nebuliser(oxygen driven)

Oral prednisolone 40-50mg daily for atleast 5days(or IV hydrocortisone 400mg daily in 4 divideddoses)

Monitor response 15-30min after nebulisation



If any signs of acute asthma persist:

Arrange hospital admission

While awaiting ambulance repeat nebulised beta 2agonist and give with nebulised ipratropium 500ug .

If symptoms have improved, respiration and pulsesetting and peak flow >50%:

Step up usual t/m & continue prednisolone foratleast 5days.



Follow up:

Monitor symptoms and peak flow

Set up asthma action plan

Review in surgery within 24hrs

Modify t/m a review



Silent chest

Cyanosis

Feeble respiratory effort (slow)

Bradycardia, exhaustion, arrythmias,hypotension, confusion or coma

Peak flow <33% of predicted or best

Arterial oxygen saturation <92%.

Arrange immediate hospital admission



Treatment:

Oral prednisolone 40-50mg daily for atleast 5days(or IV hydrocortisone 400mg daily in 4 divided

doses) (immediately) Oxygen driven nebuliser in ambulance

Nebulised beta 2 agonist with nebulisedipratropium

Stay with patient until the ambulance arrives

If nebuliser not available, give 1puff of beta 2agonist using large volume spacer and repeat 10-

20 times.



Imp:

patients with severe or life threatening attacksmay not be distressed and may not have all

these abnormalities, the presence of any shouldalert the doctor.



(CHILDREN)



Too breathless to talk

Too breathless to feed

R/R 50 b/min

Use of accessory muscles of respiration

PFR < 50%



Cyanosis

Silent chest

Poor respiratory effort

Exhaustion

Reduced level of consciousness

PFR < 33%



DIPS [Dosage, Instructions,Priming, Special

Instructions]D:

Is the patient going to be using 1 or 2 inhalations?If a bronchodilator and maintenance medications

are prescribed.I:

The instructions can vary according to whichdelivery system is being used.

P:2 to 4 sprays in the air

S:(eg, some are breath-actuated, and some require

capsules to be inserted into the device).



The health-care providershould evaluate inhaler

technique at each visit.



Spacers can help patients

who have difficulty withinhaler use and can reducepotential for adverse effectsfrom medication



Machine produces a mist ofthe medication

Used for small children orfor severe asthma episodes

No evidence that it is moreeffective than an inhalerused with a spacer



ANY

QUESTIONS???

Asthma RIPS

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