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Asthma & Acute Breathlessness

Asthma & Acute Breathlessness. Jenny Till Respiratory Nurse Specialist Cumbria PCT. Airways and lungs. Alveolar capillary bed. Asthma.

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Asthma & Acute Breathlessness

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  1. Asthma & Acute Breathlessness Jenny Till Respiratory Nurse Specialist Cumbria PCT

  2. Airways and lungs

  3. Alveolar capillary bed

  4. 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.”

  5. Asthma Triggers

  6. 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

  7. Signs of Severe Asthma • Difficulty speaking • Dyspnoea at rest > 25 breaths per min • Possible wheeze • Possible cough • Tachycardia at rest > 110 beats per min • Pulse oximetry < 96% at rest on air • (PEFR < 50% of best / predicted)

  8. Life Threatening Asthma • Poor respiratory effort / silent chest • May not appear distressed • Fatigue / exhaustion • Agitation / reduced level of consciousness • Confusion • Cyanosis • Pulse oximetry < 92% at rest on air

  9. Treatment of Acute Asthma • High dose bronchodilators • 2.5mg neb salbutamol or Spacer (up to 10 puffs salb) • Oral steroids • 40 – 50mg for 5 days • Oxygen • If O2Sats <92% • Aim to raise to at least 95% • Call for medical assessment

  10. Treatment of Acute Asthma • Review every 15 mins • Repeat 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

  11. Follow up of patients • All should be followed up within 48 hours • Ensure patients not admitted have clear instructions about when to call for help • Bronchodilator not lasting 4 hours, increased symptoms again, PEFR 50-70%

  12. 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)

  13. Airways and lungs

  14. Emphysema: a result of the air sacs being “dissolved away” and also less Support for the airways Alveoli

  15. Alveolar capillary bed

  16. Is it asthma or COPD? Asthma COPD Smoker or ex-smoker Possible Nearly always Symptoms under 45 yrs Often Rare Common Chronic productive cough Uncommon Persistent and progressive Breathlessness Variable Night time waking with breathlessness and / or wheeze Common Uncommon Significant diurnal or day to day variation in symptoms Common Uncommon

  17. 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)

  18. 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?

  19. 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

  20. SOS Admit to hospital • Severe chest pain • Cyanosis • Acute confusion • Loss of consciousness • Abnormal vital signs • Particularly severe breathlessness • Or exhaustion as a result

  21. Information gathering • Precipitating factors • Time course • Presenting symptoms / signs • Associated symptoms • Allergies • Medications • Chemist / herbal / illicit drugs • General health

  22. Presenting signs / symtoms • Onset & timing? • Anything make it worse / better? • Intermittent / persistent? • Exercise tolerance • Normal & now • Worse at night? • Worse lying flat?

  23. Equipment • Pulse Oximeter • MDI & Spacer • Oxygen

  24. 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

  25. 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%

  26. 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

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