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

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Presentation on theme: "Asthma & Acute Breathlessness Jenny Till Respiratory Nurse Specialist Cumbria PCT."— Presentation transcript:

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



4 Airways and lungs

5 Alveolar capillary bed

6 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.”

7 Asthma Triggers

8 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

9 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)

10 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

11 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 O 2 Sats <92% Aim to raise to at least 95% Call for medical assessment

12 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

13 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 %

14 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)

15 Airways and lungs

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

17 Alveolar capillary bed

18 Is it asthma or COPD? UncommonCommon Significant diurnal or day to day variation in symptoms UncommonCommon Night time waking with breathlessness and / or wheeze Persistent and progressive Variable Breathlessness Common Uncommon Chronic productive cough RareOften Symptoms under 45 yrs Nearly alwaysPossible Smoker or ex-smoker COPDAsthma

19 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)

20 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?


22 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

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

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

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

26 Equipment Pulse Oximeter MDI & Spacer Oxygen

27 Oxygen Saturation (SaO 2 ) Oxygen carried in bloodstream bound to haemoglobin (& small amount in plasma) 1 Hb can carry 4 O 2 = 100% saturated Pulse oximeter measures the average % saturation of haemoglobin in sample

28 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%

29 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 – SpO 2 readings will be falsely higher Anaemia – will give falsely high readings Less haemoglobin, less O 2 carried SpO 2 cannot determine CO 2 Levels or actual O 2 levels

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