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

4. Airways and lungs

5. Alveolar capillary bed
Obscure the title of this slide and get the group to guess what this is.
Emphasise that this is an intricate and delicate structure that is blown apart by cigarette smoke!

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.”
This is the easy bit!
Get the students to volunteer the definition.
Look for the key words – variable
- reversible
They will also come up with inflammatory. You can mention that COPD also involves inflammation, but that the processes and cells involved are different in asthma and COPD

7. Asthma Triggers

8. Worsening Asthma Increased symptoms Reliever medication less effective
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 O2Sats <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 50-70%

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)
Start the session by pointing out the main features:
Chronic
Progressive
Non-variable
Non-reversible

15. Airways and lungs

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

17. Alveolar capillary bed
Obscure the title of this slide and get the group to guess what this is.
Emphasise that this is an intricate and delicate structure that is blown apart by cigarette smoke!

18. Persistent and progressive
Is it asthma or COPD?
Asthma
COPD
Smoker or ex-smoker
Possible
Nearly always
Symptoms under 45 yrs
Often
Rare
Chronic productive cough
Uncommon
Common
Persistent and progressive
Breathlessness
Variable
This is the table from the NICE guidelines
It is not exhaustive.
Talk about
FH and PH asthma and atopy
Mention undiagnosed childhood asthma
Occupation
Variability of symptoms – Asthma has ‘good and bad days’, COPD has ‘bad days and worse days’
Night time waking with breathlessness and / or wheeze
Common
Uncommon
Significant diurnal or day to day variation in symptoms
Common
Uncommon

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 (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

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 – 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