Bronchospasm & SOB. Kim Kilmurray Senior Clinical Teaching Fellow

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1 Bronchospasm & SOB Kim Kilmurray Senior Clinical Teaching Fellow

2 LEARNING OBJECTIVES Perform a comprehensive respiratory examination & link clinical signs to underlying pathology Identify the spectrum of asthma severities & describe stepwise asthma management Describe COPD management & how it might differ from that of asthma List the signs of anaphylaxis, concerning features and key steps in management

3 B on ABCDE assessment RR Oxygen saturations Respiratory distress Use of respiratory muscles Tachypnoea Speaking in sentences Cyanosis Tripod position Drooling Stridor Wheeze

4 Respiratory examination Inspection Signs of respiratory distress Pallor Cyanosis Finger clubbing Tremor Chest wall shape Palpation Trachea position Cervical lymphadenopathy Chest expansion Tactile vocal fremitis

5 Respiratory examination Percussion Dullness Hyperresonance Auscultation Breath sounds Vocal resonance 2 zones anteriorly 3 zones posteriorly Axilla Compare right with left

7 Remember to always examine the back!

8 Bronchospasm Constriction of bronchi & bronchioles Caused by: a spasm in the smooth muscles of bronchi and bronchioles an inflammation of the airways excessive production of mucous due to: an allergic reaction irritation caused by mechanical friction of air, overcooling or drying of airways

9 Symptoms Difficulty breathing Wheezing Coughing Dyspnoea

10 Case 1 24 year old female presents by ambulance with a 3 day history of a cough productive of green sputum, coryza, intermittent temperatures and difficulty breathing. PMH Asthma Observations Temp 38.7 ⁰C Pulse 124 bpm BP 124/76 RR 34 Oxygen saturations 94% in RA PEFR 240 ml (normal 440ml)

11 What s abnormal in her observations? Pyrexia Tachycardia Tachypnoea Hypoxia PEFR < 50% normal

12 On examination Speaking in phrases Using respiratory accessory muscles Chest Reduced AE throughout Widespread expiratory wheeze

13 Treatment Salbutamol nebuliser 5mg Ipratropium Bromide nebuliser 500 mcg Prednisolone 50 mg Oxygen therapy to maintain saturations > 94%

14 She s not improving what s next? Back to back salbutamol nebulisers IV Magnesium Sulphate 2g Antibiotics IV amoxicillin 1g?Salbutamol IV infusion

15 Diagnosis Infective acute severe exacerbation of asthma

17 How do you grade asthma exacerbations? Moderate Severe Life Threatening Near Fatal

18 Moderate Asthma Increasing symptoms PEF >50 75% best or predicted No features of acute severe asthma

19 Acute Severe Asthma Any one of: PEFR 33 50% best or predicted Respiratory rate 25/min Heart rate 110/min Inability to complete sentences in one breath

20 Life Threatening Asthma PEFR < 33% best or predicted SpO 2 < 92% PaO 2 < 8 kpa Normal PaCO 2 ( kpa) Silent chest Cyanosis Poor respiratory effort Arrhythmia Exhaustion Altered conscious level Hypotension

21 Near Fatal Asthma Raised PaCO 2 and/or requiring mechanical Ventilation with raised inflation pressures

22 Case 2 59 year old male presents with a 5 day history of a cough productive of green sputum, intermittent temperatures and breathlessness. PMH : COPD Observations: Temperature 38 ⁰ C Pulse 104 bpm BP 134/86 RR 36 Oxygen saturations 86% in RA

23 What are his abnormal observations? Pyrexia Tachycardia Tachypnoea Hypoxia

24 On examination Speaking in words Central cyanosis Using respiratory accessory muscles Chest AE equal and bilateral Widespread expiratory wheeze

25 ABG po₂ 7.2 kpa pco₂ 12.4 kpa H+ 64 mmol HCO₃ 32 mmol

26 ABG Type 2 Respiratory Failure Hypoxia (low oxygen) Hypercapnia (high carbon dioxide) Respiratory Acidosis High hydrogen ion concentration High carbon dioxide

27 How does your treatment differ from asthma? Controlled oxygen therapy 24 28% oxygen No improvement after 1 hour, consider NIV Otherwise management is the same as severe asthma Salbutamol nebulisers 5 mg Ipratropium nebulisers 500 mcg Prednisolone 50 mg IV Magnesium Sulphate 2 g

29 Venturi masks

30 Case 3 18 year old female presents with a sudden onset of difficulty breathing, an itchy rash, lip and tongue swelling that started 20 minutes ago. She had been eating chicken satay 10 minutes prior to her symptoms starting No known PMH, DH and NKDA Observations: Temp 37.4 o C Pulse 126 bpm BP 90 / 60 RR 32 Oxygen saturations 90 % in RA

31 What are her abnormal observations? Tachycardia Hypotension Tachypnoea Hypoxia

32 Airway noises Wheeze Caused by lower airway swelling Expiratory Whistling Stridor Caused by upper airway swelling Inspiratory Harsh, high pitched

33 Causes of wheeze Asthma COPD Bronchiolitis Viral induced wheeze Bronchiectasis

34 Causes of stridor Anaphylaxis Angio-oedema Croup Laryngitis Severe tonsillitis Inhaled foreign body Epiglottitis Vocal cord dysfunction

35 ANAPHYLAXIS Signs & symptoms Wheeze Hoarseness Chest tightness Urticaria Angio-oedema Stridor Respiratory collapse Confusion Agitation Hypotension Cyanosis

40 Treatment Give intramuscular (IM) adrenaline 1: mg (0.5ml) Repeat IM adrenaline at 5 minute intervals until there has been an adequate response. Consider nebulised adrenaline 5mg (5ml 1:1000) Oxygen therapy via NRM 15 L IV Chlorphenamine 10mg IV Hydrocortisone 200mg IV Fluids 1 L

42 Beware!!! The Biphasic reaction A delayed reaction with further symptoms developing 4 8 hours after the initial presentation.

43 SUMMARY Covered how to perform a comprehensive respiratory examination & link clinical signs to underlying pathology Identified the spectrum of asthma severities & describe stepwise asthma management Described COPD management & how it might differ from that of asthma Listed the signs of anaphylaxis, concerning features and key steps in management

44 QUESTIONS

Printed copies of this document may not be up to date, obtain the most recent version from

Printed copies of this document may not be up to date, obtain the most recent version from Children s Acute Transport Service Clinical Guidelines Acute Severe Asthma Document Control Information Author E Randle Author Position CATS Consultant Document Owner E Polke Document Owner Position Co-ordinator