Asthma
Mx
Chronic asthma
Step 1: Newly-diagnosed asthma SABA
Step 2: Not controlled on previous step (≥ 3 times a week/night-time
waking) OR newly diagnosed w/ symptoms + low-dose ICS
Definition chronic inflammatory disorder of the airways secondary to Step 3: Initial add-on therapy + inhaled LABA (usually combination
hypersensitivity inhaler)
Reversible bronchospasm airway obstruction Step 4: Additional add-on therapy
Risk factors No response to LABA? Stop LABA + increase dose of ICS
Personal/FHx of atopy patients w/ asthma also suffer from IgE- If benefit from LABA but control still inadequate? Continue LABA +
mediated atopic conditions e.g. hay fever/eczema, antenatal factor medium dose ICS
(maternal smoking, viral infection during pregnancy- especially RSV), low Still inadequate? LABA + ICS + consider: LTRA, Theophylline, LAMA trial
birth weight, not being breastfed, exposure to high [allergens] Step 5: Increase ICS to high dose + either LTRA, LAMA, Theophylline +
Signs + symptoms specialist referral
Expiratory wheeze on auscultation + reduced PEFR Step 6: Steroid tablet e.g. Prednisolone
Cough often worse @ night, dyspnoea, ‘wheeze’, ‘chest tightness’
Ix
Spirometry measures the amount (volume) + speed (flow) of air Moderate Severe Life-threatening
during inhalation + exhalation SpO2 >92% SpO2 <92% SpO2 <92%
o FEV1 volume of air exhaled @ the end of the first second of PEFR >50% PEFR <50% PEFR <33% predicted/best value
forced expiration predicted/best predicted/best value
o FVC volume that has been exhaled after a maximal value
expiration following a full inspiration Speech normal Can’t complete Pulmonary: Silent chest,
RR < 25 sentences cyanosis/feeble respiratory effort
Obstructive lung disease Restrictive lung disease Pulse < 110bpm RR > 25 Cardiac: Bradycardia,
FEV1 – significantly reduced FEV1 - reduced Pulse > 110bpm dysrhythmia/hypotension
FVC – reduced/normal FVC – significantly reduced Cognition: Exhaustion, coma,
FEV1% (FEV1/FVC) - reduced FEV1% (FEV1/FVC) – confusion
normal/increased Mx: SABA via Mx:
Asthma Pulmonary fibrosis spacer (2-4 O2 to achieve normal SpO2
COPD Asbestosis puffs) 10 puffs
Bronchiectasis Sarcoidosis Increase by 2 puffs SABA 10 puffs via SABA + Ipratropium nebuliser
Bronchiolitis obliterans Kyphoscoliosis every 2 minutes spacer/nebulised (Salbutamol 5mg + Ipratropium
NM disorders Consider oral Oral prednisolone 0.5mg)
Prednisolone Nebulised Oral Prednisolone 40-50mg/IV
Ipratropium bromide Hydrocortisone 100mg
Fractional exhaled NO (FeNO) nitric oxide is produced by 3 types
Repeat MgSO4
of NO synthase. One of those types is inducible (iNOS) + levels bronchodilators IV Aminophylline
tend to increase in inflammatory cells, particularly eosinophils every 20-30mins as IV Salbutamol
Levels of NO = level of inflammation necessary
CXR older pts/ those w/ smoking hx Reassess in 1 hour
Assess response to Rx: RR, HR, SpO2, PEFR
Mx
Chronic asthma
Step 1: Newly-diagnosed asthma SABA
Step 2: Not controlled on previous step (≥ 3 times a week/night-time
waking) OR newly diagnosed w/ symptoms + low-dose ICS
Definition chronic inflammatory disorder of the airways secondary to Step 3: Initial add-on therapy + inhaled LABA (usually combination
hypersensitivity inhaler)
Reversible bronchospasm airway obstruction Step 4: Additional add-on therapy
Risk factors No response to LABA? Stop LABA + increase dose of ICS
Personal/FHx of atopy patients w/ asthma also suffer from IgE- If benefit from LABA but control still inadequate? Continue LABA +
mediated atopic conditions e.g. hay fever/eczema, antenatal factor medium dose ICS
(maternal smoking, viral infection during pregnancy- especially RSV), low Still inadequate? LABA + ICS + consider: LTRA, Theophylline, LAMA trial
birth weight, not being breastfed, exposure to high [allergens] Step 5: Increase ICS to high dose + either LTRA, LAMA, Theophylline +
Signs + symptoms specialist referral
Expiratory wheeze on auscultation + reduced PEFR Step 6: Steroid tablet e.g. Prednisolone
Cough often worse @ night, dyspnoea, ‘wheeze’, ‘chest tightness’
Ix
Spirometry measures the amount (volume) + speed (flow) of air Moderate Severe Life-threatening
during inhalation + exhalation SpO2 >92% SpO2 <92% SpO2 <92%
o FEV1 volume of air exhaled @ the end of the first second of PEFR >50% PEFR <50% PEFR <33% predicted/best value
forced expiration predicted/best predicted/best value
o FVC volume that has been exhaled after a maximal value
expiration following a full inspiration Speech normal Can’t complete Pulmonary: Silent chest,
RR < 25 sentences cyanosis/feeble respiratory effort
Obstructive lung disease Restrictive lung disease Pulse < 110bpm RR > 25 Cardiac: Bradycardia,
FEV1 – significantly reduced FEV1 - reduced Pulse > 110bpm dysrhythmia/hypotension
FVC – reduced/normal FVC – significantly reduced Cognition: Exhaustion, coma,
FEV1% (FEV1/FVC) - reduced FEV1% (FEV1/FVC) – confusion
normal/increased Mx: SABA via Mx:
Asthma Pulmonary fibrosis spacer (2-4 O2 to achieve normal SpO2
COPD Asbestosis puffs) 10 puffs
Bronchiectasis Sarcoidosis Increase by 2 puffs SABA 10 puffs via SABA + Ipratropium nebuliser
Bronchiolitis obliterans Kyphoscoliosis every 2 minutes spacer/nebulised (Salbutamol 5mg + Ipratropium
NM disorders Consider oral Oral prednisolone 0.5mg)
Prednisolone Nebulised Oral Prednisolone 40-50mg/IV
Ipratropium bromide Hydrocortisone 100mg
Fractional exhaled NO (FeNO) nitric oxide is produced by 3 types
Repeat MgSO4
of NO synthase. One of those types is inducible (iNOS) + levels bronchodilators IV Aminophylline
tend to increase in inflammatory cells, particularly eosinophils every 20-30mins as IV Salbutamol
Levels of NO = level of inflammation necessary
CXR older pts/ those w/ smoking hx Reassess in 1 hour
Assess response to Rx: RR, HR, SpO2, PEFR
