Asthma physical examination and management

Asthma physical examination and managementCreated OnMay 27, 2020Last Updated OnMay 29, 2020byadmin You are here: Main Clinical Examination Asthma physical examination and management < All Topics Table of Contents General examination: Vital signs Temperature of __ (febrile/afebrile) Pulse rate of tachycardia/bradycardia/pulsus paraadoxus (rate,rhythm,volume) Respiratory rate of tachypnea Blood pressure __ (normotensive? Hypotensive if severe) SpO2 <95 % Observation Assess the level of consciousness – Indicate the severity Note whether patient can speak in words/phrases/sentences/couldn’t speak Dyspnea, count respiratory rate Observe for any signs of distress Pleuritic chest pain Respiratory distress Diaphoresis Cyanosis Current oxygen therapy – Nasal prongs/ Simple face mask/ High flow mask/ Venturi mask, connected to oxygen (how many litre/min) Bedside – Inhalers, medications (Can be a COPD patient) Eyes Allergic shiners (rings under eyes due to allergic rhinitis) Nose Transverse nasal crease(A) Salute sign(B) Hypertrophied turbinates Face Cushingnoid face **Refer to common signs** Central cyanosis (severe) Hands Fine tremor (excessive use salbutamol) Pulsus paradoxus Elbow flexure look for eczema Mouth Oral candidiasis (steroids, immunocompromised) Skin Look for common site of eczema (neck, elbow, wrist, knee ankle flexures) Systemic examination: Chronic asthma Inspection *Expose the upper body, inspect the both the anterior and posterior chest wall **Look for BCG scar Chest deformity: *Look for Harrison sulcus, pectus carinatum, barrel chest Increased AP diameter Decreased chest movement Use of accessory muscles Laboured breathing or respiratory distress Inspiratory & expiratory wheezing Palpation Tracheal central, trachea tug Apex beat absent (in severe cases) Chest expansion reduced bilaterally Vocal fremitus reduced Percussion Hyperresonant Auscultation Reduced air entry Vesicular with prolonged expiration Rhonchi, wheeze, crepitation Silent chest (severe asthma) Acute asthma Inspection Normal Palpation Normal Percussion Normal Auscultation Rhonchi, wheeze Signs: tachypnea, audible wheeze, hyperinflated chest, hyperresonant percussion, reduced air entry, widespread polyphonic wheeze Sign of severe asthma Agitated Shortness of breath at rest Severe retraction Loud wheeze Unable to complete a sentence in 1 breath RR > 25/min PR >110 bpm PEFR 33-50% of predicted value or single reading <200L/min Pulsus paradoxus *refer to common signs* Sign of life-threatening asthma Exhaustion, confusion, coma Silent chest (rhonchi disappear, no air entry heard) Cyanosis, feeble respiratory effort Bradycardia Hypotension PEFR <33% / not able to blow ABG marker: normal or high PCO2, acidosis, severe hypoxemia despite O2, acidosis Investigation PEF or FEV1 (<70%) Sputum culture FBC, U&E, CRP Pulse oximetry Chest x-ray: suspected complication (pneumothorax, pneumonia, lung collapse) ABG: indicated only in acute severe asthma (PEF 30-50%)   Demonstration of airway obstruction variability Bronchodilator reversibility An improvement in FEV1 of ≥12% AND ≥200 ml is a positive bronchodilator reversibility test Other method An increase in FEV1 >12% and >200 ml (or PEF >20%) from baseline after four weeks on inhaled corticosteroid (ICS) is a positive test. Patient must not have respiratory infections. Peak flow charting Peak flow monitoring over 2 – 4 weeks Calculate mean variability. Daily diurnal PEF variability is calculated from twice daily PEF as [(day’s highest – day’s lowest)/mean of day’s highest and lowest] and average over one week Variability ≥20% or diurnal variation >15% on >3 days/ week indicates a positive test Challenge tests (not routinely performed in clinical practice) Methacholine challenge A PC20 value of ≤8 mg/ml is a positive test Detection of eosinophilic inflammation or atopy Blood eosinophils Threshold for blood eosinophils is >4.0% IgE Any allergen-specific IgE >0.35 kU/L in adult Total IgE in adults >100 kU/L FeNO A level of ≥40 ppb is a positive test Management Initial assessment Mild to moderate Severe Life-threatening Speaks in phrases Sits up Not agitated RR: 20 – 30/min PR: 100 – 120/min SpO2: 90 – 95% PEF: >50% predicted or best Speak in words Sits forward Agitated Accessory muscles used RR: >30/min PR: >120/min SpO2: Saturation <90% PEF: ≤50% predicted or          best Drowsy Confused Exhausted Cyanosis Poor respiratory effort Features of severe asthma and any of the following: PaO2: <60 mmHg Normal or ↑ PaCO2 Hypotension Silent chest PEF: <33% Initial management Mild to moderate Severe Life-threatening Maintain SpO2 >94% β2-agonist pMDI preferable with spacer (4 puffs up to a maximum of 10 puffs) or nebuliser (salbutamol 5 mg); repeat every 20 minutes for 1 hour Prednisolone 1 mg/kg with maximum of 50 mg Continue or increase usual treatment Maintain SpO2 >94% Administer β2-agonist (salbutamol 2.5 – 5mg) via oxygen driven nebuliser, repeat every 20 minutes for 1 hour Administer ipratropium bromide nebuliser 0.5 mg every 4 – 6 hours Administer IV hydrocortisone 200 mg or prednisolone 1 mg/kg with maximum of 50 mg If no improvement, refer to hospital Maintain SpO2>94% Administer B 2-agonist (salbutamol 5mg) via oxygen driven   nebuliser, repeat every   20 minutes for 1hour Ipratropium bromide   nebuliser 0.5 mg every   4 – 6 hours IV hydrocortisone 200 mg or prednisolone 1 mg/kg with maximum of 50 mg LIFE-THREATENING FEATURES Consider IV magnesium sulphate 1.2 – 2 g infusion over 20 minutes Consider intubation Senior specialists may consider use of IV β2-agonist or IV aminophylline Monitor progression (any improvement, usually 1 hour after initial treatment) Physical Examination, PEF, O2 saturation and other tests as needed Mild to moderate Severe Life-threatening DISCHARGE WAAP Continue oral prednisolone (5 – 7 days) Increase usual treatment (refer to Stepwise Treatment Ladder) Ensure follow-up within 1 – 2 weeks Column 2 Value SpO2 PR RR Measure ABG: (severe hypoxia, normal or ↑ PaCO2) CXR (if pneumothorax or consolidation suspected) Monitor PEF SpO2 PR RR Measure ABG: (severe hypoxia, normal or ↑ PaCO2) CXR (if pneumothorax or consolidation suspected) Monitor PEF Monitor conscious level – to consider intubation if patients become drowsy Monitor for improvement Mild to moderate Severe Life-threatening Refer for admission Refer to critical care Determine respond after 1-2hours Good: cont reassess, discharge Incomplete: Admit, reassess, still incomplete after 6-12 hour= ICU Poor: Admit to ICU **if initial diagnosed mild to moderate asthma worsening after initial management, manage it with severe asthma management. When progression improve, step down treatment is used. If no response to severe treatment, think of: Pneumonia Pneumothorax Lung collapse Indication for admission Pre-treatment FEV1 or PEF < 25% predicted or personal best Those with...

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