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Bronchospasm & Bronchospasm & SOB Kim Kilmurray Senior Clinical Teaching Fellow 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 B on ABCDE assessment RR Oxygen saturations Respiratory distress Use of respiratory muscles Tachypnoea Speaking in sentences Cyanosis Tripod position Drooling Stridor Wheeze 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 Respiratory examination Percussion Dullness Hyperresonance Auscultation Breath sounds Vocal resonance 2 zones anteriorly 3 zones posteriorly Axilla Compare right with left Remember to always examine the back! 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 Symptoms Difficulty breathing Wheezing Coughing Dyspnoea 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) What’s abnormal in her observations? Pyrexia Tachycardia Tachypnoea Hypoxia PEFR < 50% normal On examination Speaking in phrases Using respiratory accessory muscles Chest – Reduced AE throughout Widespread expiratory wheeze Treatment Salbutamol nebuliser – 5mg Ipratropium Bromide nebuliser – 500 mcg Prednisolone 50 mg Oxygen therapy to maintain saturations > 94% She’s not improving – what’s next? Back to back salbutamol nebulisers IV Magnesium Sulphate 2g Antibiotics – IV amoxicillin 1g ?Salbutamol IV infusion Diagnosis Infective acute severe exacerbation of asthma How do you grade asthma exacerbations? Moderate Severe Life Threatening Near Fatal Moderate Asthma Increasing symptoms PEF >50–75% best or predicted No features of acute severe asthma 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 Life Threatening Asthma PEFR < 33% best or predicted Cyanosis SpO2 < 92% Poor respiratory effort PaO2 < 8 kPa Arrhythmia Normal PaCO2 (4.6–6.0 kPa) Exhaustion Silent chest Altered conscious level Hypotension Near Fatal Asthma Raised PaCO2 and/or requiring mechanical Ventilation with raised inflation pressures 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 What are his abnormal observations? Pyrexia Tachycardia Tachypnoea Hypoxia On examination Speaking in words Central cyanosis Using respiratory accessory muscles Chest AE equal and bilateral Widespread expiratory wheeze ABG pO₂ 7.2 kPa pCO₂ 12.4 kPa H⁺ 64 mmol HCO₃ 32 mmol ABG Type 2 Respiratory Failure Hypoxia (low oxygen) Hypercapnia (high carbon dioxide) Respiratory Acidosis High hydrogen ion concentration High carbon dioxide 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 Venturi masks 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 What are her abnormal observations? Tachycardia Hypotension Tachypnoea Hypoxia Airway noises Wheeze Caused by lower airway swelling Expiratory Whistling Stridor Caused by upper airway swelling Inspiratory Harsh, high pitched Causes of wheeze Asthma COPD Bronchiolitis Viral induced wheeze Bronchiectasis Causes of stridor Anaphylaxis Angio-oedema Croup Laryngitis Severe tonsillitis Inhaled foreign body Epiglottitis Vocal cord dysfunction ANAPHYLAXIS Signs & symptoms Wheeze Hoarseness Chest tightness Urticaria Angio-oedema Stridor Respiratory collapse Confusion Agitation Hypotension Cyanosis Treatment Give intramuscular (IM) adrenaline 1:1000 0.5mg (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 Beware!!! The Biphasic reaction A delayed reaction with further symptoms developing 4–8 hours after the initial presentation. 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 QUESTIONS .
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