Asthma and COPD are different disorders, although they may share some common traits and clinical features (e.g. eosinophilia, some degree of reversibility). This course concentrates on patients who present with an acute exacerbation. However, to be able to treat these and answer patients questions, it is essential that we know about the conditions and what causes them.
Acute exacerbations of chronic asthma are most frequently caused by respiratory viruses. Other causes include bacterial infections, allergens, pollutants and occupational exposure (Geeky Medics).
A history should include;
- Triggers (pets, carpets, temperature)
- Occupation (exposure to dusts, chemicals)
- Frequency of exacerbations and previous hospital/intensive care admissions
- Personal or family history of atopy
- Best expected and recent peak expiratory flow rate (PEFR)
- Adherence with treatment
- Smoking (including passive smoking) history
It is important after managing the patient’s acute presentation that you address any of the causes above to prevent another exacerbation.
One of the most important things to do is ALWAYS check patients inhaler technique (also make sure you know what a good technique is). Refer to the materials section of this lesson for a video on inhaler technique.
If you are prescribing inhalers it is important to advise them how to use it. Even if they have had inhalers for years. You would be suprised at some patients’ techniques.
A thorough systems review is important to rule out alternative causes for the presentation.
Determine the severity of the exacerbation, bearing in mind that people with a severe or life-threatening exacerbation sometimes do not appear to be distressed.
- Note the person’s degree of agitation and consciousness. Agitation and behavioural changes may be a sign of hypoxia (especially in a child).
- Look for signs of exhaustion (inability to complete sentences), cyanosis (bluish lips or extremities), and use of accessory muscles while the person is at rest.
- Examine the person’s chest, and record their respiratory rate, pulse and blood pressure.
- Record the person’s peak expiratory flow rate (if they are old and well enough to comply) and use the best of three recordings compared to the person’s best (if measured within the last two years) or predicted PEFR value.
- Measure the person’s oxygen saturation in room air using pulse oximetry (if available).
- Inspection: increased work of breathing, cyanosis, cough, audible wheeze
- Peripheries: fine tremor (salbutamol use), tachycardia, oral candidiasis (steroid inhaler use)
- Chest: polyphonic expiratory wheeze
Consider the need for hospital admission:
- Admit all people with features of a life-threatening asthma exacerbation.
- Admit people with any feature of a severe asthma attack persisting after initial bronchodilator treatment.
- Admit people with a moderate asthma exacerbation with worsening symptoms, despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack. People with a moderate exacerbation may also require admission if they have factors that warrant a lower threshold for admission, such as:
Excercise 3: Think about the factors below which warrant a lower threshold for treatment or referral. Would any of these apply to Pat.
- Recent hospital admission
- Poor treatment adherence
- Living alone/isolation
- Psychological conditions – drugs or alcohol abuse
- Physical or learning disability
- Previous severe asthma attack
- Exacerbation despite an adequate dose of oral corticosteroids before presentation
- Recent nocturnal symptoms
See NICE Guidelines for acute exacerbation of asthma (Ref 5) in the materials section at the top of the page