Asthma


Asthma is a common disease and presents to acute healthcare services extremely frequently.

The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment. On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases.

It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about treatment plans and reasons to return.

In Part 1 of the podcast we’ll run through

  • Pathophysiology
  • How patients present
  • Guidelines
      • Salbutamol
      • Ipratropium
      • Steroids
      • MagnesiumTreatment

 

Part 2 covers

  • Ketamine
  • Ultrasound in asthma
  • NIV in asthma
  • Asthma related cardiac arrest
    •  Imaging
    • Management
  • Discharge

We hope you enjoy it and would love to hear your feedback!

SimonRob & James

References & Further Reading

BTS Asthma Guidelines 2016

Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013 

Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016

TheResusRoom; Needle Thoracostomy podcast

TheResusRoom; BTS Asthma Guidelines 2016 podcast

LITFL; Non-invasive ventilation (NIV) and asthma

Intensiveblog; Asthma mechanical Ventilation Pitfalls

BestBets; In a severe Exacerbation of asthma can Ketamine be used to avoid the need for mechanical ventilation in adults?

Australian Asthma Handbook; Quick Reference Guide

BTS Asthma Severity Criteria

BTS Admission Criteria

 

Comments

5 comments on “Asthma”
  1. Armchairflyer says:

    Great pertinent podcast. Some very interesting approaches and enthusiastically delivered. James is perfect addition.

    I trained as a paramedic in South Africa. I remember that the IC paras used to change our I:E ratio when BVMing to allow for longer expiratory times assisting lowing Eto2 and decreasing intra thoracic pressures. Also, choose the largest size ETtube possible rather than standard sizing for patient. A controversial move in intubated obtunded (but born out of necessity I guess) was using a 50ml syringe and placing the MDI ventolin can into the chamber of the syringe (by removing the plunger of the syringe). Insert syringe into drainage port of cath mount, depress syringe and deliver PPV. This was “practiced” and encouraged in pre hospital practice around Cape Town but I didn’t use it in danger. Just throwing it out there…blue skying.
    Keep up the great podcasts….

    1. Simon Laing says:

      Thanks for that, not something I’ve ever come across but will be sure to take a look.

      James is indeed a superb addition to the team, we’ll pass on your kind comments! Thanks again, great to hear some feedback.

  2. David Kaniecki says:

    Hi Guys:

    First, thanks for such a wonderful podcast each month. I listen regularly from the US and love it. However, I disagree with a statement made regarding ASTHMA and nebs post intubation…maybe I just heard this wrong.

    I have 12 years experience as both a Flight Nurse and Flight Acute Care Nurse Practioner and while I agree that a T-piece during a typical cardiac arrest is a complete waist of time….I think in the asthmatic arrest it could be helpful to keep the B2s going. Yes, absolutely not your first priority but to say it is not helpful…I disagree. Especially if you are seeing the patient late in their course and have not had time to try this treatment prior to intubation. The B2s might open them up and you get them back.

    I can set the neb up in 10 seconds if I have it in my hand so disagree it take too long.

    I’m not certain as to the ventilators you guys use but the most common vents in PreHospital and ED that I’ve seen (LTV1000 and LTV1200), once the pressure goes beyond the set PEEP it is released from the circuit to the atmosphere so the argument of barotrauma caused by the additional inflow of gas with the nebulizer, I’m not certain is true.

    Please note the visual I made public: https://drive.google.com/open?id=0B1szMGS3uYvlcEdLNUtLTnRmWTQ

    Getting away from the arrest and perhaps most importantly…I think after you intubate an asthmatic it would be a HUGE mistake NOT to keep the nebs going thru the vent circuit until you gain control and the steroids, mag, or whatever else you use kick in. Again…especially if they have not yet had a trial of these treatments.

    With many things, I have been wrong before but clarification on this would be helpful.

    Thanks and keep up the good work.

    Dave

    1. Simon Laing says:

      Hi David,

      Thanks for the comment. We were trying to make the point that when an asthmatic patients arrests that the delivery of Salbutamol could be via an iv route rather than via nebulisers in circuit. I think it’s fair to say that if you then go on to get a ROSC there maybe some debate as to whether you continue with the salbutamol initially being i.v. or switching to nebs at that point, but with the likely limited time frame you have to achieve a ROSC we thought management could be limited to iv only with respect to salbutamol delivery.

      Hope that makes sense

      Cheers

      Simon

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