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Transcript of Pharmaco2 asthma
- 1. MANAGEMENT
2. 9:30 am
- BP 140/83, HR 87bpm, spO 295%, T 36.4C
- Generalised rhonchi
- IV HCT 200mg stat given @ 9:35am.
- Neb. Combivent
- Speak in full sentence
- PEFR 300L/min, RR 30/min, O 2sat 98%
- Generalized rhonchi
- Cont neb
- pH: 7.377
- pCO 2 : 42.0mmHg
- pO 2:30.6mmHg
- Base: -0.4
- HCO 3 : 22.9mmol/L
- WBC: 8.8x10 9 /L
- Lymph#: 3.2x10 9 /L
- Gran#: 4.8x10 9 /L
- Lymph%: 35.8%
- Gran%: 54.1%
- Hb: 16.5 g/dL
- RBC: 5.13x10 12 /L
- HCT: 47%
- MCV: 91.8fL
- MCH: 32.1pg
- MCHC: 35.1 g/dL
- Plt: 252x10 9 /L
5. 6. 7. 11:30am
- BP 140/83; HR 87bpm; T 37C; spO 295%RA, 98% NPO 23L/min
- O/E generalized rhochi
- Admit 7S
- Cont a/b (h/o admission for similar problem 10 days ago)
- T azithromycin 500mg od
- IV claforan 1g tds
- NPO 23L/min
- Neb combivent 4hourly
- IV HCT 100mg qid
- ABG RA
- pH 7.498
- pCO2: 29.4mmHg
- pO2: 147mmHg
- HCO3: 25.2mmol/L
- Base: -0.3mmol/L
- Hyperinflated lungs
- Bilateral lung hazziness
- Coagulation profile
- PT: 13.2s (11.9 13.9)
- INR: 1.01 (0.86 1.14)
- aPTT: 40.5s (control 37.9)
- Na: 139mmo/L
- K: 4.1mmol/L
- Creat: 106umol/L
- Urea: 2.7mmol/L
- Cl: 108mmol/L
- Medical ward
- Assessment: infective exarcebation COPD
- Partially treated pneumonia
- Haemodynamically stable
- Not in respiratory failure
- Investigations: FBC, BUSE/creat, LFT, aPTT/INR, ESR, ECG, sputum C+S, sputum AFB (D/S x3, C+S)
- Strict I/O, encourage orally
- IVD 2 NS/24hrs
- IV claforan 2g stat & 1g tds
- T azithromycin 500mg stat & OD
- Acute reliever
- Neb combivent hourly x2 then 2hourly x2 then 6hourly
- Monitor BUSE/creat on neb combivent
- IV HCT 200mg stat & 100mg qid
- Chest physiotherapy
- Stop smoking education
- Refer quit smoking clinic
- Increase neb combivent 4hourly
- Continue a/b
- Continue IV hydrocort
- Inhaler technique
- MDI becotide 2puffs bd
- MDI combivent 2puffs tds
13. PEFR chart L/min TimeDay 1 Day 2 day3 day4 14. DIAGNOSING ASTHMA 15.
- Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors.
- Symptoms & medical history
- Lung function
- Additional diagnostic tests
- Airway responsiveness
- Skin tests with allergens or measurement of specific IgE in serum
18. 19. 20. 21. 22. Prompt tx
- Inhaled rapid-acting 2 -agonists in adequate doses are essential.
- begin with 2 to 4 puffs every 20 minutes for 1 sthour;
- then mild exacerbations will require 2 to 4 puffs every 3 to 4 hours, and
- moderate exacerbations 6 to 10 puffs every 1 to 2 hours.
- Oral glucocorticoids (0.5 to 1 mg of prednisolone/kg or equivalent during a 24 hr period) introduced early in the course of a moderate or severe attack.
- O 2is given if patient is hypoxemic (achieve O 2saturation of 95%).
23. Prompt tx
- Combination 2 -agonist/anticholinergic therapy is associated with lower hospitalization rates.
- Methylxanthines are not recommended if used in addition to high doses on inhaled 2 -agonists.
- Monitor response to tx
- Evaluate symptoms, peak flow, O 2saturation
- After exacerbations is resolved
- Identify precipitating factors
- Implement avoidance strategies
- Review pts medication
- Continue oxygen > 40%
- IV HCT 100-200 mg 6 hourly or prednisolone 30-60 mg daily.
- Neb 2 -agonist 2-4 hourly preferably in combination with anticholinergic.
- If patient is still not improving, commence aminophylline infusion (0.5-0.9 mg/kg/hour); monitor blood levels if aminophylline infusion is continued for more than 24 hours.
- Terbutaline or salbutamol infusion at 3-20 mcg/min after an initial IV bolus dose of 250 mcg over 10 mins can be given as an alternative.
- In cases where response to the above treatment is inadequate, IV MgSO 42 g in 50 ml NS infused over 10-20 mins may be given.
27. Monitoring the response to treatment
- Repeat measurement of PEF 15-30 minutes after starting treatment.
- Aim to maintain arterial oxygen saturation above 92%.
- Repeat arterial blood gas measurements if initial results are abnormal or if patient deteriorate.
- Monitor PEF at least 4 times daily throughout the hospital stay.
- Other I(x):
- ECG if indicated
28. Transfer pt to ICU or prepare to intubate if there is:
- Deteriorating PEF
- Worsening hypoxaemia, or hypercapnia
- Exhaustion or feeble respiration
- Confusion or drowsiness
- Coma or respiratory arrest
- Cont O 2
- Cont IV HCT
- If the patient is mechanically ventilated, administer neb 2 - agonist with anticholinergic via the ETT. This can be given up to every 15-30min.
- IVI aminophylline or terbutaline or salbutamol should be continued
- IVI MgSO 4may be added.
31. DISCHARGE PLAN FOR HOSPITALISED PATIENT
- Before discharge, the patient should be:
- started on inhaled steroids for at least 48 hours in addition to a short course of oral prednisolone and bronchodilators
- Stable on the medications he is going to take outside the hospital for at least 24 hours
- Having PEF of > 75% of predicted or best value and PEF diurnal variability of < 20%
- Able to use the inhaler correctly and if necessary, alternative inhaler devices could be prescribed
- Educated on the discharge medication, home peak flow monitoring and self
- Management plan (for selected, motivated patients), and the importance of regular follow up
- Given an early follow-up appointment within 2-4 weeks for reassessment of the condition and for adjustment of the medicines