RESPIRATORY EMERGENCY
Topics:
1. Asthma
2. COPD
3. Pulmonary Embolism
4. Pneumonia
5. Pneumothorax
6. Acute Respiratory Failure
Dyspnoea = subjective feeling of difficulty in breathing
Causes of dyspnoea:
Cardiac Respiratory Others
Acute pulmonary oedema (APO) Upper airway obstruction (Foreign Anaphylaxis
Heart failure body inhalation) Adult respiratory distress syndrome
Cardiac tamponade Asthma (Near drowning)
ACS COPD Anaemia
Anxiety
Pericarditis Pulmonary embolism
Hyperventilation syndrome
Aortic dissection Pneumonia Deconditioning
Pneumothorax
Respiratory failure
ASTHMA
Asthma is an inflammatory disease of the airways AEBA: Progressive or sudden onset of
triggered by external stimuli in genetically-predisposed worsening symptoms such as shortness of
individuals, leads to mucus secretion, bronchoconstriction breath, chest tightness, wheezing and coughing
and airway narrowing.
Risk factor
Genetic Environmental Comorbidities
Single parent has asthma -3% Smoking Overweight (1%)/Obese (2%)
Both parents have asthma -7% Air pollution GERD
Paint Nasal blockage, rhinorrhoea and allergic rhinitis
Pesticides Fractional exhaled nitric oxide (FeNO) and skin prick test
Asthma diagnosis is based on a combination of:
• History
✓ wheeze
✓ cough
✓ chest tightness
✓ SOB
• Presence of obstructive airflow reversibility
A response to treatment (bronchodilator or
corticosteroids) may aid the diagnosis but a
lack of response may not exclude asthma.
CAICAI_ART CRASH COURSE FOO SHUI CAI
,Investigations that may be performed for the diagnosis of asthma. (CPG)
Investigation Description
Demonstration of airway obstruction
Spirometry FEV1/FVC <70% is a positive test for obstructive airway disease
Demonstration of airway obstruction variability
Bronchodilator Positive → An improvement in FEV1 of ≥12% AND ≥200 ml
reversibility
Other method Positive → An increase in FEV1 >12% and >200 ml (or PEF >20%) from baseline
after 4 weeks on ICS. Patient must not have respiratory infections.
Peak flow charting Peak flow monitoring over 2 - 4 weeks
Positive → Variability ≥20% or diurnal variation >15% on >3 days/week
Detection of eosinophilic inflammation or atopy
Eosinophils >4%
IgE Any allergen specific IgE >0.35kU/L in adult
Total IgE in adult >100kU/L
FeNO Positive → ≥40 ppb
Stable Asthma
➔ absence of symptoms, no limitations of activities and no use of reliever medication in the last four weeks.
Alternatively, stable asthma is classified when the ACT scores are 20 - 25
Asthma patients need regular TCA to assess asthma
control and adjust treatment accordingly, which
includes:
• assessment of asthma control
• asthma attacks
• frequency of bronchodilator use
• use of OCS and absence from work/school since
last follow-up
• inhaler technique and adherence
• lung function assessment by spirometry or PEF
• use of a self-management plan/personal action
plan
Patient’s recommended TCA:
❖ within 1 - 2 weeks after an
Potentially modifiable independent risk factors for exacerbations:
exacerbation
✓ Uncontrolled asthma symptoms
❖ 1 - 3 months after starting
✓ ICS not prescribed, poor ICS adherence, incorrect inhaler
treatment
technique
❖ every 3 - 6 months once stable
✓ High SABA use (with increased mortality if >1 x 200-dose
❖ every 4 - 6 weeks in pregnancy
canister/month)
✓ Low FEV1, especially if <60% predicted
✓ Major psychological or socioeconomic problems
✓ Exposures: smoking; allergen exposure if sensitised
✓ Co-morbidities: obesity, rhinosinusitis, confirmed food allergy
✓ Sputum or blood eosinophilia, elevated FeNO in allergic adults
✓ Pregnancy
✓ Other major independent risk factors for exacerbations
include:
H/o intubation or in intensive care for asthma
Having ≥1 severe exacerbation in the last 12 months
CAICAI_ART CRASH COURSE FOO SHUI CAI
, Management of stable asthma
Criteria for Step Up/Step Down
When asthma is not controlled based on
symptom control and increased future risk,
assess the following common issues first before
consider stepping up treatment:
▪ Incorrect inhaler technique
▪ Poor adherence to medications
▪ Modifiable risk factors
▪ co-morbid conditions e.g. allergic rhinitis
Common drugs used in ward
Seretide= salmeterol +Fluticasone (usually for COPD)
COMBIVENT = (ipratropium bromide + albuterol)
SPIRIVA = Tiotropium bromide
Airflusal= combination of salmeterol +Fluticasone
Budesonide = Corticosteroid
Symbicort = Budesonide + Formoterol
Ventolin = salbutamol
Foster/Fostair inhaler = beclomethasone + formoterol
ACUTE EXACERBATION OF ASTHMA
progressive or sudden onset of worsening
symptoms such as shortness of breath, chest
tightness, wheezing and coughing → can progress rapidly to Signs of severe exacerbation of asthma:
respiratory failure and death ➢ sit forward
➔ (state AEBA secondary to ?) ➢ speak in words or short phrases
➢ use of accessory muscles
**Status asthmaticus is a life-threatening and medical
➢ agitation/altered consciousness
emergency
➢ tachypnoea (>25)
➢ tachycardia (>120bpm)
➢ hypoxia
➢ silent chest
Sign of life-threatening asthma:
➢ Silent chest, cyanosis, feeble respiratory
effort
➢ Bradycardia
➢ Hypotension
➢ Exhaustion, confusion, coma
➢ PEFR <33% of predicted
➢ ABG: normal/high PaCO2, severe
hypoxemia (PaO2 <60mmHg) despite
HFM, acidosis
Risk of asthma-related deaths:
❖ h/o near-fatal asthma requiring intubation and
mechanical
ventilation
❖ h/o hospitalisation or ED visit for asthma in the
past one year
❖ currently using or having recently stopped using
OCS
❖ not currently using ICS
❖ overuse of SABAs (>1 canister of salbutamol per
month)
❖ h/o psychiatric disease or psychosocial problems
❖ poor adherence with medications
❖ h/o food allergy
CAICAI_ART CRASH COURSE FOO SHUI CAI
Topics:
1. Asthma
2. COPD
3. Pulmonary Embolism
4. Pneumonia
5. Pneumothorax
6. Acute Respiratory Failure
Dyspnoea = subjective feeling of difficulty in breathing
Causes of dyspnoea:
Cardiac Respiratory Others
Acute pulmonary oedema (APO) Upper airway obstruction (Foreign Anaphylaxis
Heart failure body inhalation) Adult respiratory distress syndrome
Cardiac tamponade Asthma (Near drowning)
ACS COPD Anaemia
Anxiety
Pericarditis Pulmonary embolism
Hyperventilation syndrome
Aortic dissection Pneumonia Deconditioning
Pneumothorax
Respiratory failure
ASTHMA
Asthma is an inflammatory disease of the airways AEBA: Progressive or sudden onset of
triggered by external stimuli in genetically-predisposed worsening symptoms such as shortness of
individuals, leads to mucus secretion, bronchoconstriction breath, chest tightness, wheezing and coughing
and airway narrowing.
Risk factor
Genetic Environmental Comorbidities
Single parent has asthma -3% Smoking Overweight (1%)/Obese (2%)
Both parents have asthma -7% Air pollution GERD
Paint Nasal blockage, rhinorrhoea and allergic rhinitis
Pesticides Fractional exhaled nitric oxide (FeNO) and skin prick test
Asthma diagnosis is based on a combination of:
• History
✓ wheeze
✓ cough
✓ chest tightness
✓ SOB
• Presence of obstructive airflow reversibility
A response to treatment (bronchodilator or
corticosteroids) may aid the diagnosis but a
lack of response may not exclude asthma.
CAICAI_ART CRASH COURSE FOO SHUI CAI
,Investigations that may be performed for the diagnosis of asthma. (CPG)
Investigation Description
Demonstration of airway obstruction
Spirometry FEV1/FVC <70% is a positive test for obstructive airway disease
Demonstration of airway obstruction variability
Bronchodilator Positive → An improvement in FEV1 of ≥12% AND ≥200 ml
reversibility
Other method Positive → An increase in FEV1 >12% and >200 ml (or PEF >20%) from baseline
after 4 weeks on ICS. Patient must not have respiratory infections.
Peak flow charting Peak flow monitoring over 2 - 4 weeks
Positive → Variability ≥20% or diurnal variation >15% on >3 days/week
Detection of eosinophilic inflammation or atopy
Eosinophils >4%
IgE Any allergen specific IgE >0.35kU/L in adult
Total IgE in adult >100kU/L
FeNO Positive → ≥40 ppb
Stable Asthma
➔ absence of symptoms, no limitations of activities and no use of reliever medication in the last four weeks.
Alternatively, stable asthma is classified when the ACT scores are 20 - 25
Asthma patients need regular TCA to assess asthma
control and adjust treatment accordingly, which
includes:
• assessment of asthma control
• asthma attacks
• frequency of bronchodilator use
• use of OCS and absence from work/school since
last follow-up
• inhaler technique and adherence
• lung function assessment by spirometry or PEF
• use of a self-management plan/personal action
plan
Patient’s recommended TCA:
❖ within 1 - 2 weeks after an
Potentially modifiable independent risk factors for exacerbations:
exacerbation
✓ Uncontrolled asthma symptoms
❖ 1 - 3 months after starting
✓ ICS not prescribed, poor ICS adherence, incorrect inhaler
treatment
technique
❖ every 3 - 6 months once stable
✓ High SABA use (with increased mortality if >1 x 200-dose
❖ every 4 - 6 weeks in pregnancy
canister/month)
✓ Low FEV1, especially if <60% predicted
✓ Major psychological or socioeconomic problems
✓ Exposures: smoking; allergen exposure if sensitised
✓ Co-morbidities: obesity, rhinosinusitis, confirmed food allergy
✓ Sputum or blood eosinophilia, elevated FeNO in allergic adults
✓ Pregnancy
✓ Other major independent risk factors for exacerbations
include:
H/o intubation or in intensive care for asthma
Having ≥1 severe exacerbation in the last 12 months
CAICAI_ART CRASH COURSE FOO SHUI CAI
, Management of stable asthma
Criteria for Step Up/Step Down
When asthma is not controlled based on
symptom control and increased future risk,
assess the following common issues first before
consider stepping up treatment:
▪ Incorrect inhaler technique
▪ Poor adherence to medications
▪ Modifiable risk factors
▪ co-morbid conditions e.g. allergic rhinitis
Common drugs used in ward
Seretide= salmeterol +Fluticasone (usually for COPD)
COMBIVENT = (ipratropium bromide + albuterol)
SPIRIVA = Tiotropium bromide
Airflusal= combination of salmeterol +Fluticasone
Budesonide = Corticosteroid
Symbicort = Budesonide + Formoterol
Ventolin = salbutamol
Foster/Fostair inhaler = beclomethasone + formoterol
ACUTE EXACERBATION OF ASTHMA
progressive or sudden onset of worsening
symptoms such as shortness of breath, chest
tightness, wheezing and coughing → can progress rapidly to Signs of severe exacerbation of asthma:
respiratory failure and death ➢ sit forward
➔ (state AEBA secondary to ?) ➢ speak in words or short phrases
➢ use of accessory muscles
**Status asthmaticus is a life-threatening and medical
➢ agitation/altered consciousness
emergency
➢ tachypnoea (>25)
➢ tachycardia (>120bpm)
➢ hypoxia
➢ silent chest
Sign of life-threatening asthma:
➢ Silent chest, cyanosis, feeble respiratory
effort
➢ Bradycardia
➢ Hypotension
➢ Exhaustion, confusion, coma
➢ PEFR <33% of predicted
➢ ABG: normal/high PaCO2, severe
hypoxemia (PaO2 <60mmHg) despite
HFM, acidosis
Risk of asthma-related deaths:
❖ h/o near-fatal asthma requiring intubation and
mechanical
ventilation
❖ h/o hospitalisation or ED visit for asthma in the
past one year
❖ currently using or having recently stopped using
OCS
❖ not currently using ICS
❖ overuse of SABAs (>1 canister of salbutamol per
month)
❖ h/o psychiatric disease or psychosocial problems
❖ poor adherence with medications
❖ h/o food allergy
CAICAI_ART CRASH COURSE FOO SHUI CAI
