ASTHMA

on general inspection
tachypnea
dyspnoea
audible wheeze
cyanosis
cough
eczema
intercostal recession
pulsus paradoxus

FEATURES

MILD
ASTHMA

RESPIRATORY
RATE

< 25
breaths/min

MODERATE
25-30
SEVERE
breaths/min
ASTHMA

VERY
SEVERE
ASTHMA

LIFETHREATENING

> 30
breaths/min

PULSE
RATE

SPEECH

BREATHLESSNES
S

WHEEZE

PEF

SPO2

moderate
breathless when wheeze on
<
auscultation,
normal speech walking, increase
often end
100/min
chest tightness
expiratory
only

PEF >
75% of
predicted
or best
value

SpO2 >
95%
(on room
air)

100120/min

loud wheeze

between
50 to 75%
of
predicted
or best
value

SpO2 9195%
(on room
air)

loud wheeze

< 50%
predicted
or best
value

SpO2 <
90%
(on room
air)

>
120/min

talks in
phrases

talks in words

breathless when
talking

breathless at rest

PEF <
30%
silent chest on
predicted
auscultation
or best
value

on palpation
chest wall movement
(decrease)
lung expansion <5cm
(obstructive)
mediastinal displacement
(none)

on percussion
finding: normal or decreased
sound

on auscultation
prolonged expiratory phase
rhonchi heard at the end on
exhalation
normal or reduced breath
sound
silent chest

Diagnosing key to asthma:

Peak expiratory flow meter (PEF) -use normogram

Severe persistent

Moderate persistent

PEF <60% predicted

variability >30%
PEF >60%-<80% predicted
variability 30%

Mild persistent

PEF >80% predicted

variability 20-30%

Intermittent

PEF >80% predicted

variability <20%

PEF Measurements
(i) During periods of well-being
() Twice daily measurements (morning and evening) before any
inhaled bronchodilator treatment will determine the diurnal
variability of airway calibre. This is calculated as the range divided
by the highest value and expressed as a percentage.
() PEF (max) PEF (min) x 100 = _______ %
PEF (max)
() Good control of asthma means PEF variability is maintained at
<10%.
(ii) During symptomatic episodes = measures the degree of
bronchospasm
() PEF of less than 50% of normal or best suggests a very severe
attack
() PEF of less than 30% suggests a life-threatening attack.
~This was not done in this patient as she already receives her
nebulizer treatment when we saw her.

MORE DDX...
CHEST WALL
MOVEMENT

PERCUSSION
NOTE

reduced over
afected area

dull

bronchial

crackles

COLLAPSE

ipsilateral shift

decreased over
affected area

dull

absent/reduced

absent

PNEUMOTHORAX

tracheal deviation
to opposite side in
under tension

decreased over
affected area

resonant

absent/ greatly
reduced

absent

BRONCHIAL
ASTHMA

decreased
symmetrically

normal/decrease

normal/ reduced

rhonchi

INTERSTITIAL
PULMONARY
FIBROSIS

decreased
symmetrically
(minimal)

normal unaffected
by cough /
posture

normal

fine, late/ paninspiratory

crackles over
affected lobes

PLEURAL
EFFUSION

displaced to
opposite side

reduced over
affected area

DISORDER

MEDIASTINAL
DISPLACEMENT

CONSOLIDATION

stony dull

BREATH SOUND ADDED SOUND

absent; pleural rub

absent over fluid
maybe found
above effusion

Management for mild asthma

attacks
(i) INITIAL PEF > 75%
Give the patients usual inhaled
bronchodilator or nebulised bronchodilator.
Multiple doses (5-20 puffs) of inhaled
bronchodilator using a large volume spacer
can be given in place of nebulised
bronchodilator.
Observe for 60 minutes. If the patient shows
clinical improvement and PEF remains >
75%, discharge.

MANAGEMENT 30 MINUTES
AFTER INITIAL TREATMENT OF ACUTE
ASTHMA
WITH AN INITIAL PEF < 75% PREDICTED OR
BEST
Good response and
PEF > 75%
predicted
or best value

Incomplete response
and
PEF 50-75% predicted
or best value

Observe for another

60 minutes

Repeat nebulised beta2agonist and

anticholinergic

If patient is stable or
improving and PEF
remains > 75%,
DISCHARGE

Observe for 60 minutes.

1)If PEF is still < 75%,
ADMIT
2)If patient improves
and PEF > 75%,
DISCHARGE

Poor response
and PEF
<50% predicted
or
best value
ADMIT

CLASSIFICATION OF ASTHMA
SEVERITY
BEFORE
TREATMENT
SYMPTOMS
NIGHT
PEF
TIME
SYMPTO
MS
INTERMITT
ENT

< 1 time a week

Brief exacerbations
Asymptomatic and normal
PEF between exacerbations

< 2 times
a
month

> 80% predicted

Variability < 20%

MILD
PERSISTEN
T

> 1 time a week

but < 1 time a day
Exacerbations may affect
activity and sleep

> 2 times
a
month

> 80% predicted

Variability 20-30%

MODERATE
PERSISTEN
T

Daily
Daily use of beta2-agonist
Exacerbations affect activity
and sleep

> 1 time a
week

> 60% - < 80%

predicted
Variability > 30%

SEVERE
PERSISTEN
T

Daily
Frequent exacerbations
Limitation of physical activity

Frequent

< 60% predicted

Variability > 30%

Assessment of asthma
control
(for patient prescribed with
ICS only)

Patient Conditions (* this list is for patient)

Control of
asthma

You have no wheeze, shortness of breath nor cough

You are able to do usual activities
You sleep well
You do not need your bronchodilator more than once a day
Your peak flow is more than (80% of best)

Well
controlled

You notice wheeze and difficulty in breathing more than usual

during the day
Your usual activities are affected
You wake up once or twice a night with asthma
You need your bronchodilator more than 2 times a day
Your peak flow is less than (80% of best)

Uncontrolled

You notice wheeze and difficulty in breathing most of the day

You are unable to carry out usual activities such as talking and
walking
You are awake most of the night
You need your bronchodilator more than 6 times a day
Your peak flow is less than (60% of best)

Severe

Management prior to
discharge:
Give prednisolone 30-60 mg* daily
for 7-14 days plus inhaled beta2agonist to be taken as needed
(Salbutamol).
Review adequacy of usual treatment
and step up if necessary according to
guidelines for treatment of chronic
persistent asthma.

 Ensure patient has enough supply of

medications.
~ She was prescribed with additional
Salbutamol MDI.
Check inhaler technique and correct if faulty.
Arrange for follow-up within 2 weeks
Advise patients to return immediately if
asthma worsens

The following are indications for

immediate referral to hospital
1. Any life-threatening features.
2. Any features of a severe attack that
persist after initial treatment.
3. PEF 15-30 minutes after
nebulization, which is < 50% of
predicted or best value.

What to educate asthmatic

patients?
Educate the patient and their family about
the disease itself and its nature so that
they know what they are dealing with
Tell them about allergen and let them
identify the trigger factors and avoid them
Drug used and their side effects
Proper techniques of inhalers
usage
Self management plan