Tasty Morsels of EM 107 – #FRCEM Asthma and Bronchiolitis

3 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

NICE is due with a guideline later this year but the BTS/SIGN 2016 guidelines seem to be the current standard. NICE 2015 for bronchiolitis.

RCEM Learning has a 2 part podcast on it two

How do we assess asthma in adults?

  • Moderate
    • inreasing symptoms
    • PEF >50-75%
  • Acute Severe (any)
    • PEF 33-50%
    • RR>25
    • HR>110
    • inability to complete sentences
  • Life threatening (any)
    • PEF<33%
    • sats<92
    • PaO2 <8
    • Normal PaCO2
    • silent chest
    • cyanosis
    • poor effort
    • arrhythmia
    • exhaustion
    • altered conscious level
    • hypotension
  • Near Fatal
    • raised PaCO2
    • and/or requiring ventilation

Reasons to get a CXR in adults

  • suspect pneumothorax or pneumomediasatinum
  • suspect consolidation
  • lief threatening
  • not responding
  • requiring vent

Reasons to get an ABG

  • sats<92
  • any life threatening features

Criteria for admission in adults

  • any with life threatening or near fatal
  • any severe features after initial treatment
  • as a converse if PEF>75% at one hour then they can probably go home

Treatment in adults

  • oxygen only if hypoxic
  • give nebs with oxygen
  • give lots of Beta agonist nebs
  • give ipratroium bromide if acute severe and poor initial response
  • give steroids for all (40-50mg for 5 days)
  • neb magnesium not recommended for adults
  • IV mag if acute severe and poor response to initial treatment
  • (IV salbutamol noted by its absence…)

How do we assess asthma in kids?

  • acute severe (similar apart from physiological limits)
    • PEF 33-50%
    • can’t complete sentences or feed
    • HR>125 (>5 yrs)
    • HR>140 (1-5 yrs)
    • RR>30 (>5 yrs)
    • RR>40 (1-5 yrs)
    • sats<92
  • life threatening (again very similar just less of them)
    • sats<92 plus
      • PEF<33%
      • silent chest
      • cyanosis
      • poor effort
      • hypotension
      • exhaustion
      • confusion

What about Treatment in kids?

  • space Beta agonist is preferred in mild-moderate
  • add ipratropium if refractory
  • consider adding neb mag in acute severe
  • steroids
    • 10mg <2
    • 20mg 2-5
    • 30-40mg >5
    • 3 days is the standard course
  • consider IV salbutamol early (15mcg/kg) if poor response
  • consider IV aminophylline in life threatening and not responding
  • consider IV mag (40mg/kg/day) if poor response

Asthma in pregnancy?

  • give all meds as needed inc steroids, aminophylline and mag seems to be the answer

What is and how should we diagnose bronchiolitis?

  • a seasonal illness amongst kids, mainly 3-6 months but can be older
  • presents with airway obstruction type symptoms from viral inflammation and mucous plugging
  • 75% is RSV, the rest being  influenza, para influenza, adenovirus
  • NICE says diagnose it when
    • coryzal prodrome 1-3 days
    • cough and
    • tachypnoea or recession and
    • wheeze or crackles
  • They note that in under 6 weeks apnoea might be all you get
  • Risk factors
    • <6/52 old, born at <35/40
    • immunosuppresed
    • cardiac disease
    • smokers (the parents not the child…)

How do we manage it?

  • Admit
    • apnoea (even if only report)
    • sats less than 92 on room air
    • inadequate intake (50-75% of normal)
    • persistent distress (RR>70, grunting)
  • Don’t give any of the things that you might want to give including
    • hypertonic
    • salbutamol
    • steroids
    • adrenaline
  • And don’t do a CXR
  • And don’t routinely suction though do do it on all the apnoeic ones and consider where feeding is a problem


5 Replies to “Tasty Morsels of EM 107 – #FRCEM Asthma and Bronchiolitis

  1. Hi Andy,
    Your podcasts are amazing so are these notes. Which question bank do you follow for exam preparation and along OHEM what other resources do you recommend for the FRCEM…please help; your guidance is highly appreciated.

  2. Hi Andy, these notes are brill, and I like the layout. Very pleasing. Note they have squeezed in Sats<92% for Acute Severe in kids.

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