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Acute exacerbations of asthma and COPD are often initially managed with inhaled beta2-agonists (salbutamol), inhaled anticholinergics (ipratropium bromide), steroids and O2. In severe cases, treatment adjuncts such as MgSO4 IV, Salbutamol IV, Aminophylline IV and Adrenaline may be considered. Administration of salbutamol has traditionally been via nebulisation, but we will consider burst therapy as an alternative here as well.
Salbutamol nebulisation:
- nebulised in saline/sterile water (1 - 2ml)
- 2.5mg (<5yrs) or 5mg (>5yrs)
- repeat at 30min to 1hour interval, then 2 - 4hourly until recovered
Ipratropium nebulisation:
- may be combined in nebuliser with Salbutamol
- 250mcg (<5yrs) or 500mcg (>5yrs) every 20min for 3 doses
- then 2 puffs (<5yrs) or 4 puffs (>5yrs) every 6h
Salbutamol burst therapy:
- Metered dose inhaler (MDI) 100mcg
- Spacer device recommended
- Bursts -> 6 puffs/dose (<5yrs) or 12 puffs/dose (>5yrs)
- about 4 breathes between each puff
- repeat every 20min for an hour (3 doses in total) & reassess after each dose
- then give burst doses prn
- if subsequent bursts are required at <2hourly intervals consider admission, adjunct treatments and alternative diagnoses
Ipratropium burst therapy:
- MDI 21mcg
- Spacer device recommended
- Bursts -> 4 puffs per dose (<5yrs) or 8 puffs per dose (>5yrs)
- repeat bursts every 20min for an hour (3 doses in total)
- then 2 puffs (<5yrs) or 4 puffs (>5yrs) every 6h
Burst therapy vs nebuliser:
- Burst therapy is generally just as effective as nebulisation with the advantages of being faster, more targeted, cheaper and not requiring electricity or special equipment
- Nebulisation takes longer to deliver medication and patients may need to sit still for 10 or more minutes
- Nebulisation has more facial and oropharyngeal deposition of medication resulting in at best 10% reaching the lungs. This may result in side effects such as tachycardia and tremors.
- Nebulisation however is preferred where patients struggle to co-ordinate taking a deep breathes through a spacer.
- Burst therapy is therefore a useful initial approach before switching to nebulisation if it's ineffective
This information is for academic purposes only and opinions are likely to differ. Please always refer to your local guidelines and protocols for recommended clinical practices.
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The visual acuity test determines the smallest letters at 6 meters a patient
can read on a standardised eye chart such as the Snellen chart. Patients with
6/6 vision are considered to be normal because they can read at 6 meters what
most people can read at 6 meters. Those who can only read upto the 6/60 line have poor vision because they can only read at 6 meters what most people can
read at 60 meters. Reading below the 6/6 line is considered to be better than
normal vision.
Steps:
- stand the patient at the appropriate distance from the chart
- patients with glasses should be allowed to wear them during the test
- provide an occluder to cover the eye not being tested
- ask the patient to read the smallest line they can see on the chart
- if a patient can read the 6/6 line but gets 2 letters wrong, it would be recorded as 6/6 (-2) visual acuity
- if more than 2 letters are wrong, then the visual acuity is the previous best line
- repeat these steps on the opposite eye
This information is for academic purposes only and opinions are likely to differ.
Please refer to you local guidelines for clinical best practises.
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Maintaining serum urate levels within a recommended target ranges is associated with fewer gout flare ups and the resolution of tophi. With regular monitoring and optimization of urate levels (for example <0.3mmol/L), gout flare ups tend to be less severe and less frequent. This is good because the patient is less likely to require NSAIDs, colchicine or oral corticosteroids which are commonly used in flare up management. In addition to this, serum urate monitoring is essential in the dose titration of allopurinol which is used in the long-term treatment and prevention of gout. (This is not clinical advice. Please refer to your local guidelines or consult with the relevant specialists)
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Urine color and concentration can indicate your hydration status. Pale, straw-colored urine suggests adequate hydration, while darker yellow or strong-smelling urine may indicate dehydration.
Urine Specific Gravity (USG) is a quantitative measure of urine concentration. This test measures the density of urine compared to water. A USG of ≤1.020 is generally considered indicative of euhydration (adequate hydration). A higher specific gravity (e.g., above 1.020) suggests the kidneys are working to concentrate urine, possibly due to dehydration. Normal ranges are typically between 1.003 and 1.030.
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(HRE)
