Download severe exacerbation

Treatment of acute exacerbations of
asthma in adults
Seminar Training
Primary Care Asthma + COPD
04- 2015
D.Anan Esmail
What is the definition of Asthma
exacerbation?
the classic symptoms of asthma
Wheeze
Cough
Shortness of
breath
1. acute or subacute episodes of
progressively worsening
• Wheezing
• Cough
• shortness of breath
some combination
of these symptoms
2. decreases in expiratory airflow
• documented by measurement of lung
function (spirometry or PEF)
What are the causes?
Triggers
Treatment
• inhaler
techniques
Treatment
• inhaler
techniques
• Step of treatment
Treatment
Stop of
medicatiom
What is management ?
The best strategy
for management of acute exacerbations of
asthma is:
• early recognition and intervention
• before attacks become severe and
potentially life threatening
Detecting the onset of an exacerbation
Some patients are
very sensitive
to increased asthma symptoms
while others
perceive reduced airflow
only when it becomes marked
decrease in peak expiratory flow
may be the first sign that asthma
control is deteriorating
A decrement in peak
flow of greater than
20 percent from the
patient's personal
best value
presence of
asthma
exacerbation
When patients recognize the onset of an
exacerbation
• they should self-administer an inhaled
short-acting beta agonist as follows:
inhaled short-acting beta agonist
Two to six puffs
repeated in 20
minutes for the
first hour
if needed
MDI with spacer
inhaled short-acting beta agonist
(albuterol 2.5 mg(
repeated every 20
minutes for first
hour
if needed
nebulization
After the first hour
symptoms improvement
repeat a peak flow
measurement
Good response to initial home treatment
patient’s symptoms resolve
PEF ↑ to above 80 % of
baseline
safely continue self-
treatment at home
Good response to initial home treatment
short course of oral glucocorticoids
if symptoms recur
Incomplete response to initial home
treatment
continued symptoms
PEF ˂ 80 % of
baseline
Incomplete response to initial home
treatment
continued of inhaled short-
acting beta agonists
initiate oral glucocorticoids
contact the clinician urgently
for advice
Incomplete response
to initial home treatment
contact the
clinician
symptoms or signs of
severe exacerbation
high risk for a fatal
attack
Fatal Asthma Attack
Previous severe
exacerbation
(intubation or ICU
admission)
Fatal Asthma Attack
Two or more
hospitalizations
for asthma in the
past year
Fatal Asthma Attack
Three or more
emergency
department visits
for asthma in the
past year
Fatal Asthma Attack
Hospitalization or
emergency
department visit
for asthma in the
past month
Fatal Asthma Attack
Use of more than
two canisters of
short-acting beta
agonist per month
Low socioeconomic status
inner city residence
illicit drug use
major psychosocial problems
Fatal Asthma Attack
Comorbidities such
as
Cardiovascular
chronic lung
disease
Incomplete response
to initial home treatment
contact the
clinician
symptoms or signs of
severe exacerbation
high risk for a fatal
attack
Clinical Findings
Respiratory rate >30 /minute
Pulse >120 /minute
Clinical Findings
Talks in (Sentences, Phrases, Words(
Alertness (agitated, Drowsy or confused(
Clinical Findings
tripod Position
• Prefers sitting
• inability to lie
supine
Clinical Findings
use of accessory
muscles
of inspiration
Clinical Findings
Diaphoresis
Clinical Findings
Pulsus paradoxus
(ie, a fall in systolic
blood pressure by at
least 12 mmHg during
inspiration)
Mild
Moderate
Severe
Respiratory
Arrest Imminent
Respiratory rate
Increased
Increased
>30/minute
>30/minute
Pulse/minute
<100
100–120
talks in
Sentences
Phrases
Words
Alertness
-
-
agitated
use of accessory
muscles
-
-
+
Position
Can lie down
Prefers
sitting
Pulsus
paradoxus
-
-
Wheeze
Wheeze
-
-
Diaphoresis
>120
Bradycardia
Drowsy or
confused
inability to lie
supine
+
Wheeze
Absence of
wheeze
+
Unfortunately
these findings are
not sensitive
indicators of severe
up to 50 % of
attacks
patients with severe
airflow obstruction
will not manifest any
of these
abnormalities
Peak Flow
PEF
Mild
Moderate
Severe
Respiratory
Arrest Imminent
≥70 %
40–69 %
<40 %
below 200 L/min
<25 percent
Oxygen Saturation
SaO2
Mild
Moderate
Severe
Respiratory
Arrest Imminent
>95 %
> 95%
90 to 95%
<90 %
Hypercapnia (ABG)
PaCO2
Mild
Moderate
Severe
Respiratory
Arrest Imminent
-
-
-
normal or
elevated
Chest radiograph
The most common abnormality is
pulmonary hyperinflation
Chest radiograph
Other abnormal findings
Pneumothorax
Pneumomediastinum
Pneumonia
Atelectasis
occurring in
only about
2% of chest
radiographs
Chest radiograph
not routinely
required
Chest radiograph should obtained
temperature >38.3ºC
unexplained chest pain
leukocytosis
hypoxemia
Chest radiograph should obtained
patient requires
hospitalization
diagnosis is uncertain
Chest radiograph should obtained
Intravenous drug abuse
immunosuppression
recent seizures
Chest radiograph should obtained
cancer
chest surgery
heart failure
TREATMENT
Mild
Moderate
severe
Threatening
goals of therapy
airflow
airway
obstruction
inflammation
Short Acting
bronchodilator
Corticosteroid
Mild & Moderate Asthma
exacerbation
Inhaled beta agonists (SABA)
albuterol 2.5 to 5 mg
every 20 minute for
the first hour
then 2.5 to 10 mg
every one to four
hours as needed
nebulization
Inhaled beta agonists (SABA)
four to eight puffs
every 20 minute for
the first hour
then dosing every
one to four hours as
needed
MDI with spacer
Good Response
No wheezing or dyspnea
PEF ≥80% predicted or
personal best
Discharge Home
Discharge Home
SABA every 3–4 hours for
24–48 hours
short course of oral systemic
corticosteroids (prednisone
40-60 mg po 5 to 10 day)
Mild & Moderate
exacerbation
unresponsive to
treatment
Severe exacerbation
Risk factors for a fatal
asthma attack
Inhaled beta agonists (SABA)
Inhaled anticholinergics
Inhaled anticholinergics (SAMA)
recommend the addition of
ipratropium
for patients with
severe exacerbations
in the emergency department
Inhaled anticholinergics (SAMA)
the combination provides
greater bronchodilation
than beta agonists alone
Inhaled anticholinergics (SAMA)
Ipratropium
500 mcg every 20
minutes
for three doses
nebulization
Inhaled anticholinergics (SAMA)
Ipratropium
eight inhalations
every 20 minutes
for three doses
MDI with spacer
Steroids
10 to 14 days
may be given orally
or IM or IV
• methylprednisolone
60–80 mg every 6 to 12
hours
Good Response
No symptoms
PEF ≥80 predicted or
personal best
Discharge Home
Severe Asthma exacerbation
unresponsive to treatment
Or
Potentially Fatal Asthma exacerbation
For critically ill patients
Inhaled beta
agonists (SABA)
continuous
nebulization
Administering
10 to 15 mg over
one hour
Add Magnesium sulfate
Magnesium sulfate
magnesium sulfate has
bronchodilator activity
in acute asthma
Magnesium sulfate
Intravenous magnesium sulfate
2 gm infused over 20 min
Magnesium sulfate
contraindicated
• renal insufficiency
• hypermagnesemia
Nonstandard therapies
may be helpful
Not recommended for routine use
insufficient evidence of efficacy
Nonstandard therapies
1. helium-oxygen gas mixtures
2. Parenteral beta-agonists
3. leukotriene receptor antagonists
4. macrolide antibiotics
5. Nebulized furosemide
6.anesthetic agents
Helium-oxygen (low density gas)
nebulization of albuterol using a heliumoxygen gas mixture
increase the mass of albuterol delivered
by allowing smaller particles to better
penetrate to the lung periphery
Nonstandard therapies
1. helium-oxygen gas mixtures
2. Parenteral beta-agonists
3. leukotriene receptor antagonists
4. macrolide antibiotics
5. Nebulized furosemide
6.anesthetic agents
(Parenteral beta-agonists) Epinephrine
severe asthma
exacerbation
unable to use inhaled
bronchodilators
anaphylactic reaction
no evidence of anaphylaxis
0.3 to 0.5 mg IM
0.3 to 0.5 mg SC
(Parenteral beta-agonists) Terbutaline
severe asthma exacerbation
unresponsive to standard therapies
0.25 mg SC
every 20 minutes
3 doses
(Parenteral beta-agonists)
epinephrine
OR
terbutaline
not
both
Mechanical ventilation
noninvasive positive pressure
ventilation
asthma exacerbation
severe symptoms despite initial
therapy
we suggest
trial of NPPV
mechanical ventilation
Slowing of the respiratory rate
depressed mental status
worsening hypercapnia and respiratory acidosis
oxygen saturation ˂95% despite high-flow
supplemental oxygen
Ineffective therapies
intravenous methylxanthines
(theophylline or aminophylline )
inhaled glucocorticoids
recommendations for treating asthma
exacerbations
Oxygen
give sufficient oxygen
to maintain
SaO2 > 92 percent
Oxygen
give sufficient
oxygen to maintain
SaO2 >95 percent
in pregnancy
The Expert Panel does not recommend:
aggressive hydration
chest physical therapy
Mucolytics
Antibiotics
not generally recommended
for the treatment of acute asthma
exacerbations
• because most respiratory infections that
trigger an exacerbation of asthma are viral
rather than bacterial
Antibiotics
Exception
comorbid conditions
Fever AND purulent
sputum
evidence of pneumonia
bacterial sinusitis
Medications upon discharge
All patients should receive
prednisone: 30 to 60 mg once a day
for 7 to 14 days
then evaluated at a two-week
adequate supply of reliever (B2 agonist)
And
controller (inhaled corticosteroid)
What is the prevention?
Trigger avoidance
How to use a peak
flow meter
Asthma inhaler
techniques
Prompt communication between
patient and clinician
written asthma action plan
• definition of Asthma exacerbation
 1. acute or subacute episodes of
progressively worsening symptoms
(Wheezing , Cough, shortness of
breath)
 2. decreases in expiratory airflow
(A decrement in peak flow of
greater than 20 percent from the
patient's personal best value)
• patients recognize the onset of an
exacerbation
 self-administer an inhaled short acting beta agonist
 safely continue self -treatment at
home if:
• p at i e nt ’s sy m p to m s re s o l ve
• P E F ↑ to a b o ve 8 0 % o f b a s e l i n e
 short course of oral glucocorticoids
if symptoms recur
• patients should contact the
clinician if:
 Incomplete response to initial home
treatment
 symptoms or signs of severe
exacerbation
 high risk for a fatal attack
• Physical findings that suggest
severe asthma exacerbation
 Tachycardia
Tachypnea
tripod position
Use of the accessory muscles
pulsus paradoxus
Diaphoresis
• Physical findings that suggest
severe asthma exacerbation
 Alertness
 Talks in
 PEF <40 % (below 200 L/min)
 SAT: 90 to 95%
 PaCO2 normal or elevated
• Chest radiograph should obtained
 temperature > 38.3ºC, leukocytosis
 unexplained chest pain, Hypoxemia
 patient requires hospitalization
 diagnosis is uncertain
 Intravenous drug abuse,
immunosuppression
 recent seizures, cancer, heart
failure
 chest surgery
• Mild & Moderate exacerbation
 Inhaled Short Acting
bronchodilator (SABA)
 Good Response (No symptoms, PEF
≥80% predicted) → Discharge Home
• SA BA e ve r y 3 – 4 h o u rs fo r 2 4 – 4 8
h o u rs
• s h o r t co u rs e o f o ra l syste m i c
co r t i co ste ro i d s ( p r e d n i s o n e 4 0 - 6 0 m g p o
5 to 10 day)
 Poor Response → Admit to Hospital
• Severe asthma exacerbation
• admit to hospital
 i n h a l e d S h o r t A c t i n g b ro n c h o d i l ato r
( SA BA , SA M A )
 c o r t i co ste ro i d s ( m e t hy l p re d n i s o l o n e 6 0 125 mg)
• Good Response (No symptoms, PEF
≥80% predicted) → Discharge Home
• SA BA e ve r y 3 – 4 h o u rs fo r 2 4 – 4 8
h o u rs
• o ra l syste m i c co r t i co ste ro i d s
(prednisone 40-60 mg po 10to 14 day)
• Poor Response → admit to icu
• Very Severe Asthma exacerbation
(life Threatening) or sever
exacerbation unresponsive to
treatment
 Admit to ICU
 continuous nebulization Inhaled
SABA
 Add Magnesium sulfate
 NPPV
 Mechanical ventilation
 Nonstandard therapies
• Nonstandard therapies
 helium-oxygen gas mixtures
 Parenteral beta-agonists
 leukotriene receptor antagonists
 macrolide antibiotics
 Nebulized furosemide
 anesthetic agents
• Ineffective therapies
 intravenous methylxanthines
(theophylline or aminophylline )
 inhaled glucocorticoids
• Antibiotics
not recommended for the
treatment of acute asthma
exacerbations
Exception
• Fever AND purulent sputum
• evidence of pneumonia
• bacterial sinusitis