Download OMM49-AcuteAsthmaAttackER

OMM # Hr 49
December 4, 2003 1 pm
M. Garza, PDF
R. Eason for M Ohanion
Page 1 of 5
Acute asthma attack in the ER
I.
Objectives
A.
Assess a patient with an acute asthma attack, formulate a treatment plan
including OMT. Look at the whole person, not as compartmentalized.
B.
Understand and perform sitting, direct springing, and rib raising
techniques
C.
Understand and perform sitting and standing direct HVLA for the
thoracics
D.
Understand and perform percussion for the sympathetic chain ganglion
E.
Understand and perform Strain-Counterstrain Technique for C2
II.
Case presentation: 15 y/o male track runner with asthma. He is usually able to
keep his asthma under control through the use of Proventil (Albuterol) and Cromolyn
(inhaler). At a meet he finds that he has to use much larger doses of inhaler to control his
asthma, noting that it is becoming less and less effective (breathing is more labored). He
decides to forego the meet and come home. His parents bring him in to the ER that night
and who’s on call? Yes, it’s you.
III.
Physical Exam
A.
Pulse is 130 at rest
B.
Breathing is shallow and rapid with profuse expiratory wheezing.
C.
Non-productive cough is present
D.
He is only comfortable when standing or leaning forward-having a hard
time breathing
III.
Differential Diagnosis—Have a patient who is an asthmatic on therapy and
presents with dyspnea, wheezing, and a non-productive cough.
A.
Acute Asthma Attack
B.
Anaphylaxis
C.
Laryngeal Dysfunction
D.
Mechanical Obstruction
E.
Aspiration
F.
Drug induced cough
G.
Pulmonary Embolism
IV.
What is asthma?
A.
Chronic inflammatory disease with recurrent reversible airflow on
spirometry
B.
Increased responsiveness of the tracheobronchial tree to a variety of
stimuli
C.
Narrowing of the air passages which may be relieved spontaneously or as
a result of therapy
D.
Affects 4-5% of the US population (is significant number of people)
E.
Atopy is the greatest Risk Factor; definition=genetic predisposition to type
I hypersensitivity reaction to allergens.
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F.
Clinical Triad – Dyspnea, Cough, Wheezing
V.
Common Triggers
A.
Allergens-most common
B.
Air Pollution
C.
Viral Infections
D.
Exercise
E.
Emotional
F.
Psychological
VI.
Pathology
A.
Nonspecific Airway Hyperirritability
B.
Persistent Subacute Airway Inflammation
C.
Increased Edema
D.
Mucous Plugging
E.
Hyperinflation
F.
The Acute or Immediate Response
1.
Bronchoconstriction, edema, mucus secretion, and in extreme
cases hypotension
2.
Direct stimulation of subepithelial vagal (parasympathetic)
receptors provokes bronchoconstriction through both central and
local reflexes.=hyperparasympathetic tone
VII. Treatment Considerations
A.
Oxygen via nasal cannula @ 2 liters.
B.
Pharmacological Interventions
1.
Beta-2 agonists (ex. Albuterol) every 20 min by handheld
nebulizer for 2 to 3 doses
2. Anticholingergic agents (ex. Aminophylline or ipratropium) can be
added after the first hour to speed resolution
3. Corticosteroids for inflammation
C.
Osteopathic Manipulation Interventions
VIII. Osteopathic Considerations—Have a pt with hyperinflated lungs, can’t get air
out. May have ribs that are not moving, a diaphragm that is tired, using accessory
muscles and has an sternocleidomastoid that is tight. Want to use OMT to physically and
manually treat pt.
A.
Autonomics
1.
Sympathetics=want to stimulate bronchodilation
2.
Parasympathetics=vagus=want to calm down.
B.
Respiratory Mechanics=want to help muscles work better.
C.
Lymphatics-=drain tissues that are tender and boggy
D.
The Goals for the use of OMT during an attack may be dramatically
different than the goals proposed for the use of OMT between attacks.
1.
During an Attack
a. Stimulate the sympathetics for bronchodilation
b. Inhibit the vagus
c. Assist breathing and respiration
2.
Between Attacks
a. Promote maximal thoracic, sternal, and costal motion
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b. Balance the Autonomics
IX.
Sympathetics
A.
Innervation to Lower Respiratory Tract T1-T6
B.
Increased Sympathetic Tone
1. Increase Thickening of Secretions
2. Increase Vasoconstriction to Lung Tissue
3. Increase Bronchiolar Dilation
C.
Sympathetic Chain Ganglia
1. Located in the fascias under each rib head
2. Rib raising & Percussion both initially stimulate/increase the thoracic
sympathetic outflow
3. However, they then produce a lasting effect of decreased sympathetic
tone by reflexly inhibiting the higher sympathetic centers in the
medulla
4. Slide 13 shows the sympathetic chain ganglia. Note the close
proximity of the ganglia to the rib heads. Stimulate the chain ganglia
by stimulating the ribs.
X.Parasympathetics
A.
Vagus Nerve
1.
OA, AA, C2
2.
Occipitomastoid suture (Jugular Foramen)
B.
Increase Parasympathetic Tone
1.
Thinning of secretions
2.
Profuse secretions
3.
Relative bronchiole constriction
XII.Respiratory Mechanics
A.
Rib Motion=want to make as free as possible
B.
Accessory Muscles of Respiration
1.
Muscles that raise the rib cage (inspiration)= Scalenes,
Sternocleidomastoid, Anterior Serratus, External Intercostals
2.
Muscles that depress the rib cage (expiration)= Abdominal Recti,
Internal Intercostals, Obliques
XIII.Lymphatics-Remember the right lung and left lower lobe drain to the right
lymphatic duct and the left upper lobe drains to the left to the thoracic duct.
A.
Sibson’s Fascia, bilaterally
B.
Redome the Diaphragm (Respiratory), is flattened and has a problem with
movement.
C.
Myofascial Restrictions
D.
Thoracic Pump, if pt can lay supine.
XIV.Techniques
A.
Rib raising, Sitting, Direct - LVMA (springing anterior and laterally)—
treats sympathetics
1.
Patient seated, Physician standing
2.
Patient crosses arms in front of them and places head on his/her
arms (I Dream of Genie)
3
Physician loops hands through patient’s folded arms and contacts
the posterior rib angles bilaterally with fingers at the ribs at the
junction with the transverse processes (is lateral to the spinous
processes).
4.
Work your way from T1 to T6, and then back up again.
5.
Apply lateral traction bilaterally at the rib angle while pulling the
patient toward you.
6.
Have the patient breath deeply to aid the mobilization of the entire
rib cage.
7.
Do this for approximately 1 min until you feel increased motion
there.
8.
Dr. Gamber said that the doctor can stand on the side of the pt and
support the patient’s folded arms as a variation. This can be used
with elderly, more frail pts. He teaches it to the spouse of the pt
and then the spouse can use it with pt at home.
Thoracic Som Dys, Multiple Planes, Standing/Seated, Direct- HVLA—
with three variations for the superior, middle and inferior segments of the
thoracic spine.
1.
For Upper Thoracics
a.
Patient standing, Physician stands behind patient
b.
Physician puts arms underneath pt’s arms and folds hands
behind the pt’s head.
c.
Patient places hands over physician’s hands
d.
Patient is instructed to keep body fairly rigid as the
physician takes a step backward supporting the patient’s
weight
e.
Patient takes a deep breath and upon exhalation drops
his/her bottom.
f.
Physician provides a slight upward thrust from the
epigastrum/chest
2.
For Mid-Thoracics
a.
Patient standing, Physician stands behind patient
b.
Patient puts hands behind neck with elbows in front of
him/her
c.
Physician wraps arms around patient’s elbows and takes a
step backward, supporting the patient’s weight
d.
Patient takes a deep breath and upon exhalation drops
his/her bottom.
e.
Physician provides a slight upward thrust from the
epigastrum/chest
3.
For Lower Thoracics
a.
Patient standing, Physician stands behind patient
b.
Patient uses hands, one on top of the other, as a fulcrum
behind their back over the segment you intend to treat.
c.
Physician wraps arms up around patient’s shoulders and
takes a step backward, supporting the patient’s weight
3.
B.
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d.
e.
Patient takes a deep breath and upon exhalation drops
his/her bottom.
Physician provides a slight upward thrust from the
epigastrum
4.
TIPS:
a.
If you are tall and your patient is short, you can perform
this technique with the patient seated and the physician
standing
b.
If you find your epigastrum lacking, you can create one
with a pillow!!
c.
If your patient has “spaghetti” arms, and this inhibits your
localization, place the pillow under their arms to assist.
C.
Sympathetic chain ganglia Sitting, Direct – Percussion
1.
Patient is seated, Physician sits or stands behind the patient
2.
Physician cups his/her hands and percusses the patient’s back
along the paraspinal region
3.
Variation – instead of cupping the hand, the physician can bunch
up the fingers
4.
Concentrate on the area from T1 to T5
5.
Used by respiratory therapists. Helps increase the sympathetic
response and also break up and expel secretions
D.
Parasympathetic: Strain-Counterstrain For C2
1.
TP is on the superior surface of the spinous process of C2
2.
Treat in Extension – caudad pressure high on the occipital bone,
with slight sidebending and rotation (hold for 1 ½-2 min)
3.
Rem want tender pt to decrease from 103 in intensity.
Treatments can be used in small children, e.g., infants to 2 y.o. Can use rib raising to
treat asthma. Teach parents how to do it so they can do it at home. The parent can hold
the baby up and do gentle rib raising. Also can teach them to do soft tissue on the
thoracic paraspinal muscles. With older children, the child can sit on the parent’s lap.
References
Braunwald, E. Harrison’s Principles of Internal Medicine, 15th Ed.
Levine. Foundations of Osteopathic Medicine.
Kimberly, PE. Outline of Osteopathic Manipulative Procedures.
Kuchera, WA. Osteopathic Principles in Practice.
Kuchera, ML. Osteopathic Considerations in Systemic Dysfunction.
Cotran, RS. Robbins Pathologic Basis of Disease.
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