Download ASTHMA

Asthma
Acute Management of
COPD
Community Acquired
Pneumonia
Pulmonary embolism
ASTHMA
INITIAL ASSESSMENT OF THE PATIENT WITH ACUTE ASTHMA

A brief history and physical examination are usually appropriate prior to treatment. However, if
the patient is acutely distressed, give oxygen and inhaled beta 2 agonist immediately.

A more detailed history and complete physical examination should be performed once therapy has
been initiated.
Early intervention is the best strategy to prevent
deterioration and stop an asthma attack.
THE IMPORTANT ISSUES ARE:
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Cause of the present exacerbation – non-compliance, smoking, or allergy
Duration of symptoms (with increasing duration of the attack, exhaustion and muscle fatigue may
precipitate ventilatory failure)
Severity of symptoms, including exercise limitation and sleep disturbance
Details of all current asthma medications, doses and amounts used and including the time of the
last dose
Details of other medication which might aggravate asthma
Prior hospitalisations and Emergency Department visits for asthma, particularly within the last
year
Prior episodes of severe life-threatening asthma, especially Intensive Care Unit admission and / or
ventilation
Significant co-existing cardiopulmonary disease
Known immediate hypersensitivity to food
Consider other diagnosis – LVF, pneumonia, foreign body, anaphylaxis or pulmonary vasculitis
Wheeze is an unreliable indicator of the severity of an
asthma attack and may be absent in severe asthma
RAPID PHYSICAL EXAMINATION
Perform a rapid physical examination to evaluate severity.
spirometry and peak flow measurement whenever practical.
Perform
INITIAL ASSESSMENT OF SEVERITY OF ACUTE ASTHMA
SYMPTOMS
MILD
MODERATE
Accessory muscle use
Altered consciousness
Physical exhaustion
Nil
No
No
Mild
No
No
Talks in
Pulse rate
Pulsus paradoxus
Central cyanosis
Wheeze intensity
Peak expiratory flow (%
predicted)
FEV1 (% predicted)
Oximetry on
presentation (Sa02)
Arterial blood gas
Sentences
<100
Not palpable
absent
Variable
>60%
Phrases
100 – 120
May be palpable
May be present
Moderate – loud
40 – 60%
>60%
>94%
40 – 60%
94 – 90%
Test not
necessary
<20
If initial response is
poor
20 – 30
Respiratory rate and
pattern
*SEVERE AND
LIFE-THREATENING
Marked or minimal
Yes
Yes, may have paradoxical chest
wall movement
Words
>120
Palpable#
Likely to be present#
Often quiet
<40% or
<100 litres per min.+
<40% or <1 litre+
<90% (but may be N).
Yes
>30 or low
# CYANOSIS AND PARADOXICAL PULSE MAY BE ABSENT, BUT WHEN
PRESENT INCIDATE SEVERE OBSTRUCTION
* Any of these features indicate that the episode is severe. The absence of any feature does not
exclude a severe attack
+ Patient may be incapable of performing test
INITIATION OF TREATMENT
The initial treatment of an asthma attack is determined by severity.
INITIAL MANAGEMENT OF ACUTE ASTHMA IN ADULTS
TREATMENT
Admission necessary
Oxygen
Nebulised beta2 agonist
salbutamol with
8L/min02
MILD
MODERATE
SEVERE AND
LIFE-THREATENING
Probably not
Probably
Yes – consider DCC
High flow of at least 8L/min to achieve an inspired oxygen concentration of
about 50%. Monitor effect by oximetry. If oxygen saturation remains
abnormal, use a non-rebreathing mask with a reservoir bag with 15 litres
02/min.
5mg salbutamol +
5mg salbutamol +
5mg salbutamol + 2mls saline
2mls saline
2mls saline 1 to 4
nebulised continuous  30
hourly
min.
Consider IV salbutamol 5 –
10g/kg repeated prn or 0.1 –
Nebulised ipratropium
bromide
Oral corticosteroids
prednisolone or
intravenous steroids
hydrocortisone
0.3 g/kg/min
500mcg ipratropium bromide
with beta2 agonist 2 hourly
Consider 30 – 60mg
30 – 60mg
30 – 60mg / daily initially
or
or
Not necessary
200mg stat if can’t
commence IV therapy 200mg 6
tolerate oral
hourly for 24 hours, then
review
Uncertainty exists regarding the benefits of this drug: reserve for those
unresponsive to maximal doses of beta2 agonist.
IV aminophylline 5 – 7mg/kg then 0.5 – 0.9mg/kg/hr IV. Use ½ this
loading dose of aminophylline if the patient is maintained on regular
oral theophylline. Level therapeutic 55 – 110mmol/L
Not indicated
Not indicated
Adrenaline 0.5mg IM (0.5ml of
1:1000) for anaphylaxis, or
1mg IV (diluted to 10ml with
saline) for cardio-respiratory
arrest
Not necessary
250mcg 4 hourly
Chest X-ray
Not necessary unless
focal signs present
Not necessary
unless focal signs
present or poor
response to
treatment
Necessary if no response to
initial therapy or suspect
pneumorthorax or infection
Observations
ABG
Regular
Not required
Continuous
Usually not
required e.g. if poor
response to
treatment
Continuous
ABG – hypercapnia
- hypoxaemia
- acidosis
beware normocapnia as =
impending failure
Check for hypokalaemia –
steroids, B2 agonists shift
aminophylline
IV
Last resort for impending
respiratory arrest
Theophylline /
Aminophylline
Adrenaline
Fluids
Intubation and
ventilation
Oral
No
Should see
hypocapnia 20 to
hyperventilation
Oral / IV
No
DISCHARGE FROM EMERGENCY DEPARTMENT
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Mild symptoms / signs
Check inhaler technique
Advice regarding stopping smoking
Discuss Asthma Management Plan

Monitor and record peak flow
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Asthma under control …………………………….Continue regular treatment

Waking at night, getting a cold, ………………….Start or increase preventer
or needing more reliever
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Getting worse / reliever lasting 2 – 3 hours …….. Prednisone and contact doctor

Very severe attack / reliever not working…………Call 111 or Emergency Doctor
REVIEW
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General Practitioner
Asthma Nurse Practitioner
Respiratory clinic if severe or difficult to control
Asthma and Respiratory Foundation of New Zealand have information for patients
 PO Box 1459, Wellington
 (04) 4994592
 [email protected]
 www.asthmanz.co.nz
REFERRENCES
1.
2.
3.
4.
5.
Asthma Management Handnook1996. National Asthma Campaign
Rowe BH, Spooner CH, Ducharme FM et al. The Effectiveness of Corticosteroids in the
Treatment of Acute Exacerbations of Asthma: A Meta-analysis on tTheir Effect on Relapse
Following Acute Assessment. Cochrane Database of Systemic Reviews. Issue 4, 1998.
Jagoda A, Shepard SM, Spevitz A, Joseph MM. Refractory Asthma, Part 1: Epidemiology,
Pathophysiology, Pharmacological Intervention. Ann Emerg Med February 1997; 29: 262 – 274.
4. Jagoda A, Shepard SM, Spevitz A, Joseph MM. Refractory Asthma, Part 1: Epidemiology,
Pathophysiology, Pharmacological Intervention. Ann Emerg Med February 1997; 29: 275 – 281.
Formulary and Prescribing Guide. Auckland Healthcare.
ACUTE MANAGEMENT OF COPD
ASSESSMENT

A brief history and physical examination are usually appropriate prior to treatment. However, if
the patient is acutely distressed, give oxygen and inhaled beta2 agonist immediately.

A more detailed history and complete physical examination should be performed once therapy has
been initiated.
THE IMPORTANT ISSUES ARE:









Cause of the present exacerbation – infection, non-compliance, smoking, other illness eg
abdominal pain, chest injury, pulmonary oedema, PE, electrolyte abnormalities
Duration of deterioration (with increasing duration of the attack, exhaustion and muscle fatigue
may precipitate ventilatory failure)
Severity of both acute and chronic symptoms, including exercise limitation and ability to perform
ADLs
Details of all current medications
Prior hospitalisations and Emergency Department visits
Significant co-existing disease
Resuscitation status
Is the patient known to the COPD nurse?
Social factors impacting on presentation – caregivers and patients ability to cope at home
PHYSICAL EXAMINATION
Evaluate severity and search for precipitant.
Perform spirometry and peak flow measurement whenever practical.
ASSESSMENT OF PATIENT WITH ACUTE EXACERBATION OF COPD
SYMPTOMS/ SIGNS/
INVESTIGATION
Accessory muscle use
Altered consciousness
Physical exhaustion
MILD
MODERATE
*SEVERE AND
LIFE-THREATENING
Marked or minimal
Yes
Yes, may have paradoxical chest
wall movement
Words
>120
Palpable#
Likely to be present#
Often quiet
<90% (may be N).
<40% or
<100 litres per min.+
Mild
No
No
Moderate
No
No
Talks in
Pulse rate
Pulsus paradoxus
Central cyanosis
Wheeze intensity
SaO2
Peak expiratory flow (%
of patients normal
PERF)
Sentences
<100
Not palpable
Absent
Variable
> 94%
>60%
Phrases
100 – 120
May be palpable
May be present
Variable
CXR
If signs of
infection
Usually
Required
ABG
Usually not
required
Usually required
Hypercapnia, hypoxaemia,
respiratory acidosis, metabolic
alkalosis, Increased A-a gradient,
Indicates Acute vs chronic
Electrolytes
40 – 60%
May show precipitants
Hypokalaemia,
hypophosphataemia,
hypomagnesaemia
FBC – polycythaemia
ECG - arrhythmias
# cyanosis and paradoxical pulse may be absent, but when present indicate severe obstruction
Patients usual state must be taken into count. A small deterioration in a patient with severe disease where
exhaustion and progressive respiratory failure may be precipitated by a mild exacerbation and is more
significant than in a patient with mild disease.
TREATMENT OF ACUTE EXACERBATION OF COPD
TREATMENT
Admission necessary
Oxygen
Nebulised beta2 agonist
salbutamol with
8L/min02
Nebulised ipratropium
bromide
Oral corticosteroids
prednisolone
or
intravenous steroids
hydrocortisone
Theophylline /
Aminophylline
Antibiotics
Indicated if infective
exacerbation ie fever,
leukocytosis, CXR
changes, increased
volume of sputum or
purulence
10 – 14 days
Treat pneumonia as
usual
Treat arrhythmias
Observations
Correct electrolytes
hypokalaemia,
hypophosphataemia,
hypomagnesaemia
Fluids
Ventilation
MILD
MODERATE
SEVERE AND
LIFE-THREATENING
Probably not
Probably
Yes – DCC or Respiratory Unit consult
Monitor effect by oximetry. Maintain oxygen saturations >92% or as close as possible to
usual for patient. A small minority have a reduced hypoxic respiratory drive, these patients
should have their respiratory status closely monitored rather than be deprived of oxygen.
Hypoxia kills.
5mg salbutamol +
5mg salbutamol +
5mg salbutamol + 2mls saline nebulised
2mls saline
2mls saline 1 to 4
continuous  30 min.
hourly
Consider IV salbutamol 5 – 10g/kg
repeated prn or 0.1 – 0.3 g/kg/min
Rarely necessary
Consider 250mcg 4
500mcg ipratropium bromide with beta2
hourly
agonist 2 hourly
30 - 40mg
30 – 60mg
30 – 60mg / daily initially
Not necessary
Not necessary
or
commence IV therapy 200mg 6 hourly
for 24 hours, then review
Reserve for those unresponsive to other treatment
IV aminophylline 5 – 7mg/kg then 0.5 – 0.9mg/kg/hr IV. Use ½ this loading dose of
aminophylline if the patient is maintained on regular oral theophylline. Level therapeutic
55 – 110mmol/L
Amoxicillin 500mg
TDS or
Doxycycline 200mg
then 100mg daily or
Amoxicillin /
clavulanic acid
500mg TDS
Amoxicillin 500mg TDS or
Doxycycline 200mg then
100mg daily or
Amoxicillin / clavulanic
acid 500mg TDS or
Cefaclor 500mg TDS or
Roxithromycin 300mg
daily
Cefuroxime 1g IV 8 hrly or
Amoxicillin / clavulanic acid 500mg
TDS
Plus Erythromicin 500mg IV 6 hrly
Till oral tolerated
Regular
Continuous
Continuous
Oral
No
Oral / IV
No
IV
BIPAP if available
Consider intubation and ventilation
for impending respiratory arrest
DISCHARGE FROM EMERGENCY DEPARTMENT

Mild worsening of chronic symptoms / signs

Able to cope at home.

Maximise treatment

 Check inhaler techniques, is another delivery method more appropriate
 Stop smoking
 Steroids – oral

Follow up
- Respiratory clinic - consider for home oxygen if PaO2 < 55mmHg
when stable
- General Practitioner review
- COPD Nurse
- Social worker
COMMUNITY ACQUIRED PNEUMONIA
ASSESSMENT
History
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Age - > 60 increases mortality
Typical / Atypical History
Co-existant respiratory disease including bronchiectasis and cystic fibrosis
Other significant disease – diabetes, renal insufficiency, cardiac failure, chronic liver disease,
alcohol abuse, post-splenectomy – as these all increase mortality
Possible aspiration eg seizures, alcohol intoxication
Possible Staphylococcal eg post - influenza
Examination and Investigation
Apart from making the diagnosis is aimed at detecting severe pneumonia which is defined by the
presence of any one of the following:
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RR > 30/min
Diastolic BP < 60 mmHg
Systolic BP< 90 mmHg
Shock
Confusion
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CXR - Bilateral or multilobar involvement
CXR - increase in size of opacity by > 50% within 48hrs
WCC < 4or > 30x109 / L
PaO2 < 60 mmHg
PaCO2 > 50mmHg
Deterioration in renal function
Investigations
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CXR – consider other causes – viral eg varicella, CMV, influenza, adenovirus, Pneumocystis
carinii, TB
 - empyema eg Staph
ABG if low SaO2
FBC
Electrolytes and creatinine
LFTs if severe pneumonia
Consider atypical serology
Blood cultures if severe as bacteraemia increases mortality.
MANAGEMENT
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ABCs
Oxygen if SaO2 < 96%
Control fever – paracetamol 1g
Fluids if dehydrated
Antibiotic
Antibiotics
1. Atypical Pneumonia
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Doxycycline 200mg then 100mg BD orally
Erythromycin 500mg QID orally
Roxithromycin 300mg daily orally
2. Lobar Pneumonia – No co-existing respiratory disease
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3.
Benzylpenicillin 600mg IV 6 hrly
Phenoxymethylpenicillin (penicillin V) 500mg orally QID
Erythromycin 500mg O/IV 6hrly
Roxithromycin 300mg daily
Amoxicillin 500mg TDS
Lobar Pneumonia – With respiratory disease or bronchopneumonia

Amoxicillin / Clavulanic acid 500/ 125 mg orally TDS
+/- Erythromycin 500mg orally QID or Roxithromycin 300mg orally daily

Cefuroxime 1g IV 8 hourly or cefuroxime axetil 500 orally TDS
+/- Erythromycin 500mg orally QID or Roxithromycin 300mg Orally daily
4. Severe Pneumonia

Cefuroxime 1g IV 8 hourly + Erythromycin 500mg IV 6hourly
5. Aspiration Pneumonia / Lung Abscess

Benzylpenicillin 600mg IV 4 hourly + metronidazole 500mg IV 12 hourly
If suspect gram negative
 Cefotaxime 1g IV 6 hourly + metronidazole 500mg IV 12 hourly
6. Staphylococcal Pneumonia

Flucloxacillin 500mg IV 6hourly
DISPOSITION
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Home – Mild pneumonia, < 65, no co-existant disease and safe home environment
Medical Ward
Intensive Care – Severe pneumonia
REFERENCES
Antimicrobial Guidelines Auckland Hospital 1999
Antibiotic Guidelines. VMPF Edition 9 1996/97
PULMONARY EMBOLISM
Assessment
See Investigation Algorithms #1-DVT and #2-PE
History
Virtually all patients will present with a recent onset of dyspnoea, chest pain or both
(sensitivity 97%, specificity 10%):


Assess for risk factors
Assess for other causes
Examination
More useful for excluding other causes. Tachycardia, tachypnoea, elevated SVP, loud
S2, pulmonary systolic murmur and T 0 <380 are associated with PE.
Investigations
ABG
- hypoxia (but 12% of those with PE have Pa0 2 >80mmHg)
- elevated A-a gradient in >75%
- DO NOT remove oxygen from a hypoxic patient to do an
ABG on air. Use a venturi mask that gives a relatively fixed 0 2
concentration
D- Dimer - not clinically useful, but done as part of current
investigation protocol
U&E / Cr - Cr prior to contrast
FBE -  WCC in infection;  Hb is risk factor for PE
ECG - tachycardia + other abnormalities
- ischaemia as DDx
CXR - abnormal in 80% PE, but signs are subtle
- pneumonia as DDx
Further investigations as per algorithms
Management
See also investigation algorithms
1.
Resuscitation
2.
Massive PE

Thrombolysis
- streptokinase 250,000 units over 30 minutes then 100,000
units/hour for 12-72 hours or
- tPA 10mg over 1-2 minutes then 90mg over 2 hours
(max 1.5mg/kg if <65kg)
3.

Consider thoracotomy and embolectomy if thrombolysis contraindicated

Consider radiographically controlled pulmonary embolectomy.
Minor – Moderate PE

Heparin 5,000 units IV following by 1,000 units/hour, modified by
coagulation results

Warfarin to commence once appropriate anticoagulation with heparin
(clexane 1mg/kg sc – inadequate trials to justify its
use in PE, but looks promising. First choice in DVT)
References:
Van der Belt, Prins, Lensing et al. Fixed dose subcutaneous low molecular weight
heparins versus adjusted dose unfractionated heparin for venous thromboembolism.
Cochrane Database of Systemic Reviews. Issue 4 1998.
INVESTIGATION ALGORITHM x2 ? PE
INVESTIGATION ALGORITHM #1 DVT