Download BRONCHIAL ASTHMA

BRONCHIAL ASTHMAMANAGEMENT
ABIRAMI SA
DEFINITION
A chronic inflammatory disorder of
the airway (Airway hyper
responsiveness)
Infiltration of mast cells,
eosinophils and lymphocytes
Widespread, variable and often
reversible airflow limitation
Diagnosis
Symptoms: cough,
wheeze, dyspnea
Investigations:
1. PFT
2. Chest Xray
3. AEC
RED FLAG SIGNS
1. RR is increased
2. DANGER SIGNS: drowsiness, agitation,
cyanosis, inability to vocalise, silent
chest
3. DEHYDRATION
4. PNEUMOTHORAX
5. HYPOTENSION
6. DIAPHORESIS
7. PULSUS PARADOXUS
8. PARADOXICAL RESPIRATION
9. CHEST INDRAWING
ACUTE SEVERE
ASTHMA
CLINICAL FEATURES
ALERT, NORMAL TONE
INCREASED RR, HR, BREATH
SOUNDS
NORMAL PERFUSION
PEFR < 60%
SPO2 < 90%
TREATMENT
1. O2 by mask
2. Neb. with Salbutamol [0.03ml/kg/dose]
+
Oral Prednisolone [1mg/kg/day]
If improving, continue neb. Q4h/q6h &
discharge with Oral Salb & steroids x 3-4
days
If not improving treat as life threatening
asthma
LIFE THREATENING ASTHMA
CLINICAL FEATURES
Agitated / irritable / inconsolable
Increased RR, HR
Decreased breath sounds
Reduced perfusion
Spo2 < 92%
Danger signs +
TREATMENT
1. O2 by mask
2. investigations: CBC, electrolytes,
CXR, ABG at later stage
3. Start antibiotics: Ampicillin
[100mg/kg/day]
4. IVF as maintainance
5. Triple nebulisation:
Salb [0.03ml/kg/dose]
Budesonide [0.5mg/kg/dose]
Ipratropium [0.5 ml < 10 kg,
1 ml > 10 kg]
6.
IV Hydrocortisone 10 mg/kg
7.
If improving, continue neb. with Salb 1-3 hrly
+
Ipravent q6h,
and discharge with oral steroids, antibiotics & salb
8. If no improvement, start IV Aminophylline [5
mg/kg] loading dose in 20 ml dextrose solution
followed by infusion Aminophylline [1mg/kg/hr]
+ Hydrocortisone [1mg/kg/hr]
9. Start IV MgSO4 0.1 ml/kg 50% solution in 50
ml NS given as IV over 30 min (q6h)
10. Methyl prednisolone 2 mg/kg bolus followed
by 1 mg/kg/dose q8h simultaneously
11. If no improvement, TERBUTALINE 10
mg/kg IV bolus over 10 min and then 210 mg/kg/hr as IV
12. If still no improvement, consider
MECHANICAL VENTILATION
INDICATIONS FOR MECH. VENTILATION
Exhausted/ Comatose child
Silent chest
ABG: PO2 <60mmhg, PCO2 >60
mmhg
LONG TERM MANAGEMENT
OF ASTHMA
Classification of Asthma Severity
CLASSIFY SEVERITY
STEP 4
Severe
Persistent
Clinical Features Before Treatment
Nighttime
PEF
Day Symptoms
Symptoms
Continuous
<60% predicted
Frequent
Limited physical
Variability >30%
activity
STEP 3
Moderate
Persistent
Daily
Use b2-agonist daily
Attacks affect activity
>1 time a week
STEP 2
Mild
Persistent
>1 time a week
but <1 time a day
>2 times a month
< 1 time a week
Asymptomatic
and normal PEF
between attacks
<2 times a month
STEP 1
Intermittent
>60%-<80%
predicted
Variability >30%
>80% predicted
Variability 2030%
>80% predicted
Variability <20%
The presence of one of the features of severity is sufficient to place a patient in that
category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002
CATEGORY
DAILY MANAGEMENT
STEP 1
No daily medications
STEP 2
Inhaled SABA + Inhaled low dose CS
[<400mcg] / Cromolyn / SR / LTRA
STEP 3
Inhaled SABA + Inhaled low – med dose
CS [400-800mcg] + Inhaled LABA / SR
Theophylline
STEP 4
Inhaled SABA + Inhaled high dose CS
[400 – 1000mcg] + Inhaled LABA / SR
Theophylline + low dose CS on alt. days
BRONCHODILATORS
SALBUTAMOL INHALER
100 mcg:
1 or 2 puffs as necessary
LEVOSALBUTAMOL INHALER
50 mcg :
1 or 2 puffs as necessary
Long acting b2 agonists:
Bambuterol,
Formoterol
Salmeterol
OTHERS
Corticosteroids
Prednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
Anti-leukotrienes
Montelukast, Zafirlukast
Xanthines
Theophylline SR
Mast cell stabilisers
Sodium cromoglycate
COMBINATIONS
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone
All Asthma Drugs Should
Ideally Be Taken
Through The Inhaled
Route
Why inhalation therapy?
Oral
Slow onset of action
Large dosage used
Greater side effects
Not useful in acute
symptoms
Inhaled route
Rapid onset of action
Less amount of drug
used
Better tolerated
Treatment of choice
in acute symptoms
Aerosol delivery systems
Commonly used
Metered dose inhalers
Dry powder inhalers
(Rotahaler)
Spacers / Holding chambers
Inhalation devices you can
use
Dry Powder
Inhaler
Metered Dose
inhaler
Spacer
Advantages of Spacer
No co-ordination required
No cold - freon effect
Reduced oropharyngeal deposition
Increased drug deposition in the lungs
Small, portable, easy to carry  Child
friendly
Rotahaler - The dry powder
advantage
Overcomes hand-lung
coordination problems that
are encountered with MDIs.
Can be easily used by children.
Can take multiple inhalations if the entire
drug has not been inhaled in one
inhalation.
Age-wise selection of inhaler
devices
< 3 years – MDI + Spacer + Mask or
nebulisers
3 – 5 years – MDI + Spacer + Mask or
Rotahaler
5 – 8 years – Rotahaler or MDI + Spacer
> 8 years – Rotahaler or MDI + Spacer
Goals to Be Achieved in
Asthma Control
Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Minimal use of medication
No emergency visits to doctors or hospitals
Maintain normal activity levels, including
exercise
Maintain pulmonary function as close to
normal as possible
Minimal (or no) adverse effects from medicine
Patient Education
Explain nature of the disease (i.e.
inflammation)
Stress need for regular, long-term therapy
Allay fears and concerns
Key Messages
Asthma can be effectively controlled, although it
cannot be cured.
Effective asthma management include
education, objective measures of lung function,
environmental control, and pharmacologic
therapy.
Thank you