acute attack asthma

8/12/2019 Acute Attack Asthma

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Managing acute episodes

Some pharmacology


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Relievers

Short-acting 2-agonists

Salbutamol

Terbutaline

Non selective -agonist

Adrenaline

Anticholinergics

Ipratropium bromide

Steroids

Theophylline

(Select situations)


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Oxygen

Hypoxia due to V / Q mismatch.

agonists may paradoxically worsen hypoxia

Maintain SaO2 > 92%.

Use oxygen to nebulise 2agonists


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Inhaled 2-agonists

Drugs of choice.

Salbutamol / Terbutaline are similar.

Severe acute episodenebuliser preferred

Dose- < 6 months-0.25 ml of respirator soln,

> 6 months- 0.5-1ml of respirator soln

Dilute in salineonly, NEVER distilled water

Beware of hypokalemiawith high dose nebulization.


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Rescue steroids

Early usage- reduces morbidity/ hospitalization

Oral prednisolone1-2 mg/kg for 3-7 days.

No tapering needed / No adverse effects

Injectablesdo not confer quicker benefit.

Hydrocortisone( 5-10 mg/kg) q 6hr or

IV Methylprednisolone (1-2 mg/kg) q6hr

IV / IM Dexamethasone (0.10.2 mg / Kg) q 6 hr

if patient unable to take orally (drowsy/distressed/vomiting)

High dose inhaled / nebulised steroids not proven


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Aminophylline

Retains its role as reliever in acute severe attacks

improves diaphragmatic contractility

mucociliary function

inflammatory modulation

Dose: Loading dose 5 mg/kgslow diluted IV bolus

(Avoid if patient on SR theophylline)

Followed by 0.51.0mg/kg/hr as infusion

(Avoid subsequent bolus doses)

Toxicity

Gl , Cardiac, CNS

Monitor levels if possible


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Oral 2agonists for mild intermittent airflow

obstruction.

Oral prednisolone for rescue therapy

Oral drugs as relievers


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Managing acute episodes

Back to Arpit and his friends


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Case..

Arpit decides to help his mother with Diwali cleaning. He starts

coughing continuously and his mother rushes him to the

clinic

What questions will you ask the mother?


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During an acute attack

Enquire

Duration ?

Relievers taken? - Response?

Brittleness (Rapid worsening)

Precipitant / trigger factors

On regular preventers?

Number and severity of previous attacks

Last theophylline dose (if relevant)


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Case contd

On examination, Arpit has a respiratory rate of 40 per minute

and a mild increase in accessory muscle activity. He

appears comfortable and is able to talk in sentences.

Auscultation reveals a wheeze towards the end of

expiration.

How will you grade Arpits acute attack and

manage him?


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Grading severity

Over a period of time-

helps to decide regarding need and choice of preventer drugs

At a point in time -

helps to decide regarding the level and drugs for acute

care.


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Quick assessment

Respiratory rate

Too breathless to feed / sleep

Talking words, not sentences

Poor or only transient (< 2hr) response to bronchodilator

Worsening despite 23 recent doses of inhaled 2agonistsat

15 minute intervals

SaO2< 92%


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Pulmonary score index

Score Respiratory Rate Wheezing* Accessory muscle6 years Sternomastoid activity

0 < 30 < 20 None No apparent activity

1 3145 2135 Terminal Questionable increaseexpiration with

stethoscope2 4660 3650 Entire expiration Increase apparent

with stethoscope

3 > 60 > 50 During inspiration Maximal activityand expirationwithout stethoscope

Score 03 Mild *If no wheezing due to minimal air exchange, score>346 Moderate

> 6 SevereThose children whose score is > 6 should be admitted to a pediatric ICU


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Home managementPS < 3 (mild grade)

SA 2agonist: 2 - 4 puffs through MDI + spacer +

mask

Repeat every 15 - 20 mins for max 3 times

If response ill sustained (< 4 hrs), start 1st

dose of

rescue steroid


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Case..

Sanjana calls you in the middle of the night. She is

proceeding to the casualty once again. You rush in

to see her and find her to have a respiratory rate

of 40 per min. She is wheezing audibly.

Assess her severity and manage her


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E Room planPS 4-6(moderate)

O2 SA 2agonist

Nebulised q 20 min x 3

or

MDI + spacer + mask 2 puffs q 2 min increasing by 2 puffs till10 puffs reached / 10 puffs q 20 min x 3

or (if inhaled therapy not available)

Adrenaline / Terbutaline 0.01mg/kg sc q 20 min x 3

Commence / Continue rescue steroid

Continuous assessment

SA 2agonist neb hourly p.r.n.

If good response(PS


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Sanjana does not respond to this treatment. One hour later, her

respiratory rate has gone up to 50 per minute. You decide to

admit her to the ward.

What do we do next? asks your resident doctor

Outline your plan to him


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Ward plan

Continue oxygen,

Start IV fluids, IV/oral steroid

SA 2nebulization - hourly/ back-to-back

Ipratropium neb q 30 min x 3 and then q 6 hours

Aminophyllinebolus and IV infusion

Monitor SaO2and serum K+

CBC, X-Ray chest to identify complications


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Intensify if not better

Pulmonary score q 15-30 minutes

Consider blood gas studies if SaO2< 92%

Terbutaline continuous iv infusion.

Magnesium sulfate iv infusion over 30 mins


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Your resident doctor is new but means well. What

complications should I expect? he asks and Sir/Madam, no

antibiotics? he continues with a bewildered look.

What will you teach this young lad?


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Complications

Pneumothorax

Pneumomediastinum

Subcutaneous emphysema

Atelectasis

Secondary infection

Therapy related


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Role of antibiotics

Consider only in those with poor response, purulent

secretions and radiological evidence of infection.

Bacterial infections seldom trigger asthma


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Case

36 hours later Sanjana is showing signs of improvement. On your

morning round, you find her sitting up comfortably sipping her tea.

She says she slept well through the night. On examination she is

mildly tachypnoeic and her wheeze is now only in the terminal phase

of respiration.

Can I go home? she asks

How will you reduce her medication and when will you

decide to discharge her?


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Stepping down acute care

Follow the principle last in first out

Discontinue terbutaline /aminophylline drip in 24

hours

Discontinue ipratropium neb in 24-48 hours

Reduce SA 2agonist to q 2-4 hrly and then q 4-

6hrly

Replace iv steroid with oral steroid


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Discharge criteria

Pulmonary score < 3

Slept well at night

Feeding well

Appears comfortable.


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Cases. contd

What will you advise Arpit and Sanjana when they areready to go home?


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Discharge plan

Inhaled SA 2agonist MDI + spacer + mask q 4-6 hour till

symptoms

Continue course of rescue steroid for 3-7 days (Tapering not

necessary)

Review compliance, trigger elimination, preventer regime

Educate regarding home plan / long term strategy

Plan follow up visit within 7-14 days


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If a child requires

rescue steroids / 2 - agonists frequently,

explore reasons for poor control.


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Case.

Meanwhile, Raju, a 8 year old with asthma is brought to the hospital in an

ambulance with oxygen by mask. He is too breathless to speak, is

sweating and quite agitated. On examination his nails are dusky and on

auscultation you hardly perceive any air entry. He has shown no

response to 3 doses of nebulized bronchodilator given while he was

rushed in with sirens blaring.

ACT FAST beg the parents.


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AsthmaRed flagsigns

Unable to talk or cry

Cyanosis

Feeble chest movements Absent breath sounds

Fatigue or exhaustion

Agitated

Altered sensorium

Oxygen saturation < 92%


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ICU plan

Continue / initiate intensified ward plan

Blood gas studies

Possible intubation and mechanical ventilation withketamine and midazolam / fentanyl iv infusion

Paralysis with vecuronium, if required


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To summarize

Asthma is an inflammatory illness

Diagnosis of asthma is clinical, and relies on history

All asthma does not wheeze

In children < 3 yrs, WALRI is an important differential diagnosis

2 out of 3 children outgrow their asthma

A family history of asthma / atopy increases risk of asthma

Diagnosis


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To summarize

Patient education is a very important part of asthma management

Drugs control, but do not cure asthma

Clinical grading over time, decides long term management plan

Mild intermittent asthma does not merit preventers

Inhaled steroids are mainstay of long term asthma management

Treatment should be stepped up or stepped down depending upon patient

response

Long term management


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To summarize

Grading at a point in time decides management

SA inhaled 2agonists are used to manage acute exacerbations

Frequent use of SA 2agonists indicate poor control of asthma

Taking care of the home environment reduces exacerbations of asthma

MDI should always be used with spacer

Acute management

Devices

acute attack asthma

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