acute severe asthma - glasgow, scotland, uk · self discharge alcohol or drug ... if spo 2

Professor Neil C ThomsonProfessor Neil C Thomson

Respiratory Medicine Respiratory MedicineRespiratory MedicineDivision of Immunology, Infection & InflammationDivision of Immunology, Infection & Inflammation

Gartnavel General Hospital Gartnavel General Hospital Glasgow Glasgow

Acute severe Acute severe asthmaasthma

Acute Respiratory Care Day, Faculty of MedicineAcute Respiratory Care Day, Faculty of Medicine

Acute asthma is importantAcute asthma is important

Patient perspectivePatient perspectiveExacerbations of asthma can have a huge impact Exacerbations of asthma can have a huge impact on patients on patients

Exacerbations can be life threateningExacerbations can be life threateningUp to 90% of the deaths from asthma are preventable Up to 90% of the deaths from asthma are preventable

Health costs considerableHealth costs considerableDirect costs for asthma (UK): Direct costs for asthma (UK): ££900 million per yr 900 million per yr There are over 69,000 hospital admissions each yrThere are over 69,000 hospital admissions each yr

Estimated 75% of admissions avoidableEstimated 75% of admissions avoidable

UK hospital admissions for acute UK hospital admissions for acute asthmaasthma

Females 0Females 0--14 yrs14 yrs

Males 0Males 0--14 yrs14 yrs

Males 15+ yrsMales 15+ yrs

Females 15+ yrsFemales 15+ yrs

Rate per 10,000 populationRate per 10,000 population

National & international guidelinesNational & international guidelines

www.sign.ac.ukwww.sign.ac.uk

2008

GINAGINABritish GuidelinesBritish Guidelines

www.ginasthma.comwww.ginasthma.com

Definition of asthma exacerbationsDefinition of asthma exacerbations

No generally accepted definitionNo generally accepted definition

‘‘A sustained worsening of a patientA sustained worsening of a patient’’s condition from s condition from the stable state and beyond normal daythe stable state and beyond normal day--toto--day day variations, that is acute in onset and necessitates a variations, that is acute in onset and necessitates a change in medicationchange in medication’’

Criteria:Criteria:–– Lung function e.g. fall in peak expiratory flow (PEF) in 2 Lung function e.g. fall in peak expiratory flow (PEF) in 2

consecutive days of 25% of baselineconsecutive days of 25% of baseline–– Medication e.g. use of systemic steroidsMedication e.g. use of systemic steroids

07-002-1107

Risk factors for near fatal/fatal asthmaRisk factors for near fatal/fatal asthma

Severe asthma, recognised by 1 or more of:Severe asthma, recognised by 1 or more of:Previous near fatal asthmaPrevious near fatal asthmaPrevious admission (last year)Previous admission (last year)Repeat emergency department attendanceRepeat emergency department attendanceHeavy use of betaHeavy use of beta22 agonistagonistBrittle asthmaBrittle asthma

And adverse psychological features, recognised by 1 And adverse psychological features, recognised by 1 or more of:or more of:

NonNon--compliance with treatmentcompliance with treatmentSelf dischargeSelf dischargeAlcohol or drug abuseAlcohol or drug abuseSocial isolation Social isolation Psychosis, depressionPsychosis, depression

British Guidelines on Management of asthma, 2008British Guidelines on Management of asthma, 2008

Causes of exacerbationsCauses of exacerbationsVirusesViruses

Children: 80% of episodes (mainly rhinoviruses)Children: 80% of episodes (mainly rhinoviruses)Johnston et al, BMJ 1995;Johnston et al, BMJ 1995;

Adults: 26Adults: 26--50% of episodes 50% of episodes Green et al, BMJ 2002; Green et al, BMJ 2002; AtmarAtmar et al, Arch et al, Arch IntInt Med 1998Med 1998

Atypical bacterial infectionsAtypical bacterial infectionsMycoplasma & Mycoplasma & chlamydiachlamydia pneumoniae pneumoniae

Johnston & Martin, AJRCM 2005Johnston & Martin, AJRCM 2005

Air pollutionAir pollution SunyerSunyer et al, Thorax 1997et al, Thorax 1997

Allergens Allergens Green et al, Green et al, BMJ 2002; BMJ 2002; BacharierBacharier et al, et al, PediatricsPediatrics 20032003

Cigarette smoke Cigarette smoke Eisner, Thorax 2005Eisner, Thorax 2005

Air pollution & risk of Air pollution & risk of hospital admissionhospital admission

SunyerSunyer et al, Thorax 1997et al, Thorax 1997

Children with asthma admitted to hospital in 4 European citiesChildren with asthma admitted to hospital in 4 European cities

Pathology of fatal asthmaPathology of fatal asthma

Airway inflammation in acute asthmaAirway inflammation in acute asthma

Induced sputum cell counts: Induced sputum cell counts:

FahyFahy et al, JACI 1995et al, JACI 1995

Neutrophils

Eosinophils

Initial assessmentInitial assessment

Clinical featuresClinical featuresNon specific for a severe attackNon specific for a severe attack

Peak expiratory flow (PEF) or FEVPeak expiratory flow (PEF) or FEV11Improves recognition of degree of severityImproves recognition of degree of severity

Pulse Pulse oximetryoximetryMeasurement of oxygen saturation (SpOMeasurement of oxygen saturation (SpO22))

Blood gasesBlood gasesIf SpOIf SpO22 <92% or features of life threatening asthma<92% or features of life threatening asthma

Chest xChest x--ray: Not routineray: Not routineSuspected pneumothorax, pneumonia, Suspected pneumothorax, pneumonia, life threatening attacklife threatening attack

Management of acute asthma. British Asthma Guidelines 2008Management of acute asthma. British Asthma Guidelines 2008

Levels of severity of acute asthma Levels of severity of acute asthma exacerbationsexacerbations

Acute severeAcute severePEF >33PEF >33--50% best or predicted50% best or predicted

Life threatening Life threatening PEF <33% best or predictedPEF <33% best or predictedSpOSpO22 <92%<92%

Near fatal Near fatal Raised PaCORaised PaCO22 / mechanical ventilation/ mechanical ventilation

Management of acute asthma. Thorax 2008; 58 (Management of acute asthma. Thorax 2008; 58 (SupplSuppl I): i1I): i1--i92i92

Criteria for admissionCriteria for admission

Life threatening or near fatal attack [Grade B]Life threatening or near fatal attack [Grade B]

Severe attack after initial treatment [Grade B]Severe attack after initial treatment [Grade B]

Consider discharge if PEF is > 75% best or Consider discharge if PEF is > 75% best or predicted 1 hour after initial treatment unless predicted 1 hour after initial treatment unless other factors [Grade C]other factors [Grade C]

Concern about compliance, living alone, pregnancy, etcConcern about compliance, living alone, pregnancy, etc

Management of acute asthma. Thorax 2008Management of acute asthma. Thorax 2008

Establish plan for treatingEstablish plan for treatingexacerbationexacerbation

Primary therapies for exacerbations:Primary therapies for exacerbations:

Repetitive administration of rapidRepetitive administration of rapid--acting acting inhaled inhaled ββ22--agonistagonistEarly introduction of systemic Early introduction of systemic corticosteroidscorticosteroidsOxygenOxygen supplementationsupplementation

Closely monitor response to treatment with serial Closely monitor response to treatment with serial measures of lung functionmeasures of lung function

Treatment of acute asthma in adultsTreatment of acute asthma in adults

OxygenOxygenGive high flow oxygen to all patients Give high flow oxygen to all patients with acute asthma [Grade C]with acute asthma [Grade C]Aim to keep SpOAim to keep SpO22 at least 92%at least 92%

BetaBeta22 agonist bronchodilatorsagonist bronchodilatorsHigh dose inhaled betaHigh dose inhaled beta22 agonist [Grade A]agonist [Grade A]Rarely require IV betaRarely require IV beta22 agonistsagonistsIn severe asthma (PEF <50%) consider In severe asthma (PEF <50%) consider continuous nebulisation [Grade A]continuous nebulisation [Grade A]


Steroid therapySteroid therapy

Give systemic steroids in adequate doses Give systemic steroids in adequate doses to all cases of acute asthma [Grade A]to all cases of acute asthma [Grade A]

Tablets as effective as injectionsTablets as effective as injectionsModerate doses as effective as Moderate doses as effective as very high dosesvery high doses

Continue prednisolone 40Continue prednisolone 40--50 mg daily for 50 mg daily for at least 5 days or until recovery at least 5 days or until recovery

e.g prednisolone 2 x 25 mge.g prednisolone 2 x 25 mgManagement of acute asthma. Thorax 2008Management of acute asthma. Thorax 2008

Other therapies for acute asthma in Other therapies for acute asthma in adultsadults

Ipratropium bromideIpratropium bromideNebulised ipratropium should be added Nebulised ipratropium should be added to inhaled betato inhaled beta22 agonist for acute severe or agonist for acute severe or life threatening or poor initial response life threatening or poor initial response

[Grade A]; Rodrigo et al Thorax 2005[Grade A]; Rodrigo et al Thorax 2005

Intravenous aminophyllineIntravenous aminophyllineNot likely to result in any additional bronchodilationNot likely to result in any additional bronchodilation

AntibioticsAntibioticsRoutine prescription not indicated [Grade B]Routine prescription not indicated [Grade B]


Other therapies for acute asthmaOther therapies for acute asthma

Intravenous magnesium sulphateIntravenous magnesium sulphate

Consider giving a single dose of IV Consider giving a single dose of IV magnesium sulphate for patients with:magnesium sulphate for patients with:

Acute severe asthma who have not had a good Acute severe asthma who have not had a good initial response to inhaled bronchodilator initial response to inhaled bronchodilator therapytherapyLife threatening or near fatal asthmaLife threatening or near fatal asthma

[Grade A][Grade A]


Monitoring of adults with acute asthmaMonitoring of adults with acute asthma

Measure and record Measure and record PEFPEF 1515--30 minutes after starting treatment, 30 minutes after starting treatment, and before/after and before/after ββ22 agonist bronchodilator (at least four times daily) agonist bronchodilator (at least four times daily) until controlled until controlled Record Record oxygen saturationoxygen saturation by by oximetryoximetry and maintain arterial SaOand maintain arterial SaO22>92%. >92%. Repeat measurements of Repeat measurements of blood gas tensionsblood gas tensions within 2 hours of within 2 hours of starting treatment if: starting treatment if:

Initial PaOInitial PaO22 <<8 8 kPakPa unless SaOunless SaO22 >>92%; 92%; ororInitial PaCOInitial PaCO22 is normal or raised; is normal or raised; ororPPatientatient’’s condition deteriorates or not improved by 4s condition deteriorates or not improved by 4--6 hours6 hours

Record Record heart rateheart rate

Measure Measure serum potassiumserum potassium and and blood glucoseblood glucose concentrationsconcentrations

Criteria for referral to intensive careCriteria for referral to intensive care

ClinicalClinicalExhaustionExhaustionDrowsinessDrowsinessRespiratory arrestRespiratory arrest

Lung functionLung functionDeteriorating PEFDeteriorating PEF

Gas exchangeGas exchangePersisting or worsening hypoxiaPersisting or worsening hypoxiaHypercapniaHypercapniaFall in ph or rising HFall in ph or rising H++ concentrationconcentration


Hospital discharge & followHospital discharge & follow--upup

Timing of dischargeTiming of dischargeNo single physiological parameterNo single physiological parameter

PEF > 75% best or predictedPEF > 75% best or predicted

Patient educationPatient educationInhaler technique, PEF record keeping, action planInhaler technique, PEF record keeping, action planRole for asthma liaison nurse serviceRole for asthma liaison nurse service


Self management or action planSelf management or action plan

Evidence for self management or Evidence for self management or action plansaction plans

Can be conducted by either selfCan be conducted by either self--adjustment with the aid of adjustment with the aid of a written action plan or by regular medical review a written action plan or by regular medical review

Action plans based on peak flow are equivalent to action Action plans based on peak flow are equivalent to action plans based on symptoms plans based on symptoms

Reducing the intensity of selfReducing the intensity of self--management education or management education or level of clinical review may reduce its effectiveness level of clinical review may reduce its effectiveness

Cochrane review Cochrane review Powell HPowell H, , Gibson PGGibson PG, 2003, 2003: 15 : 15 RCTsRCTs in adults over 16 years of age with asthmain adults over 16 years of age with asthma

Hospital discharge & followHospital discharge & follow--upup

Timing of dischargeTiming of dischargeNo single physiological parameterNo single physiological parameter

PEF > 75% best or predictedPEF > 75% best or predicted

Patient educationPatient educationInhaler technique, PEF record keeping, action planInhaler technique, PEF record keeping, action planRole for asthma liaison nurse serviceRole for asthma liaison nurse service

FollowFollow--upupReasons for exacerbationReasons for exacerbationReview medicationReview medicationArrange followArrange follow--up with GP within 2 weeks &/or with up with GP within 2 weeks &/or with respiratory service within 4 weeksrespiratory service within 4 weeks


OutpatientsOutpatients

British Guidelines on Asthma 2008

Stepwise management of Stepwise management of chronic asthma in adultschronic asthma in adults

Step 1: Mild intermittent asthma:Step 1: Mild intermittent asthma: Short Short acting acting ββ--agonistagonist

Step 5: Continuous or frequent use Step 5: Continuous or frequent use of oral steroidsof oral steroids

Step 4: Persistent poor control:Step 4: Persistent poor control: High dose ICS + High dose ICS + other addother add--onsons

Step 3: AddStep 3: Add--on therapyon therapy:: Long acting Long acting ββ--agonist (LABA)agonist (LABA)

Step 2: Regular preventer therapy:Step 2: Regular preventer therapy:Inhaled steroid (ICS)Inhaled steroid (ICS)

Check listCheck list::Asthma controlAsthma controlAdherenceAdherenceInhaler techniqueInhaler techniqueSelfSelf--managementmanagement

StepStep--downdown

Summary: assess & treatSummary: assess & treat

Assess severity

Acute severe asthma Life-threatening asthma Near fatal asthma

Notify anaesthetist

/ITU early

Immediate treatment:

Oxygen: maintain SaO2 >92%Nebulised bronchodilatorsCorticosteroids

Summary: next stepsSummary: next steps

If patient not improving within 15If patient not improving within 15--30 min or life 30 min or life threatening or near fatal attackthreatening or near fatal attack

Discuss with middle grade/senior clinicianDiscuss with middle grade/senior clinician

Nebulised salbutamol + Nebulised salbutamol + iprotropiumiprotropium bromide every 15 minbromide every 15 min

Add IV magnesium: 1.2Add IV magnesium: 1.2--2g infusion over 20 min2g infusion over 20 min

Other treatments: consider IV salbutamol or aminophylline Other treatments: consider IV salbutamol or aminophylline

Alerting onAlerting on--call anaesthetist/referral to ITUcall anaesthetist/referral to ITU

Summary: monitoring/investigationsSummary: monitoring/investigations

OximetryOximetryMaintain OMaintain O22 >92>92%%

Repeat blood gases if : Repeat blood gases if : Initial paOInitial paO22 <8 <8 KPaKPa unless SpOunless SpO22 >92%>92%PCOPCO22 normal or raisednormal or raised

PEFPEF

ChestChest--rayray

ElectrolytesElectrolytes

Summary: discharge planningSummary: discharge planning

Check inhaler technique & assess adherence with therapyCheck inhaler technique & assess adherence with therapy

Stop nebulised therapy 24 hrs before dischargeStop nebulised therapy 24 hrs before discharge

Review maintenance treatmentReview maintenance treatment

Written asthma action planWritten asthma action plan

Smoking cessation advice, if appropriateSmoking cessation advice, if appropriate

Questions?Questions?Questions?

acute severe asthma - glasgow, scotland, uk · self discharge alcohol or drug ... if spo 2

Documents