approche to acute asthma management

ACUTE ASTHMA MANAGEMENT

ANAS SAHLE , MDDAMASCUSE

HOSPITAL

Risk factors for death from asthma

1. Prior severe exacerbation(eg: ICU admit, intubation).2. 2 or more asthma hospitalization in past year.3. 3 or more ED visit for asthma in past year.4. Hospitalization or ED visit for asthma in prior month.5. Use of >2 SABA canisters per month.6. Difficulty perceiving asthma symptoms or severity of

exacerbation.7. Lack of written asthma action plan, sensitve to

ALTERNARIA(fungus).8. Other social and comorbidity risks.

EPR-3 national heart lung and blood 2007

Risk factors for death from asthma

1. Sudden severe attacks2. Recent systemic steroids.3. >2 SABA canisters in prior month.4. Hospital\ER in last month.5. ≥ 2 ER\hospitalization in last year.6. Prior intubation\ICU stay.7. Illicit drug use.8. Heart\psychiartic disorder.9. Low socioeconomic class.

curr Opin pulm med 2008

PEFR≥75% predicted

Β2 Agonist(neb),(MDI)PEFR≥75% and clinically stable

Observe 2H and discharge if stable

PEFR<75% and clinically stable

Treat as moderate exacerbation

Check 15-30 min

Mild exacerbation

PEFR=50-75% predicted

5 mg SALBUTAMOL(NEB) 30-60 mg PREDNISOLONE

PEFR=50-75% clinically stableRepeat 5 mg SALBUTAMOL(NEB)

PEFR<50% or clinically deteriorating

Treat as severe

PEFR>50% ,clinically stable

Deteriorating: treat as severe Observe for 2H discharge if stable +PEF increasing

PEFR<50% Or clinically deteriorating

Treat as severe

Check at 30 min

Check at 30 min

Moderate exacerbation

PEFR=33-50%predicted, cannot complete sentences , RR>25\min , HR>110\min

High flow O2,5mg salbutamol(neb),

30-60mg prednisolone\200mg hydrocortisone(IV)

If improving: admit continue 4-6 hourly (neb)

continue prednisolone 40-50mg daily

If not improving repeat 5mg salbutamol(neb) every 15-30 min till

improving 500mcg ipratropium(neb)

consider magnesium(1,2-2)g over 20 min(IV) check ABG

If improving: admit continue 2-4 hourly nebs daily

prednisolone or 6 hourly hydrocortisone

If not improving start aminophylline(IV) treat as life-

threatening discuss with ICU

CHECK at 15 min

CHECK at 15 min

IF ABG:normal\raised PCO2severe hypoxia<58 low PH

Severe exacerbation

PEFR<33% O2 SAT<92%

Silent chest Cyanosis

Bradycardia Hypotension

Exhaustion\confusion

High flow O2measure ABG

5mg salbutamol (neb) 500mcg ipratropium (neb) hydrocortisone100mg (IV)

magnesium 2g(IV)250mg aminophylline (IV)؟؟±

REFER TO ICU

Life-threatening exacerbation

REFERRAL TO INTENSIVE CARE

• deteriorating PEF• persisting or worsening hypoxia• Hypercapnea• arterial blood gas analysis showing fall in pH• exhaustion, feeble respiration• drowsiness, confusion, altered conscious state• respiratory arrest

NON-INVASIVE VENTILATION

• It is unlikely that NIV would replace intubation in these very unstable patients.

• but it has been suggested that this treatment can be used safely and effectively.

Discharge planningOn discharge , all patients should have:

1. Patients should be on home medication for 24 hours prior to discharge.

2. PEF>75% predicted , <25% variability.3. Prednisolone 40mg for at least 5 days.4. Oral antibiotics if confirmed evidence of infection.5. Supply of all inhalers and technique checked.6. PEF meter.

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Definition

The peak expiratory flow rate is an effort-dependent assessment of a patients ability to forcibly expel air from their lungs

Airways Obstruction

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Peak Expiratory Flow Rate / PEFR

Usually used in children over 5 years

Assessment of Reversibility of Airways limitation or Hyperresponsiveness

Diurnal variation : Self -Monitoring in asthma

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Peak Expiratory Flow Rate / PEFR

Usually used in children over 5 years

Assessment of Reversibility of Airways limitation or Hyperresponsiveness

Diurnal variation : Self -Monitoring in asthma

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Peak Expiratory Flow Rate / PEFR

Usually used in children over 5 years

Assessment of Reversibility of Airways limitation or Hyperresponsiveness

Diurnal variation : Self -Monitoring in asthma

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Peak expiratory flow rate measurement

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Peak expiratory flow rate measurement

Ask the patient to stand up & hold

the peak flow in a horizontal position

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Peak expiratory flow rate measurement

Take care not to place your fingers

over the scale

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Peak expiratory flow rate measurement

Ask the patient now to take a deep breath in & make a

tight seal with their lips around the mouth piece

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Peak expiratory flow rate measurement

Now ask the patient to blow out as hard & as fast as they can

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Peak expiratory flow rate measurement

Remember fast blast is better than slow blow

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Peak expiratory flow rate measurement

Note the number where

the sliding pointer has

stopped on the scale

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Peak expiratory flow rate measurement

Reset the pointer to 'zero'

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Peak Expiratory Flow

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Personal Best PEFR Value Baseline Predicated PEFR Value

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Personal Best PEFR Value

A baseline measure The baseline values should be

obtained when the patient is feeling well after a period of maximal asthma therapy

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Personal Best PEFR Value

The patient should then record PEFR measurements 2 to 4 times daily for two weeks

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Personal Best PEFR Value

The personal best is generally the highest PEFR measurement achieved during this post-treatment monitoring period

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Personal Best PEFR Value

The patient's normal PEFR range is defined as 80 and 100 percent of the patient's personal best.

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Baseline Predicated PEFR Value

Tall – 80 X 5 = Prv PEFRExample: 150 – 80 x 5 = 350

L/min

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Predicated PEFR value vs Personal Best value

of PEFR

The patient's normal value of PEFR:

Self -Monitoring in asthma

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Percentage PEFR Variability

Highest – Lowest /

Highest x 100

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Inhalation of 200-400 µg of Salbutamol

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01تمرين

عمره لديه 10مريض أن أشتبه سنوات،الصدر/ إصغاء عند منتشر وزيز ربو

PEFR : المتوقعL/min 300كان فحصه 150المقاس PEFRعندفحص له Reversibilityأجري

250المقاس PEFRكان Ventolineبعد هناك ؟Reversibilityهلربو؟ لديه هل

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التمرين 01حل

250 – 150 / 250 = 40 %Yes

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Self -Monitoring in asthma

100 %

80 %

50 %

All clear

Caution

Medical Alert