module 6 - acute asthma management.pdf

1Acute Asthma

Management

Module 6

Training of Inhalation Therapy

& Pediatric Asthma Management

Departemen IKA FKUI-RSCM

UKK Respirologi PP IDAI

2Prof. Dr. Mardjanis Said, Sp.A(K)Prof. Dr. Mardjanis Said, Sp.A(K)

Born: Born: Payakumbuh, 1 September 1945Payakumbuh, 1 September 1945

Education:Education:

1.1. Faculty medicine, University Indonesia, 1970Faculty medicine, University Indonesia, 1970

2.2. Medical Post Graduate (Pediatrics), Faculty of Medical Post Graduate (Pediatrics), Faculty of

Medicine Universitas Indonesia, 1976Medicine Universitas Indonesia, 1976

3. Pediatric Pulmonology Subspecialty, Faculty of Indonesia 19871987

Recent position :Recent position :

Staff member of Division of Respirology

Lecturer on Pediatric Pulmonology and Respirology,Dept of Child Health, Faculty of Medicine University of Indonesia

Asthma : chronic respiratory disease that can have acute attack (two in one disease)

AsthmaAcute Asthma

Chronic Asma

Asthma, 2 aspects

Classification of pediatric asthma

Chronic asthma

1. Infrequent episodic asthma

2. Frequent episodic asthma

3. Persistent asthma

Acute asthma

1. Mild attack

2. Moderate attack

3. Severe attack

Asthma managements

Chronic asthma

Long term management

Algorithm diagnosis

& treatment

Acute asthma

Attack

management

Algorithm attack

management

Asthma managements

Chronic asthma

Long term management

Reliever &

Controller

Acute asthma

Attack

management

Reliever

Asthma medication

Controller

drug to control asthma ie attack or symptom not easily emerge

Inhaled steroid

LABA, ALTR

Reliever

drug to relieve asthma attack or symptoms

-agonist Xanthine

anticholinergic

Definition

Acute asthma = asthma attack = asthma excacerbation

Rapid progressive worsening episode of cough, dyspnea, wheezing, chest tightness etc

84.4%

3.9%11.7%

Mild

Moderate

Severe

Type of asthma attacks

in Cipto Mangunkusumo hospital

AsthmaTriggers

Acute attacks

Inhalant house dustmite Smoke Food

Failed of long term management

triggers

bronchoconstriction, edema, secretion

Airway obstruction

non-uniformventilation

Lung hyperinflation

Ventilation-perfusionmismatch

Compliance disturbances

Atelectasis

Alveolar hypoventilation work of breathing

surfactant

PaCO2 PaO2

acidosis

Pulmonaryvasoconstriction

Pathophysiology of acute asthma

Michael Sly. Nelson Textbook, 1996

Respiratory track of healthy children

Triggers(dust, animal danders, smoke, etc)

Bronchus Bronchus

Keep on wide, opened(not hypersensitive,

not easily constricted)

Respiratory track of asthmatic children

triggers(dust, animal danders, smoke, etc)

Bronchus

no symptoms attack

muscle spasmwall oedema

hyper secretions

Bronchus

very fragilevery sensitive

constrict easily

Triggers of asthma Respiratory infection (viral, mycoplasma)

Exercise

Allergens : - inhaled

- ingested (rare)

Irritants (cigarette smoke, air pollution)

Weather changes

Medications (ASA)

Chemical (tartrazine, sulfites, menosodium glutamate)

Emotional stress

Gastroesophageal reflux

Symptoms of asthma attack:

Rigorous cough/without stopping

Dyspnea, difficult breathing

Wheezing

Tachypnea, fast breathing

Chest pain

Difficult to speak

Cyanosis

20

Asthma management principles

1.Avoidance

2.Avoidance

3.Avoidance

4.Drugs inhalation therapy

Goal of acute asthma management

Rapid resolution of acute symptoms

To reduce hypoxemia

Normal lung function as soon as possible

Reevaluation to prevent asthma attacks

Lenfant C et al, GINA 2002

22

Acute asthma management

Asthma attack / symptoms present:

First line therapy

-agonist : terbutaline, salbutamol anticholinergic: ipratropium bromida

Chronic asthma (long term management)

First line therapy

Inhaled steroid

Long-acting beta-2 agonist (LABA)

Assessment of severity

Mild Moderate SevereRespiratory

arrest imminent

Breathless Walking

Can lie down

Talking

Infant-softer

Shorter cry

Difficult feeding

Prefers sitting

At rest

Infant stops feeding

Hunched forward

Talks in Sentences Phrases Words

Alertness Maybe agitated

Usually agitated

Usually agitated

Drowsy or confused

Respiratory rate

Increased Increased Often >30x/min

Normal rates of breathing in awake children:

Age Normal rates

Pulsus paradoxus

Absent

Acute asthma algorithm

Clinic/ERAsses attack severity

1st management nebulitation -agonis 3x, 20 min interval

3rd nebulitation + anticholinergic

Moderate attack(nebulization 2-3x, partial response)

give O2 asses: Moderate

ODC IV line

Mild attack(nebulization 1x,

complete response)

persist 1-2 hr:discharge

symptom reappear:Moderate attack

Severe attack(nebulization 3x,

no response) O2 from the start IV line asses: Severe -

hospitalized CXR

One Day Care (ODC) Oxygen therapy Oral steroid Nebulized / 2 hour Observe 8-12 hours,

if stable discharge Poor response in 12h,

admission

Admission room Oxygen therapy Treat dehydration and

acidosis Steroid IV / 6-8 hours Nebulized / 1-2 hours Initial aminophylline IV,

then maintenance Nebulized 4-6x

good response per 4-6 h If stable in 24 hours discharge

Poor response ICU

Discharge give -agonist

(inhaled/oral) routine drugs viral infection:

oral steroid Outpatient clinic in

24-48 hours

Notes: In severe attack, directly use -agonist + anticholinergic If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times Oxygen therapy 2-4 l/min should be early treatment in moderate

and severe attack

At home

Known of asthma symptoms

Nebulized 2 agonist

If not available: MDI with/without spacer or orally

In Indonesia: not popular

Be careful with OTC

Early management

Initial assessment of severity asthma attacks

Nebulized 2-agonist, interval 20 minute

3rd nebulization: anticholinergic agent

Severe attacks: directly with anticholinergic agent

If nebulizer not available:

MDI with Spacer

Adrenalin SC

MDI with Spacer Vs Nebulizer

2 agonist: bronchodilator

Mild-moderate attacks

MDI with spacer: as effective as nebulizer

Severe attacks:

Nebulizer is recommended

MDI with spacer vs nebulizer

Take less time

Fewer side effects

More portable

Cheaper

Easier use

2 agonist + ipratropium bromide.

Symptoms score decrease

Lung function better than alone

Hospitalized

Activity: longer

Mild attacks

Good response post nebulization

Observe: 1-2 hours

Discharge if the response is good

Treat as moderate attacks if symptoms still remain

Use routine drugs

Out patient clinics

Management of asthma attacks

Mild

NebulizationNebulizationNebulizationNebulization

Observe 1Observe 1Observe 1Observe 1----2 hours2 hours2 hours2 hours

DISCHARGE

Moderate

Routine drugsOutpatient clinic

Moderate attacks

Partial response post nebulization

ODC admission

Oxygen therapy

Oral steroid

IV line

Repeated nebulization

Good response: discharge

Poor response: admission

Management of Asthma Attack

MILDMILDMILDMILD

Nebulization

Observe: 1-2 hours

DISCHARGEDISCHARGEDISCHARGEDISCHARGE

MODERATEMODERATEMODERATEMODERATE

OxygenOxygenOxygenOxygen


IVFDIVFDIVFDIVFD

Oral steroidOral steroidOral steroidOral steroid

ODCODCODCODC SEVERESEVERESEVERESEVERE

???

Why is not response?

Dehydration

Metabolic acidosis

Atelectasis

Severe attacks

Poor response postnebulization

Oxygen therapy

IV line: rehydration and treat acidosis

Corticosteroids (IV)

Initial Aminophylline (IV), then maintenance

Repeated nebulization

Chest X-ray

Good response : Discharge

Poor response : Intensive care

Management of asthma attack

MILDMILDMILDMILD

Nebulization

Observe 1-2 hours



Oxygen

Nebulization

IVFD

Oral steroid


OOOO2222, steroid, steroid, steroid, steroid


HydrationHydrationHydrationHydration

AminophyllineAminophyllineAminophyllineAminophylline

RRRR

ICU (?)ICU (?)ICU (?)ICU (?)

Others drugs (asthma attacks)

Adrenalin: maximal dose, and b effects

Salbutamol SC: be careful

MgSO4: not significant

Inhaled steroid : high dose (1600 mg)

Asthma attacksAsthma attacksAsthma attacksAsthma attacks

Stable asthmaStable asthmaStable asthmaStable asthma

(No attack)(No attack)(No attack)(No attack)

Infrequent Infrequent Infrequent Infrequent

episodicepisodicepisodicepisodic

Frequent Frequent Frequent Frequent

episodicepisodicepisodicepisodicPersistentPersistentPersistentPersistent

Reliever (+)Reliever (+)Reliever (+)Reliever (+)

Controller (Controller (Controller (Controller (----))))


Controller (+)Controller (+)Controller (+)Controller (+)


Controller (+)Controller (+)Controller (+)Controller (+)

Assess the severity Assess the severity Assess the severity Assess the severity

of attacksof attacksof attacksof attacks

Assess class of Assess class of Assess class of Assess class of

diseasediseasediseasedisease

Educations and AVOIDANCE

Acute asthma attacks

Nebulization 1-2 x

Good response

Discharge

Bronchodilator

Partially response

One Day CareOxygenNebulizationOral steroid IVFD

Good response Poor response

Discharge

Hospitalization

OxygenNebulizationIVFD: rehydrationSystemic steroid Aminophylline

-Agonist

Oxygen therapy

Reduce hypoxemia

To achieve saturation > 95%

Should be titrated according to oximetry

Inhalation therapy

2 agonist and ipratropium bromide Vs 2 agonist alone:

Hospitalization

Symptoms score

Lung function

Duration of action:

Mucolytics: worsen

Schuh et al. J Pediatr 1995; 126:639-45.

IVFD

Replacement therapy for dehydration

Intake because dyspnea

Vomiting

Treat acid-base and electrolyte imbalance

Parenteral medications

Steroids

Intravenous or oral

Anti-inflammations

Inhaled steroids: controversial

Aminophylline

Initial: 6-8 mg/kgBW IV in 10-20 minute

Maintenance dose 0.5 - 1 mg/kgBW/hour

Monitoring: aminophylline serum level

Narrow safety margin

National guidelines for childhood asthma, 2004

Other drugs

Adrenalin: maximal dose !!!, and effects Salbutamol SC: be careful

MgSO4: not significant than salbutamol

Inhaled Steroid : high dose (1600-2000 mg)

LABA: Nocturnal asthma, EIA

Antibiotics: Not necessary except sinusitis

Lenfant C et al, GINA 2002Lenfant C et al, GINA 2002Lenfant C et al, GINA 2002Lenfant C et al, GINA 2002

Inhaled steroid

Controversial (limited literature)

High dose (1600-2000 mg)

Reduced asthma attacks

Not effective in severe attacks

Alternative therapy

Management of acute asthmaMILDMILDMILDMILD

Nebulization

Observe 1-2 hours



Oxygen

Nebulization

IVFD

Oral steroid


OOOO2222, steroid, steroid, steroid, steroid


HydrationHydrationHydrationHydration

AminophyllineAminophyllineAminophyllineAminophylline

RRRR

ICU (?)ICU (?)ICU (?)ICU (?)

Severe acute asthmaNo response after initial serial nebulization

Oxygen

IV line: dehydration and acidosis

Systemic steroid: oral or IV

Frequent nebulization

Aminophylline IV drip: initial + maintenance

Chest X ray

Non responsive

Dehydration: inadequate intake, the longer the more

evaluate: clinically, laboratory; overcome

Acidosis: correction

Atelectasis & mucus plug: CXR mandatory; physiotherapy

Monitoring

Vital sign: consciousness, RR, HR, temperature

Cyanosis, retraction, wheezing

Hydration state and acid base, electrolite

Complication: pneumothorax, atelectasis, encephalopathy

Nonresponsive

Excessive use of -agonist down regulation of -agonist receptors tachyphylaxis, subsensitivity

Systemic steroid

reduce the edema

up regulates more -agonist receptors sensitive again to -agonist drugs

Conclusion Asthma labelling

Acute asthma: mild, moderate, and severe

Avoidance is a very important prevention

Initial management is important to prevent mortality

Nebulisation in severe acute asthma: agonist + ipratropium bromida

Pedoman Nasional Asma Anak

56

Thanks for

your attention

module 6 - acute asthma management.pdf

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