asthma management exacerbation

7/31/2019 Asthma Management Exacerbation

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LULUK ADIPRATIKTO


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1.Develop Patient/DoctorPartnership

2. Identify and Reduce Exposureto Risk Factors

3.Assess, Treat and Monitor

Asthma4. Manage Asthma Exacerbations

5. Special Considerations

Asthma Management and PreventionProgram: Five Components

2009


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Exacerbations of asthma (asthma attacks or acute

asthma) are episodes of progressive increase inshortness of breath, cough,wheezing, or chest tightness,or some combination of these symptoms.

Exacerbations are characterized by decreasesin expiratory airflow that can be quantified andmonitored by measurement of lung function

(PEF or FEV1).


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The aims of treatmentare to relieve airflowobstruction and

hypoxemia as quicklyas possible,and to planthe prevention of future

relapses.


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ASSESEMENT OF SEVERITY

MILD

MODERATESEVERE

RESPIRATORY ARREST IMMINENT


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Mild Moderate SevereRespiratory arrest

imminent

Breatkless Walking Talking At rest

Infant-softer Infant stop feeding

Shorter cry

Can lie down Prefer sitting Hunched forward

Talks in Sentences Phrases Words

Alertness Maybe agitated Usually Agitated Usually Agitated Drowsy or confuse

Respiratory rate Increased Increased Often>30/min

Normal rate of breathing in awake childrenAge Normal rate


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Mild Moderate Severe

Respiratory arrestimminent

Pulse/min 120 Bradycardia

Guide to limits of normal pulse rate in children:

Infants 2-12 monthsNormal Rate < 160/min

Preschool 1-2 years < 120/min

School age 2-8 years < 110/min

Pulsus paradoxus Absent Maybe present Often present Absence suggests

25 mmHg(adult) respiratory musle

20-40(child) fatiquePEF Over 80% Aprprox.60-80%


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Milder exacerbations, defined by a reduction inpeak flow of less than 20%, nocturnal

awakening,and increased use of short acting 2-agonists can usually be treated in a communitysetting.


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Bronchodilators. For mild to moderateexacerbations,repeated administration of rapid-acting inhaled 2-agonists (2 to 4 puffs every 20minutes for the first hour)

Bronchodilator therapy delivered viametered-dose inhaler (MDI), ideally with a spacer,nebulizer.

No additional medication is necessary if the rapid-acting inhaled 2-agonist produces a complete response (PEF returns to greater than 80%of predicted orpersonal best) and the response lasts for 3 to 4 hours.

TREATMENT


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Inhaled glucocorticosteroidsare effective as part oftherapy for asthma exacerbations. In one study, thecombination of high-dose inhaled glucocorticosteroids andsalbutamol in acute asthma provided greater bronchodilationthan salbutamol alone(Evidence B), and conferred greaterbenefit than the addition of systemic glucocorticosteroidsacross all parameters, including hospitalizations, especially forpatients with more severe attacks.

Glucocorticosteroids. Oral glucocorticosteroids(0.5 to 1mg of prednisolone/kg or equivalentduring a 24-hour period) should be used to treatexacerbations


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Severe exacerbations of asthma are life-threatening

medical emergencies, treatment of which is often mostsafely undertaken in an emergency department


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With a history of near-fatal asthma requiring intubation and mechanicalventilationWho have had a hospitalization or emergency care visit for asthma inthe past yearWho are currently using or have recently stopped using oralglucocorticosteroids

Who are not currently using inhaled glucocorticosteroidsWho are overdependent on rapid-acting inhaled 2-agonists, especiallythose who use more than one canister of salbutamol (or equivalent)monthlyWith a history of psychiatric disease or psychosocial problems,

including the use of sedativesWith a history of noncompliance with an asthma medication plan.

High risk of asthma


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Initial AssessmentHistory, physical examination (auscultation, use of accessory muscles,

heart rate, respiratory rate, PEF or FEV1, oxygensaturation, arterial blood gas if patient in extremis)

Initial TreatmentOxygen to achieve O2 saturation 90% (95% in children)Inhaled rapid-acting 2-agonist continuously for one hour.

Systemic glucocorticosteroids if no immediate response, or if patientrecently took oral glucocorticosteroid, or if episode is severe.Sedation is contraindicated in the treatment of an exacerbation.


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Criteria for Moderate Episode: PEF 60-80% predicted/personal best Physical exam: moderate symptoms, accessory muscle use

Treatment:

Oxygen Inhaled 2-agonist and inhaled anticholinergic every 60 min Oral glucocorticosteroids Continue treatment for 1-3 hours, provided there is

improvement

REASSES


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Criteria for Severe Episode: History of risk factors for near fatal asthma PEF < 60% predicted/personal best Physical exam: severe symptoms at rest, chest retraction No improvement after initial treatment

Treatment: Oxygen Inhaled 2-agonist and inhaled anticholinergic Systemic glucocorticosteroids

Intravenous magnesium


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Good Response within 1-2 Hours: Response sustained 60 min after last treatment

Physical exam normal: No distress PEF > 70% O2 saturation > 90% (95% children

Improved: Criteria for Discharge Home PEF > 60% predicted/personal best Sustained on oral/inhaled medication

Home Treatment:

Continue inhaled 2-agonist Consider, in most cases, oral glucocorticosteroids Consider adding a combination inhaler Patient education: Take medicine correctlyReview action planClose medical follow-up


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Incomplete Response within 1-2 Hours: Risk factors for near fatal asthma Physical exam: mild to moderate signs PEF < 60% O2 saturation not improving

Admit to Acute Care Setting Oxygen Inhaled 2-agonist + anticholinergic Systemic glucocorticosteroid

Intravenous magnesium Monitor PEF, O2 saturation, pulse


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Poor Response within 1-2 Hours: Risk factors for near fatal asthma Physical exam: symptoms severe, drowsiness, confusion PEF < 30% PCO2 > 45 mm Hg P O2 < 60mm Hg

Admit to Intensive Care Oxygen Inhaled 2-agonist + anticholinergic

Intravenous glucocorticosteroids Consider intravenous 2-agonist

Consider intravenous theophylline Possible intubation and mechanical ventilation


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asthma management exacerbation

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