ASTHMAASTHMA

Victor Politi, M.D., FACPVictor Politi, M.D., FACP

Medical Director, SVCMC Medical Director, SVCMC School of Allied HealthSchool of Allied Health

What is Asthma?What is Asthma?

Asthma is a chronic condition that occurs Asthma is a chronic condition that occurs when the main air passages of the lungs, the when the main air passages of the lungs, the bronchial tubes, become inflamed. bronchial tubes, become inflamed.

The muscles of the bronchial walls tighten The muscles of the bronchial walls tighten and extra mucus is produced, causing the and extra mucus is produced, causing the airways to narrow. airways to narrow.

can lead to minor wheezing to severe can lead to minor wheezing to severe difficulty in breathing. difficulty in breathing.

In some cases, breathing may be so labored In some cases, breathing may be so labored that an asthma attack becomes life-that an asthma attack becomes life-threatening threatening

AsthmaAsthma – Reversible airway obstruction Reversible airway obstruction – Airway inflammation Airway inflammation – Increased bronchial Increased bronchial

hyperresponsiveness hyperresponsiveness

Status AsthmaticusStatus Asthmaticus – Severe airway obstruction Severe airway obstruction

developing over days-weeks developing over days-weeks

DefinitionsDefinitions

The Respiratory The Respiratory SystemSystem

PathophysiologyPathophysiology

Hallmark of AsthmaHallmark of Asthma -Bronchial wall -Bronchial wall Hyperresponsiveness Hyperresponsiveness

Early Phase Asthma ReactionEarly Phase Asthma Reaction Bronchoconstriction Bronchoconstriction

– Antigenic Stimulation of bronchial wall Antigenic Stimulation of bronchial wall – Mast Cell Degranulation releases Mast Cell Degranulation releases

Histamine Histamine Chemotactics Chemotactics Proteolytics Proteolytics Heparin Heparin

– Smooth Muscle Bronchoconstriction Smooth Muscle Bronchoconstriction

Late Phase Asthma ReactionLate Phase Asthma Reaction: Bronchial : Bronchial Inflammation Inflammation – Inflammatory Cells Recruited Inflammatory Cells Recruited

Neutrophils Neutrophils Monocytes Monocytes Eosinophils Eosinophils

– Release Cytokines, Vasoactives, Release Cytokines, Vasoactives, Arachidonic acid Arachidonic acid

– Epithelial and Endothelial Cell inflammation Epithelial and Endothelial Cell inflammation – Release of Interleukin 3-6, TNF, Interferon-Release of Interleukin 3-6, TNF, Interferon-

gamma gamma

PathophysiologyPathophysiology

Risk Factors Risk Factors

Family History Family History – One parent with asthma: up to 25% risk for child One parent with asthma: up to 25% risk for child – Two parents with asthma: up to 50% risk for child Two parents with asthma: up to 50% risk for child

Parental tobacco use Parental tobacco use Associated aspirin or NSAID allergy Associated aspirin or NSAID allergy Classic Triad: Classic Triad:

– Asthma, Nasal polyps, Aspirin allergy Asthma, Nasal polyps, Aspirin allergy RSV Bronchiolitis history RSV Bronchiolitis history Strongly associated with later development Strongly associated with later development

of asthma of asthma Strenuous exercise in areas of high ozone Strenuous exercise in areas of high ozone

(pollution) (pollution)

Types of AsthmaTypes of Asthma

Extrinsic Asthma (Allergic) Extrinsic Asthma (Allergic) Intrinsic Asthma (Non-allergic)Intrinsic Asthma (Non-allergic) Mixed Asthma (Extrinsic and Intrinsic) Mixed Asthma (Extrinsic and Intrinsic) Occupational Asthma Occupational Asthma Drug Induced Asthma Drug Induced Asthma

– Aspirin-induced Asthma Aspirin-induced Asthma – NSAID-induced Asthma NSAID-induced Asthma

Exercise Induced Asthma Exercise Induced Asthma Cough Variant Asthma Cough Variant Asthma

– Very common! (Especially in children)Very common! (Especially in children)

Asthma StatisticsAsthma Statistics

For reasons no one quite understands, the For reasons no one quite understands, the number of asthma cases has risen dramatically number of asthma cases has risen dramatically during the past decade, especially among during the past decade, especially among children living in the inner city. children living in the inner city.

Approximately 14 million Americans have Approximately 14 million Americans have asthma, including more than 6 million children.asthma, including more than 6 million children.

Asthma is the most common chronic illness of Asthma is the most common chronic illness of childhood. childhood. – Among young children, asthma is more common in Among young children, asthma is more common in

boys than in girls. boys than in girls. – After puberty asthma becomes more common in girlsAfter puberty asthma becomes more common in girls

Intrinsic Asthma Intrinsic Asthma Non-allergic asthmaNon-allergic asthma

PathophysiologyPathophysiology – Non-IgE, Non-allergic asthma Non-IgE, Non-allergic asthma

Precipitating FactorsPrecipitating Factors – Irritant exposure Irritant exposure

(Air Pollution, Fumes, Perfumes, Household cleaning (Air Pollution, Fumes, Perfumes, Household cleaning agents, Insecticides, paint, tobacco, cold air agents, Insecticides, paint, tobacco, cold air

– Infection Infection URI, purulent rhinitis, acute sinusitisURI, purulent rhinitis, acute sinusitis

– GERD GERD EpidemiologyEpidemiology

– Much more common in adults than children Much more common in adults than children – Onset age over 40 years old Onset age over 40 years old

Extrinsic Asthma Extrinsic Asthma Allergic AsthmaAllergic Asthma

PathophysiologyPathophysiology – IgE mediated response to allergens IgE mediated response to allergens

Immediate allergic reactionImmediate allergic reaction Late-phase allergic reactionLate-phase allergic reaction

CausesCauses – Indoor allergens Indoor allergens

House –Dust mites (most common extrinsic allergen) House –Dust mites (most common extrinsic allergen) Animal proteins (animal dander) Animal proteins (animal dander) Mold spores Mold spores Cockroaches Cockroaches

– Outdoor allergens Outdoor allergens Pollens , mold spores Pollens , mold spores

EpidemiologyEpidemiology – Much more common in children than adults Much more common in children than adults – Age Onset under 40 years oldAge Onset under 40 years old

Asthma TriggersAsthma Triggers

Asthma TriggersAsthma Triggers

Asthma TriggersAsthma Triggers

All Asthma attacks All Asthma attacks give a warninggive a warning Warning signs and symptoms for Warning signs and symptoms for

adults can include:adults can include: Increased shortness of breath or wheezing Increased shortness of breath or wheezing Disturbed sleep caused by shortness of breath, Disturbed sleep caused by shortness of breath,

coughing or wheezing coughing or wheezing Chest tightness or pain Chest tightness or pain Increased need to use bronchodilators — Increased need to use bronchodilators —

medications that open up airways by relaxing medications that open up airways by relaxing the surrounding muscles the surrounding muscles

A fall in peak flow rates as measured by a peak A fall in peak flow rates as measured by a peak flow meterflow meter

Warning signs and symptoms for Warning signs and symptoms for children may include children may include – An audible whistling or wheezing when the An audible whistling or wheezing when the

child exhales child exhales – Coughing, especially if the cough is Coughing, especially if the cough is

frequent and occurs in spasms frequent and occurs in spasms – Waking at night with coughing or wheezing Waking at night with coughing or wheezing – Shortness of breath, which may or may not Shortness of breath, which may or may not

occur when the child exercises occur when the child exercises – A tight feeling in the child's chest A tight feeling in the child's chest

All Asthma attacks All Asthma attacks give a warninggive a warning

Asthma and Other Asthma and Other ConditionsConditions Differentiating between asthma and chronic Differentiating between asthma and chronic

obstructive pulmonary disease (COPD) such as obstructive pulmonary disease (COPD) such as emphysema and chronic bronchitis can be especially emphysema and chronic bronchitis can be especially challenging. challenging.

Asthma and COPD each cause similar symptoms. Asthma and COPD each cause similar symptoms.

Not uncommon for older adults — especially longtime Not uncommon for older adults — especially longtime smokers — to have both conditions. smokers — to have both conditions.

Various tests — including skin or blood tests for Various tests — including skin or blood tests for allergies, and spirometry — can help determine allergies, and spirometry — can help determine whether asthma is present.whether asthma is present.

What is cardiac What is cardiac asthma? asthma? Cardiac asthma isn't actually Cardiac asthma isn't actually

asthma. asthma. It refers to the wheezing that's It refers to the wheezing that's

caused by CHFcaused by CHF– Excess fluid in the lungs (pulmonary Excess fluid in the lungs (pulmonary

edema) associated with heart failure edema) associated with heart failure causes signs and symptoms such as causes signs and symptoms such as shortness of breath, coughing and shortness of breath, coughing and wheezing, which mimic asthma wheezing, which mimic asthma

Exercise Induced Exercise Induced AsthmaAsthma Exercise-induced asthma — or Exercise-induced asthma — or

exercise-induced constriction of the exercise-induced constriction of the bronchial tubes (bronchospasm) bronchial tubes (bronchospasm) – a condition in which the airways narrow a condition in which the airways narrow

significantly during vigorous exercise. significantly during vigorous exercise.

Typical SymptomsTypical Symptoms– Cough, Wheezing, Shortness of breath, Chest Cough, Wheezing, Shortness of breath, Chest

tightness tightness – Typically symptoms present about 10 minutes after Typically symptoms present about 10 minutes after

stopping exercisestopping exercise

Exercise Induced Exercise Induced AsthmaAsthma Exercise-induced wheezing or Exercise-induced wheezing or

shortness of breath is typical for shortness of breath is typical for people who have chronic asthma. people who have chronic asthma.

But exercise-induced wheezing or But exercise-induced wheezing or shortness of breath can occur when shortness of breath can occur when sensitive airways constrict when sensitive airways constrict when exercising, especially when exercising, especially when combined with cold air, low humidity combined with cold air, low humidity or pollution.or pollution.

Chronic Asthma or Chronic Asthma or Exercise Induced Exercise Induced AsthmaAsthma Basic difference between chronic Basic difference between chronic

asthma and exercise-induced asthma asthma and exercise-induced asthma – People with exercise-induced asthma People with exercise-induced asthma

have symptoms only with physical have symptoms only with physical activity. activity.

– People with chronic asthma often have People with chronic asthma often have exercise-induced wheezing or shortness exercise-induced wheezing or shortness of breath, but they may have asthma of breath, but they may have asthma symptoms at other times as well. symptoms at other times as well.

Exercise Induced Exercise Induced Asthma - MedicationsAsthma - Medications The most common medications for The most common medications for

exercise-induced asthma are exercise-induced asthma are bronchodilators, which are taken about bronchodilators, which are taken about 15 to 30 minutes before exercising 15 to 30 minutes before exercising

Medications Include:Medications Include:– Albuterol (Proventil, Ventolin) Albuterol (Proventil, Ventolin) – Pirbuterol (Maxair) Pirbuterol (Maxair) – Ipratropium and albuterol combination Ipratropium and albuterol combination

(Combivent) (Combivent)

What's the difference What's the difference between asthma and between asthma and COPD?COPD? similar symptoms but very differentsimilar symptoms but very different

– Asthma causes reversible lung Asthma causes reversible lung inflammation, inflammation,

– COPD causes irreversible lung damageCOPD causes irreversible lung damage

– It's important to distinguish between the It's important to distinguish between the two conditions because they're treated two conditions because they're treated differently differently

Smoking history.Smoking history. Asthma may Asthma may occur in nonsmokers as well as in occur in nonsmokers as well as in smokers. But COPD is usually smokers. But COPD is usually associated with a long history of associated with a long history of smoking smoking

What's the difference What's the difference between asthma and between asthma and COPD?COPD?

SymptomsSymptoms– Periodic wheezing and chest tightness, Periodic wheezing and chest tightness,

especially at night, is typical of asthma. especially at night, is typical of asthma. – COPD is more likely to cause a daily COPD is more likely to cause a daily

morning cough that produces mucus. morning cough that produces mucus. – In COPD, patients may develop a In COPD, patients may develop a

permanently expanded barrel chest permanently expanded barrel chest because too much air is trapped in the because too much air is trapped in the lungs. lungs.

What's the difference What's the difference between asthma and between asthma and COPD?COPD?

Cough Variant Asthma Cough Variant Asthma

Chronic cough – Chronic cough – – Cough > 3 weeks Cough > 3 weeks – NonproductiveNonproductive– Usually nocturnal – but can occur anytimeUsually nocturnal – but can occur anytime

Occur any age groupOccur any age group PFTs –normalPFTs –normal Rule out other causes of chronic coughRule out other causes of chronic cough TXTX

– Similar to common forms of asthmaSimilar to common forms of asthma

Asthma EvaluationAsthma EvaluationDifferential Diagnosis Differential Diagnosis General General

– All that wheezes is not asthma!! All that wheezes is not asthma!! – However most recurrent cough and wheeze is However most recurrent cough and wheeze is

asthma asthma Upper airway disease Upper airway disease

– Allergic rhinitis Allergic rhinitis – sinusitis sinusitis – Large airway obstruction Large airway obstruction – Foreign body Foreign body – Vocal cord dysfunction Vocal cord dysfunction – Vascular rings of laryngeal webs Vascular rings of laryngeal webs – Laryngotracheomalacia Laryngotracheomalacia – Tracheobronchial-stenosis Tracheobronchial-stenosis – Enlarged lymph node or tumor Enlarged lymph node or tumor

Small Airway obstruction Small Airway obstruction – Viral Bronchiolitis Viral Bronchiolitis – Bronchiolitis obliterans Bronchiolitis obliterans – Cystic Fibrosis Cystic Fibrosis – Bronchopulmonary dysplasia Bronchopulmonary dysplasia – Heart disease Heart disease

Other Causes Other Causes – Psychogenic cough Psychogenic cough – GERD GERD – ACE inhibitors ACE inhibitors

Asthma EvaluationAsthma EvaluationDifferential Diagnosis Differential Diagnosis

Asthma EvaluationAsthma EvaluationHistoryHistory General: History is not always accurate General: History is not always accurate

– Confirm with PFTs every 3-6 month Confirm with PFTs every 3-6 month – Patient may underplay symptoms Patient may underplay symptoms – 10% of patients do not recognize severe Symptoms 10% of patients do not recognize severe Symptoms

of their asthma of their asthma Age of onset and asthma diagnosis Age of onset and asthma diagnosis Past history of respiratory failure or Past history of respiratory failure or

intubation intubation Recognize cohorts at additional risk Recognize cohorts at additional risk

– Elderly Elderly – Pregnancy Pregnancy

Asthma EvaluationAsthma EvaluationHistoryHistory History of early life injury to airways History of early life injury to airways

– Bronchopulmonary Dysplasia Bronchopulmonary Dysplasia – Parental smoking Parental smoking

Disease progression Disease progression Present management and response Present management and response Frequency of systemic corticosteroid use Frequency of systemic corticosteroid use

– History steroid-induced complications History steroid-induced complications Comorbid conditions Comorbid conditions

– Chronic sinusitis Chronic sinusitis – Assess in all asthma patients Assess in all asthma patients – Consider empiric treatment if refractory asthma Consider empiric treatment if refractory asthma

Asthma EvaluationAsthma EvaluationHistoryHistory Family History (any asthma, allergic Family History (any asthma, allergic

rhinitis, etc.)rhinitis, etc.) Social History Social History

– Home characteristics Home characteristics Heating and cooling system Heating and cooling system Wood burning stove Wood burning stove Humidifier Humidifier Carpeting over concrete Carpeting over concrete

– Smokers in home Smokers in home – Daycare and school situation impacting Daycare and school situation impacting

compliance compliance

Asthma EvaluationAsthma EvaluationSigns: Respiratory distressSigns: Respiratory distress

Tachypnea Tachypnea Dyspnea Dyspnea Anxiety Anxiety Accessory Muscle Use Accessory Muscle Use

– Intercostal muscle use Intercostal muscle use – Sternocleidomastoid use Sternocleidomastoid use – Scalenes Muscle use Scalenes Muscle use

Cyanosis in severe cases (lips) Cyanosis in severe cases (lips) Tachycardia Tachycardia

Asthma EvaluationAsthma EvaluationRadiology: chest x-rayRadiology: chest x-ray IndicationsIndications

– Initial asthma diagnosis Initial asthma diagnosis Low yield in acute asthma exacerbationsLow yield in acute asthma exacerbations

– Abnormal findings at presentation: 5% Abnormal findings at presentation: 5% – Abnormal findings if no improvement in 12 hours: Abnormal findings if no improvement in 12 hours:

34% 34% Status Asthmaticus or no acute asthma Status Asthmaticus or no acute asthma

improvementimprovement – Excludes other diagnoses Excludes other diagnoses

CHF CHF Pneumonia Pneumonia

– Excludes complications Excludes complications Pneumothorax Pneumothorax PneumomediastinumPneumomediastinum

Asthma EvaluationAsthma EvaluationLabs Labs ABGs ABGs

– Hypoxemia Hypoxemia – Hypercarbia (or normal CO2) with decompensation Hypercarbia (or normal CO2) with decompensation

CBC CBC – Eosinophilia may be present Eosinophilia may be present – Increased Levels of IgE may be present Increased Levels of IgE may be present

Sputum Sample Sputum Sample – May show casts of small airways May show casts of small airways – Thick mucoid sputum Thick mucoid sputum – Curschmann's spirals Curschmann's spirals – Charcot-Leyden crystals Charcot-Leyden crystals

Asthma EvaluationAsthma EvaluationOther Diagnostic TestsOther Diagnostic Tests PFT’s – Pulmonary Function PFT’s – Pulmonary Function

TestingTesting– SpirometrySpirometry– Methacholine ChallengeMethacholine Challenge

What are PFT's?What are PFT's?

Pulmonary function testing is one of the Pulmonary function testing is one of the basic tools for evaluating a patient's basic tools for evaluating a patient's respiratory status. respiratory status.

In patients with suspected pulmonary In patients with suspected pulmonary disease, it is often the first diagnostic test disease, it is often the first diagnostic test employed in the work up. employed in the work up.

Pulmonary function tests (PFT's) are also Pulmonary function tests (PFT's) are also used for pre-operative evaluation, used for pre-operative evaluation, managing patients with known pulmonary managing patients with known pulmonary disease, and quantifying pulmonary disease, and quantifying pulmonary disability disability

PFT- SpirometryPFT- Spirometry

A versatile test of pulmonary physiology. A versatile test of pulmonary physiology. Reversibility of airways obstruction can Reversibility of airways obstruction can

be assessed with the use of be assessed with the use of bronchodilators. bronchodilators.

After spirometry is completed, the After spirometry is completed, the patient is given an inhaled patient is given an inhaled bronchodilator and the test is repeated. bronchodilator and the test is repeated.

The purpose of this is to assess whether The purpose of this is to assess whether a patient's pulmonary process is a patient's pulmonary process is bronchodilator responsive by looking for bronchodilator responsive by looking for improvement in the expired volumes and improvement in the expired volumes and flow rates flow rates

spirometry can be used to detect the spirometry can be used to detect the bronchial hyperreactivity that bronchial hyperreactivity that characterizes asthma. characterizes asthma.

By inhaling increasing concentrations of By inhaling increasing concentrations of histamine or methacholine, patients with histamine or methacholine, patients with asthma will demonstrate symptoms and asthma will demonstrate symptoms and produce spirometric results consistent produce spirometric results consistent with airways obstruction at much lower with airways obstruction at much lower threshold concentration than normal threshold concentration than normal

PFT- SpirometryPFT- Spirometry

PFT- SpirometryPFT- Spirometry

Normal values vary depending on Normal values vary depending on gender, race, age, and height. gender, race, age, and height.

It is therefore not possible to It is therefore not possible to interpret PFT's without such interpret PFT's without such information. information.

There is no single set of standard There is no single set of standard reference values, however, and reference values, however, and "normal" varies with the reference "normal" varies with the reference value used in each laboratory value used in each laboratory

PFT- SpirometryPFT- SpirometryDefinitions Definitions FEV1 - forced expiratory volume 1 - the FEV1 - forced expiratory volume 1 - the

volume of air that is forcefully exhaled in one volume of air that is forcefully exhaled in one second. second.

FVC - forced vital capacity - the volume of air FVC - forced vital capacity - the volume of air that can be maximally forcefully exhaled that can be maximally forcefully exhaled

FEV1/FVC - ratio of FEV1 to FVC, expressed as FEV1/FVC - ratio of FEV1 to FVC, expressed as a percentage a percentage

FEF25 - 75 - forced expiratory flow - the FEF25 - 75 - forced expiratory flow - the average forced expiratory flow during the mid average forced expiratory flow during the mid (25 - 75%) portion of the FVC (25 - 75%) portion of the FVC

PEF - peak expiratory flow rate - the peak flow PEF - peak expiratory flow rate - the peak flow rate during expiration rate during expiration

PFT- SpirometryPFT- Spirometry

In general, a > 12% increase in the In general, a > 12% increase in the FEV1 (an absolute improvement in FEV1 (an absolute improvement in FEV1 of at least 200 ml) or the FVC FEV1 of at least 200 ml) or the FVC after inhaling a beta agonist is after inhaling a beta agonist is considered a significant response. considered a significant response.

However, the lack of an acute However, the lack of an acute bronchodilator effect during bronchodilator effect during spirometry does not exclude a spirometry does not exclude a response to long term therapy response to long term therapy

Normal Flow Volume Loop

                           

Mild Obstruction Flow Volume

                        

                                                      

                                         

Asthma MedicationsAsthma Medications

Two general types of asthma Two general types of asthma medicationsmedications– Anti-inflammatoryAnti-inflammatory

Corticosteroids reduce swelling & Corticosteroids reduce swelling & mucous in airwaysmucous in airways

– BronchodilatorsBronchodilators Relax muscle bands around airways Relax muscle bands around airways

allowing more air to flow, also increases allowing more air to flow, also increases mucous movementmucous movement

Quick Relief Quick Relief Medications Medications Short acting beta-agonists Short acting beta-agonists

– (bronchodilators that are the drug of choice to (bronchodilators that are the drug of choice to relieve asthma attack and prevent exercise-relieve asthma attack and prevent exercise-induced asthma symptoms) induced asthma symptoms)

Anticholinergics Anticholinergics – (bronchodilators used in addition to short-acting (bronchodilators used in addition to short-acting

beta agonists when needed or as an alternative to beta agonists when needed or as an alternative to these drugs when needed) these drugs when needed)

Systemic corticosteroids Systemic corticosteroids – (anti-inflammatory drug used in an emergency to (anti-inflammatory drug used in an emergency to

get rapid control of the disease while initiating get rapid control of the disease while initiating other treatments and to speed recovery)other treatments and to speed recovery)

Status AsthmaticusStatus Asthmaticus

Emergency Management Emergency Management of Asthma Exacerbationof Asthma Exacerbation

Indications of severe Indications of severe attackattack Breathless at restBreathless at rest Hunched forwardHunched forward Talking in words rather than Talking in words rather than

sentencessentences AgitatedAgitated Peak flow rate < than 60% of Peak flow rate < than 60% of

normalnormal

Status AsthmaticusStatus Asthmaticus

A medical emergency in which A medical emergency in which symptoms are refractory to initial symptoms are refractory to initial bronchodilator therapy bronchodilator therapy – Symptoms: chest tightness, rapidly Symptoms: chest tightness, rapidly

progressive shortness of breath, dry cough, progressive shortness of breath, dry cough, and wheezing. and wheezing.

– Typically, patients present a few days after Typically, patients present a few days after the onset of a viral respiratory illness, the onset of a viral respiratory illness, following exposure to a potent allergen or following exposure to a potent allergen or irritant, or after exercise in a cold irritant, or after exercise in a cold environment. environment.

Asthma Exacerbation Asthma Exacerbation ManagementManagement

Step 1: Initial AssessmentStep 1: Initial Assessment – Routine asthma evaluation as previously Routine asthma evaluation as previously

mentioned mentioned – Vital Signs (heart rate, respiratory rate, Vital Signs (heart rate, respiratory rate,

Peak Expiratory Flow Rate (PEF) or FEV1 Peak Expiratory Flow Rate (PEF) or FEV1 – O2 saturation O2 saturation – Respiratory Status Respiratory Status

Lung auscultation Lung auscultation Assess accessory muscle use Assess accessory muscle use Chest x-ray has low yield in acute exacerbations Chest x-ray has low yield in acute exacerbations ABGsABGs

Inhaled short acting Beta Agonist (nebulized) Inhaled short acting Beta Agonist (nebulized) – One dose up to every 20 minutes for one hour One dose up to every 20 minutes for one hour

Anticholinergic Anticholinergic (Ipratropium bromide or Atrovent(Ipratropium bromide or Atrovent) ) – Add to nebulized albuterol Add to nebulized albuterol – Indication: FEV1 or PEF <50% of predicted (Severe) Indication: FEV1 or PEF <50% of predicted (Severe)

Systemic Corticosteroid (PO or IV Indications) Systemic Corticosteroid (PO or IV Indications) – Severe episode (FEV1 or PEF <50% predicted) Severe episode (FEV1 or PEF <50% predicted) – No immediate response No immediate response – Oral corticosteroid recently taken by patient Oral corticosteroid recently taken by patient

Oxygen indications Oxygen indications – Adults: O2 saturation <91% Adults: O2 saturation <91% – Children: 02 saturation <96% Children: 02 saturation <96%

Asthma Exacerbation Asthma Exacerbation ManagementManagement

Additional measures for Additional measures for severe exacerbationsevere exacerbation

Nebulized Albuterol w/Atrovent Nebulized Albuterol w/Atrovent – hourly or continuoushourly or continuous

Systemic corticosteroid Systemic corticosteroid Epinephrine 0.01 mg/kg up to 0.3 mg SC Epinephrine 0.01 mg/kg up to 0.3 mg SC

– May be repeated every 5 minutes May be repeated every 5 minutes Oxygen 100% (warm, humidified) by non-rebreather Oxygen 100% (warm, humidified) by non-rebreather

mask mask Two Intravenous Lines Two Intravenous Lines

Consider :Consider :– Aminophylline or Theophylline Aminophylline or Theophylline – Magnesium 40 mg/kg up to 2 grams IV for 1 dose Magnesium 40 mg/kg up to 2 grams IV for 1 dose

Rapidly effective in pediatric asthma exacerbations Rapidly effective in pediatric asthma exacerbations Also shown effective in severe adult acute asthma Also shown effective in severe adult acute asthma Some studies question benefit Some studies question benefit

– Intubation is best done semi-electively before crisis Intubation is best done semi-electively before crisis – Intubation criteria are based on clinical judgment Intubation criteria are based on clinical judgment – Oral intubation is preferred Oral intubation is preferred

Lower resistance and easier suctioning Lower resistance and easier suctioning Lower incidence of sinusitis Lower incidence of sinusitis

– Indications Indications Impending or actual respiratory arrest Impending or actual respiratory arrest Extreme fatigue Extreme fatigue Altered mental status Altered mental status Significant respiratory distress Significant respiratory distress Severe respiratory acidosis & metabolic acidosisSevere respiratory acidosis & metabolic acidosis

Additional measures for severe Additional measures for severe exacerbation – exacerbation – Intubation/mechanical Intubation/mechanical ventilationventilation

Medications To Be Wary Of Medications To Be Wary Of with Asthma Patientswith Asthma Patients

Many adults take multiple prescription and Many adults take multiple prescription and over-the-counter medications to treat a over-the-counter medications to treat a variety of conditions. Some medications may variety of conditions. Some medications may trigger or worsen asthma symptoms.trigger or worsen asthma symptoms. – Angiotensin-converting enzyme (ACE) Angiotensin-converting enzyme (ACE)

inhibitorsinhibitors Won’t directly trigger asthma, can produce persistent Won’t directly trigger asthma, can produce persistent

cough causing increased wheezing cough causing increased wheezing

– Beta blockersBeta blockers

– NSAIDsNSAIDs can trigger severe and even fatal asthma attacks can trigger severe and even fatal asthma attacks

Asthma Management Asthma Management GoalsGoals

Asthma Management Asthma Management GoalsGoals Medical professionals need to be Medical professionals need to be

alert to the signs/symptoms of alert to the signs/symptoms of asthma asthma

They must be able to treat They must be able to treat asthma cases in a timely manner asthma cases in a timely manner to avoid worsening of the to avoid worsening of the condition and/or the development condition and/or the development of status asthmaticus of status asthmaticus

Questions?Questions?