Managing Asthmatic Attacks

Christopher H. Fanta, M.D.

Partners Asthma CenterBrigham and Women’s Hospital

Harvard Medical School

Objectives

• Consider strategies for prevention of severe asthmatic attacks.

• Discuss treatments for asthmatic attacks that require emergency care.

• Address patient education opportunities prior to discharge home.

Case History: Chief Complaint

Five days after developing an upper respiratory infection, a 35-year old woman with long-standing asthma presented to the Emergency Department with severe shortness of breath and wheezing.

Case History: Recent History

Her 3-year old son and then her husband had come down with similar “colds.” With her illness, she had progressively worsened despite increasing her inhaled budesonide from 4 to 8 inhalations/day. Last night she slept little due to cough and wheezing.

Case History: Physical Exam

In the Emergency Department she appeared in respiratory distress. RR 28/min with accessory muscle use. BP 140/70 mm Hg with 20 mm Hg paradoxical pulse. HR 112/min, regular. T 99.1o F. Chest: diffuse insp. and exp. wheezes.

PEFR = 150 L/min (33% of normal).

The Best Management Is Prevention

“Treatment of status asthmaticus is best started 3 days prior to the attack.”

-- Thomas Petty, M.D

Preventive Strategies

Early recognition of deterioration

Prompt patient-provider communication

Written “asthma action” plan

Intensification of anti-asthma medications, often including a short course of oral corticosteroids

Patient Assessment

History

Physical exam

Peak flow determination

(Chest X-ray)

(Arterial blood gases)

Principles of Care for Acute Asthma

Principal goal: rapid reversal of airflow obstruction

Repetitive administration of inhaled beta-agonists (+ ipratropium bromide)

Early addition of systemic corticosteroids

Correction of hypoxemia

Close monitoring, including serial measurements of lung function

Treatment of Acute Asthma: Overview

Problem Treatment

•Bronchoconstriction Frequent inhaled beta-agonist bronchodilator

•Airway swelling and Systemic mucus plugging corticosteroids

Initial Treatment

Nebulized albuterol 2.5 mg every 20 minutes

Alternatives:

Albuterol by MDI with spacer 4 puffs every 10 min

Continuous nebulization of albuterol

Nebulized albuterol 5 mg every 20 min.

Nebulized levalbuterol 1.25 mg every 20 min

MDI and Nebulizer Equivalence

Turner JR, et al., Chest 1988

Time (min)30 60 90

0 30 60 90

0

0.4

0.8

1.2

1.6

MDI (n=27)

Neb (n=28)

0

10

2

6

8

4

0

Dys

pnea

(Bor

g sc

ale)

FEV 1

(L)

0 30 60 90

Patterns of Response to Albuterol

Strauss L, et al. Am J Respir Crit Care Med 1997; 155:454.

Additional Bronchodilators in Acute, Severe Asthma

Ipratropium bromide

Magnesium sulfate

2 gm i.v. over 20 min

Additional sympathomimetics

Epinephrine 0.3 mg s.c.

(Intravenous montelukast)

Steroids in Acute, Severe Asthma

Systemic steroids (tablets/liquid, intramuscular, intravenous) speed the resolution of asthma attacks and reduce the likelihood of recurrences (“relapses”).

Inhaled steroids begun at the time of ED discharge decrease the likelihood of recurrent attacks.

Oral vs. Intravenous Corticosteroids

When given in comparable doses, there is no difference in efficacy between oral and intravenous corticosteroids for acute, severe asthma.

Systemic Steroids for Hospitalized Patients

Oral prednisone 40 – 80 mg/day

Exception: vomiting or other GI intolerance

The Outpatient “Steroid Burst”

No specific schedule proven better than another

Taper not necessary if treatment continued until lung function has recovered to normal or near-normal

Risk of recurrent asthmatic symptoms reduced by use of inhaled steroids

The Outpatient “Steroid Burst”

One example: prednisone 40 mg/day for 4 days; 30 mg/day for 4 days, 20 mg/day for 4 days; 10 mg/day for 4 days

Oral steroids can be administered once daily

Antibiotics for Acute, Severe Asthma

Empiric antibiotics of no proven benefit in hospitalized patients with acute attacks

Other Therapies of Unproven/Unlikely Benefit

Hydration

Chest physiotherapy

Mucolytics

Antihistamines

Controversial Therapies in Acute, Severe Asthma

Helium-oxygen gas mixture

CPAP/Non-invasive mask ventilation

Indications for Intubation and Mechanical Ventilation

Respiratory arrest/agonal respirations Acute respiratory acidosis (PCO2 >55 mm Hg;

pH <7.28) in patient: Who is in respiratory distress; Whose PCO2 is rising despite aggressive treatment;

or Who cannot or will not cooperate with

other therapies

Patients at High-Risk for Severe Attacks

On daily prednisone prior to admission

>2 E.D. visits in last 6 months

>1 prior hosp’ns in last 12 months

Ever intubated for asthma

Severe psychosocial problems

Patient Education Prior to Hospital Discharge

Proper use of inhalers

Indications for different medications

Use of spacers

Peak flow monitoring

Individualized “asthma action plan”

Discussion of environmental control issues

Conclusions

• Early intervention (by patients and providers) can often prevent asthmatic attacks from becoming severe.

• Key elements of treatment of asthmatic attacks are intensive use of inhaled beta-agonist bronchodilators plus systemic corticosteroids.

Conclusions

• Peak flow monitoring is useful in assessing the severity of attacks and response to treatment.

• An asthmatic attack represents a “teachable moment” for the asthma educator, with opportunities to improve patient understanding and co-management skills.