Management of patients with asthma in the emergency department and in hospital Dr. Hassanzadeh Firouzabadi Hospital بيمارستان فيروزآبادي

astham Reactive airway disease Chronic inflammatory lung disease Inflammation causes varying degrees of obstruction in the airways بيمارستان فيروزآبادي

triggers Allergens Exercise Respiratory Infections Nose and Sinus problems Drugs and Food Additives GERD Emotional Stress بيمارستان فيروزآبادي

Early and late phases بيمارستان فيروزآبادي

Factors that cause obstruction بيمارستان فيروزآبادي

Management of the exacerbations of asthma requires; Rapid access to facilities or personnel capable of delivering bronchodilators appropriately Defining the severity of the asthma episode 0bjectively Ensuring appropriate monitoring of oxygen delivery Instituting safe referral and disposition بيمارستان فيروزآبادي

Patient assessment (all ages): Use of structured forms has been shown to improve documentation and patient outcomes are improved when physicians are given a brief educational program on asthma guidelines with a poster summery. بيمارستان فيروزآبادي

Objective measurements of airflow(All patients more than 5 years old); Physicians estimate of response to therapy are often inaccurate in acute asthma. Failure of initial bronchodilator therapy to significantly improve the FEV1 or PEF is predictive of a more prolonged attack course or need for hospital admission. The Sao2 may correlate with PEF Low SaO2 may indicate a need for hospital admission but normal levels do not exclude sever asthma or possibility of relapse. بيمارستان فيروزآبادي

Treatment بيمارستان فيروزآبادي

DRUG THERAPY 1.OXYGEN: Oxygen therapy will help normalize oxygen content while fixed airway obstruction related to airway inflammation and ventilation-perfusion mismatching resolve. Oxygen reduces the catecholamine response that can cause tachycardia and increased blood pressure. بيمارستان فيروزآبادي

2.Inhaled β2-agonists : The most rapid relief from acute bronchospasm with the fewest side effects. Before treatment with inhaled β2-agonists dose not preclude successful reversal of airflow limitation in the emergency department. Salbutamol is more effective and safer when Inhaled than when taken intravenously. The dosage of inhaled bronchodilators should be adjusted based on symptoms and airflow limitation. بيمارستان فيروزآبادي

. Maximum dose is 1puff every seconds puffs may be required. Sometimes continuous wet nebulizer treatment is indicated. MDI using a chamber or spacer is associated with a more rapid onset of bronchodilation, shorter duration of emergency department treatment, fewer side-effects and greater patient preference. بيمارستان فيروزآبادي

3.glucocorticoesteroid Systemic glucocorticoid should be given as soon as possible in all patients with moderate or sever asthma (FEV1 or PEF<60 percent of predicted value)..IV therapy has no advantages on oral therapy in terms of resolving the airflow limitation. The recommended oral dose is 40-60mg of prednisone or equivalent and single IV dose is 200 mg hydrocortison. بيمارستان فيروزآبادي

The combination of ipratropium bromide and a β2- agonist is more effective than a β2-agonist alone especially to patients with FEV1<1L or PEF <140 L/min. Use Mg in people with sever asthma who fail to respond to titrated bronchodilaotrs and glucocorticoids. Parenteral bronchodilator may be indicated when the inhaled rout is not practical. بيمارستان فيروزآبادي

Intubated patients with asthma who do not respond to conventional bronchodilator therapy may benefit from an inhaled anesthetic agent with bronchodilating properties, such as ether,halothane,enflurane or isoflurane. Hypotension and cardiac dysrhythmias are associated with the use of these agents. بيمارستان فيروزآبادي

Discharge treatment plan and follow up care: Spirometry and clinical assessment are used to establish risk of relapse. Important risk factors are: Admission to hospital or a visit to the emergency department in the previous 12 months. Recent uses of glucocorticoids. Use of multiple categories of asthma medications. A previous sever or life threatening asthma attack and the presence po psychological problems. The higher the recommended dose of inhaled glucocorticoids the more asthma related death. Educating patients is the key to optimum disease control. بيمارستان فيروزآبادي

Management of acute asthma in hospital: Patients over 5 years of age who achieve percent of predicted or previous best lung function will not require admission to hospital. Following maximum bronchodilator therapy,the schedule of therapy should be based on combination of serial PEF and any worsening of symptoms. The arterial oxygen saturation (SaO2) should be measured before and after treatment Supplemental oxygen should be used in treating patients with acute asthma to maintain (SaO2) > 94% Short-acting β2-agonists should be considered the primary class of medication for the management of exacerbations بيمارستان فيروزآبادي

The choice of delivery device (MDI with spacer, wet nebulization, dry-powder inhaler) will depend on the need for expedient treatment, availability of staff and the individual patient of any age. The use of an MDI with a chamber (valved spacer device) is preferred over the use of a wet nebulizer for patients of all ages at all levels of severity. بيمارستان فيروزآبادي

All patients in the emergency for an acute episode of asthma should be considered candidates for systemic glucocorticosteroid therapy (oral or intravenous). An anticholinergic drug should be added to β2- agonist therapy for severe acute asthma. Aminophylline is not recommended for use as a bronchodilator during the first 4 hours of asthma management بيمارستان فيروزآبادي

Epinephrine (IM or IV), salbutamol (IV) and inhaled anesthetics are recommended as alternatives to conventional therapy in unresponsive cases of life-threatening asthma. Magnesium sulfate and heliox may be useful for refractory asthma. Ketamine and succinylcholine for rapid- sequence intubation. بيمارستان فيروزآبادي

Patients with a pretreatment FEV1 or PEF below 25% or post-treatment below 40% of previous best level or the predicted value usually require admission to hospital. Adults discharged from the emergency who require glucocorticosteroid should be given mg/d of prednisone orally for 7-14 days. No tapering is required over this period. Children should receive 1-2 mg/kg a day of prednisone for 3-5 days بيمارستان فيروزآبادي

15. Inhaled glucocorticosteroids should be prescribed for almost all patients at discharge, including those receiving oral glucocorticosteroid 16. A treatment plan and clear instructions for follow-up should be given to patients discharged from the emergency. Patients with high-risk factors, poor lung function or indications of chronic poor control should be referred to an asthma education clinic بيمارستان فيروزآبادي

17. All patients admitted to hospital should be given systemic glucocorticosteroids, preferably by the oral and inhaled glucocorticosteroid. 18. Bronchodilators: The choice of delivery device (MDI with spacer, wet nebulization, DPI) will depend on the need for expedient treatment, the availability of staff and patient selection. Rapid onset, the possibility of titration, reduced cost, more effective use of hospital staff, better side-effect profile and increased opportunities for education all make MDIs or DPIs preferable to nebulization in all age groups بيمارستان فيروزآبادي

19. Inhaled anticholinergics should be added to β2- agonist therapy for hours in severe and moderate asthma 20 Patients with severe airflow obstruction or those who are hypercapnic, are unresponsive to treatment, have been intubated must have continuous care in the emergency or continuous monitoring of oxygenation until their condition is stable or improved. بيمارستان فيروزآبادي

21. Supplemental oxygen guided by oximetry to achieve SaO2 > 94%. 22 Serial administration of ABG is for critically ill patients and severe asthma if SaO2 is< 90% or if there is suspicion of hypercapnia. 23 Patient education, including a formal written action plan for treatment after discharge. بيمارستان فيروزآبادي

23. Follow-up arrangements with the primary care physician or asthma specialist must be made before discharge 24 Patients with severe disease (FEV1 or PEF < 40% of previous best or predicted post- treatment value and/or frequent attacks) should be seen by a specialist during the hospital stay or as a follow-up after discharge. بيمارستان فيروزآبادي

Nursing management In summary بيمارستان فيروزآبادي

1.diagnosis Ineffective airway clearance Anxiety Ineffective therapeutic regimen management بيمارستان فيروزآبادي

2.Health promotion Teach patient to identify and avoid known triggers Use dust covers Use of scarves or masks for cold air Avoid aspirin or NSAIDs بيمارستان فيروزآبادي

treatment of upper respiratory infections and sinusitis may prevent exacerbation Fluid intake of 2 to 3L every day Adequate nutrition Adequate sleep Take β-adrenergic agonist 10 to 20 minutes prior to exercising بيمارستان فيروزآبادي

4.Acute intervention Monitor respiratory and cardiovascular systems Lung sounds Respiratory rate Pulse BP ABGs Pulse oximetry FEV and PEFR Work of breathing بيمارستان فيروزآبادي

5.Nursing intervention Administer O2 Bronchodilators Chest physiotherapy Medications (as ordered) Ongoing patient monitoring بيمارستان فيروزآبادي

6.decrease the patient’s sense of panic Stay with patient Encourage slow breathing using pursed lips Position comfortably بيمارستان فيروزآبادي

7.teaching Seek medical attention for bronchospasm or severe side effects Maintain good nutrition Exercise within limits of tolerance Patient must learn to measure peak flow at least daily بيمارستان فيروزآبادي

Important points:* The patient must learn about medications and develop self-management strategies Patient and health care professional must monitor responsiveness to medication Patient must understand importance of continuing medication when symptoms are not present بيمارستان فيروزآبادي

Thanks for participating بيمارستان فيروزآبادي