1. APPROACH TO A PATIENT WITH ACUTE SEVERE ASTHMA
DR.AFZAL

2. Airway inflammation and narrowing Bronchial hyper responsiveness
ASTHMA
Asthma is a chronic inflammatory lung disorder characterized by :
Airway inflammation and narrowing
Bronchial hyper responsiveness
Inflammation of bronchi

3. Epidemiology Most common childhood chronic disorder.
Increase in incidence by 50 % over the last two decades.
Current incidence of 8.5 % and lifetime prevalence of 12.5 % among children < 18 years.
Asthma more common in developed
countries: highest rates being in New Zealand, Australia,U.K.

4. pathophysiology Mucosal oedema Secretion of mucus Epithelial damage
Key features:
Mucosal oedema
Secretion of mucus
Epithelial damage
Bronchoconstriction

6. Risk Factors that Lead to Asthma
Environmental Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Socioeconomic factors
Diet and drugs
Obesity
Host Factors
Genetic predisposition
Atopy
Airway hyper-
responsiveness
Gender
Race

7. Cough. Wheezing. Dyspnea. Chest tightness.
Symptoms
Cough.
Wheezing.
Dyspnea.
Chest tightness.
Limitation of physical activity most commonly in response to specific triggers.

8. asthma diagnosis
History and patterns of symptoms.
Physical examination.
Measurements of lung function.
Allergic status to identify risk factors.

9. asthma?
Recurrent episodes of wheezing.
Troublesome cough at night.
Cough or wheeze after exercise.
Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants.

10. Stepwise Approach to Asthma Therapy
Outcome: Best Possible Results
Outcome: Asthma Control
Controller:
High-dose inhaled corticosteroid plus long –acting inhaled β2-agonist
plus (if needed)
When asthma is controlled, reduce therapy
Monitor
Controller:
Medium-dose inhaled corticosteroid
Controller:
Low-dose inhaled corticosteroid
Controller:
None
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid
Reliever:
Rapid-acting inhaled β2-agonist
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate Persistent
STEP 4:
Severe Persistent
STEP Down

11. MANAGEMENT OF ACUTE SEVERE ASTHMA

12. Presenting features.
Feature suggesting severe/ life threating attack.
Phases of asthmatic attack.
Management.
Monitoring.
When to discharge.

13. PRESENTATION
Acute breathlessness.
Wheeze.

14. Ask about
Previous Severe fatal asthma. Previous asthma admission. Requiring 3 classes of asthma medication. Heavy use of ß2 agonist. Repeated attendances at ER dept for asthma care.

15. SEVERE ATTACK
Unable to complete a sentence.
Respiratory rate > 25/min.
Pulse rate > 110/min.
Peak Expiratory Flow < 50% of predicted value.

16. Life-threatening ATTACK
Silent chest.
Cyanosis.
Bradycardia or hypotension.
Exhausted appearance.
PEF <30% of predicted value.
Exhaustion, confusion, or coma.

17. D/d
Upper respiratory tract obstruction.
Pulmonary embolism.
Anaphylaxis.
Pulmonary edema.
Bronchilolitis.

18. PHASES OF ASTHAMIC ATTACK
Early/Immediate Phase :
characterized by Bronchoconstriction
Late Phase (6-8 hours) :
airway inflammation and hyper responsiveness

19. Asthma exacerbation is a medical emergency
Asthma exacerbation is a medical emergency. Don’t delay evaluation and treatment.
Management should emphasize on
1) Initial stabilization.
2) Progressive monitoring and treatment.
3) Eventually discharge planning.

20. Immediate management
Sit patient up.
Oxygen therapy 40-60%
Salbutamol 5mg nebulize with oxygen.
0.5mg Ipratropium nebulize with oxygen.
Start glucocorticoid therapy - prednisolone mg p.o. or hydrocortisone 200mg i.v.

21. Chest X-ray to exclude pneumothorax.
No sedatives of any kind.
Blood gases measurement.
If life-threatening features present:
Add MgSO g i.v over 20min.
Give salbutamol nebulizer every 15 min.

22. If not improving after 15-30min
If Improving
40-60% oxygen
Prednisolone 30-60mg/24h PO.
Nebulize Salbutamol every 4hrs.
Monitor peak flow and oxygen saturations.
If not improving after 15-30min
Continue oxygen and steroids.
Give salbutamol nebulization every 15 min.
Continue Ipratropium nebulization every 4-6 hrs.

23. If still not improving:
Consider i.v. aminophylline if not previously on aminophylline.
Load with 5mg/kg iv over 20min then 500ug/kg/hr.
If no improvement:
Transfer to ITC/HDU to intubate

24. Complications of SEVERE ATTACK
Aspiration pneumonia.
Pneumothorax.
Respiratory failure and arrest.
Cardiac arrest.
Hypoxic-ischemic brain injury.
Death.

25. MONITORING 2) Oxygen saturation monitoring, 3) Pulse,
1) Chart the repeated measurements of PEF following nebulize or inhaled beta2-agonists
2) Oxygen saturation monitoring,
3) Pulse,
4) Respiratory rate.
5) Blood tests - FBC, serum potassium and glucose, serum theophylline (where aminophylline is used for more than 24 hours).

26. 6) Repeat blood gas measurements within 2 hours of starting treatment if life-threatening features are present. 7) IV fluids where dehydrated and correction of hypokalemia (caused/exacerbated by beta2-agonist and steroid regimes

27. ONCE PATIENT IS IMPROVING
Wean off and stop aminophylline over hrs
Step down initially by converting from nebulised to usual inhaled device checking that their technique is adequate.
When PEFR is normalised patient should be discharged on high-dose inhaled glucocorticoid, which should continue, until they are reviewed after a week.
Look for cause of acute attack.

28. Notes
Oral prednisolone works as quickly as i.v. hydrocortisone but the patient may be too distressed to swallow tablets!
Intravenous salbutamol can be used if on oral theophylline or history of epilepsy.
Check plasma K when using aminophylline infusions in view of risk of hypokalemia arrhythmia.
Antibiotic therapy in acute asthma is only indicated if there are signs of bacterial infection e.g. fever

29. THANKS