1. Medical management of Acute Severe Asthma & COPD Acute Exacerbation vivek

2. Case 1: Elderly gentleman in casualty 68 year old retired school teacher, known case of CAD (old AWMI) and COPD is brought to the casualty with c/o increased cough and sputum production since morning. He was supervising some maintenance work at home a few days back. On examination Afebrile PR 128/min, BP 134/76mm, RR 40/min Chest B/L breath sounds equal, scattered wheeze SaO2 90% (room air)

3. Is this COPD exacerbation? Yes Exacerbation is a worsening of dyspnoea, cough or sputum production that exceeds day to day variability and persists for more than a day or two. Anything more than usual symptoms

4. COPD exacerbations Exacerbations are important clinical events in COPD 2.74 million death worldwide.

6. What is the precipitating event in this case? Bacterial infection Viral infection Exposure to respiratory irritants/ air pollution Co-morbid conditions

7. In the ER.. Patient received 2L/min oxygen, nebulized bronchodilator and IV steroids Partial relief Basic labs sent Chest X-ray requested

8. Should we admit him? Yes Management depends upon severity Home care Vs Hospital care Bronchodilators increase dose and frequency Steroid Prednisolone 30-60mg for 1-2 weeks ?Antibiotics

9. Indications of hospitalization Sudden onset of severe symptoms Unusual symptoms Diagnostic uncertainty (Pneumonia, PE, Cancer) New signs (oedema, cyanosis, drowsiness) Inability to eat/sleep Underlying severe COPD Co-morbidities (DM, cardiac/renal/hepatic failure) Failure to respond to initial treatment Older age Inadequate home/social support Poor adherence to treatment → → → → →

10. Investigations Chest X-Ray ABG Sputum culture ECG ± Echo

11. Inpatient management Bronchodilators Steroid ?Antibiotics Oxygen Oral or IV route of antibiotics and steroids? How much oxygen can be given? Which antibiotic is better?

12. Oxygen Required in all hypoxemic patients Don’t withhold low flow oxygen for fear of worsening CO2 retention Monitor SaO2

13. Bronchodilator therapy Inhaled beta-2 agonists (salbutamol, levo-salbutamol) and ipatropium either alone or in combination Role of tiotropium in acute setting not established at present Delivery by nebulizer or MDI + spacer device is equally effective

14. Antibiotics

15. Suggested antibiotic GroupClinical statePathogenAntibiotic 0Tracheobronchitis`usually viralIf persists for >10 days, macrolides 1Chronic bronchitisStrep pneumoniae H influenza M catarrhalis Macrolide Qunolone Cephalosporins Bl-BLI Doxycycline Septran Amoxycillin 2Chronic bronchitis (complicated) All given above plus Gram negatives Fluroquinolones BL/BLI 3Chronic suppurative bronchitis All given above plus Pseudomonas Treatment based on C&S reports Balter MS, La Forge J, Low DE et al: Can Respir J 10:3B-32B;2003

16. Steroids Short term use Oral and IV steroids are equally effective Prednisolone 30-60mg/day IV Methyl Prednisolone 40-125mg Q 6h (OR) IV Hydrocortisone 100mg Q 6h

17. Complications Pneumonia Pneumothorax Cor pulmonale Arrhythmias

18. What advice can we give to prevent future exacerbations? Vaccination Health education Inhalation technique

19. When to discharge? Clinically stable for 24 hours Patient able to eat, walk and sleep Nebulized bronchodilators ≤ 4 hours ABG stable for 24 hours

20. Case 2: Young advocate 28 year old chronic wheezer on irregular treatment was brought to the casualty with c/o cough and wheezing since 1 week. Soon after appearing for a case in the morning, he developed severe dyspnoea and collapsed in his office. On examination Cyanosed PR 132/min, BP 130/76mm, RR 34/min Chest B/L extensive wheeze SaO2 88% (room air)

21. In the ER.. Patient received 5L/min oxygen, nebulized bronchodilator and IV steroids No relief PR 67/min BP 100/60mm Chest- ↓ wheeze

22. Is this acute severe asthma? Yes A severe exacerbation that fails to improve rapidly with intensive bronchodilator therapy.

23. ‘Danger signals’ Feeble respiratory movement Silent chest Cyanosis Bradycardia Hypotension Confusion Coma Convulsion

24. In the ER.. Patient received 5L/min oxygen, nebulized bronchodilator and IV steroids No relief PR 67/min BP 100/60mm Chest- ↓ wheeze → →

25. Good practice point Patients with near fatal asthma attacks may not be distressed and may not have all these abnormalities. The presence of any should alert the doctor.

26. Triage

27. Near fatal asthma Near fatal asthma is defined as Raised PaCO 2 and / or Requiring mechanical ventilation due to severe asthmatic attack.

28. Near fatal asthma In- hospital mortality is high. Poor long term prognosis. Consumes health care resources

29. Who is at risk? Severe Asthma Adverse Psychosocial Features High risk of NFA Past h/o NFA Past h/o hospitalization Repeated ER visits Heavy use of β 2 agonists Brittle asthma Non compliance Psychosis, depression, others Drugs, alcohol, tranquillizers Stress (domestic, marital, legal, job related) → → → →

30. Medical management Oxygen Bronchodilators Steroids Aminophylline Magnesium

31. Long term prognosis A 6 year follow-up study of 145 patients who underwent mechanical ventilation for near fatal attack of asthma. Marquette CH, Sauliner F, Leory O, Wallaert B,Chopin C, Demarcq CM, Durocher A,Tonnel AB.

32. What is the prognosis? oIn hospital mortality 16.1 % oPost hospitalization mortality After 1 year 10.1 % After 3 years 14.4 % After 6 years 22.6 % Pulmonary function test 58.5 % PFR recording 16 %

34. Thanks