1. LA CRISI ASMATICA Angelo Corsico Clinica di Malattie dell’Apparato Respiratorio Fondazione IRCCS Policlinico S.Matteo Università di Pavia le urgenze pneumologiche in pronto soccorso Pavia, 24 novembre 2006

2. le urgenze pneumologiche in pronto soccorso Pavia, 24 novembre 2006  Premessa  Gestione delle crisi asmatiche  La gestione in Pronto Soccorso  Altri trattamenti

3. Six-part Asthma Management Program Part 5: Managing Severe Asthma Exacerbations  Severe exacerbations are life-threatening medical emergencies  Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department  Severe exacerbations are life-threatening medical emergencies  Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department

4. Adult and child asthma emergency department rates, United States: 1992–2001 Source: National Hospital Ambulatory Care Survey; National Center for Health Statistics Children Adults

5. During exacerbations: a linear decline of PEF over a period of a few days, a sharp point of inflection, then a linear increase. During poor asthma control: wide diurnal variability and bronchodilator reversibility. Reddel, Lancet 1999

6. Severe asthma 7% Clinical respiratory infections 15% Acute exposure to allergens or other triggers 14% Poor asthma control (inadequate treatment) 64% % OF SUBJECTS WITH ED ADMISSIONS BY CAUSES OF ASTHMA ATTACK EMERGENCY VISITS FOR ASTHMA Policlinico San Matteo, Pavia 2002 Cerveri et al. ATS 2004

7. Rapid exacerbation characterized by one or more of the following features:  Accessory muscle activity  Paradoxical pulse exceeding 25 mmHg  Heart rate > 100 beats/min  Respiratory rate > 25-30 breaths/min  Limited ability to speak  PEF rate or FEV 1 < 50% pred.  Arterial oxygen saturation < 91-92% CONSENSUS DEFINITION OF ACUTE SEVERE ASTHMA McFadden, AJRCCM 2003

8. Deaths Due to Asthma, United States, 1979-2001 Source: Compressed Mortality Files age group 0 to 45 to 1415 to 3435 to 6465 +

9. Krishnan, AJRCCM 2006 Our study indicates that 1,499 deaths (33% of all 4,487 deaths from asthma in the United States in 2000) occurred in patients hospitalized for asthma exacerbations. Improvements in the management of asthma exacerbations before hospitalization (e.g., at home, during transportation to the emergency department) will have the greatest benefit in further reducing the overall risk of death.

10. Becker, JACI 2004 263 potential asthma-related athletic deaths between July 1993 and December 2000.  The subjects were usually white male aged 10 to 20 years.  Mild intermittent or persistent asthma by history was commonly identified.  Sudden fatal asthma exacerbations occur in both competitive and recreational athletes and can be precipitated by sporting activity. The positive benefits to an active lifestyle cannot be negated by the risks outlined here.

11. le urgenze pneumologiche in pronto soccorso Pavia, 24 novembre 2006  Premessa  Gestione delle crisi asmatiche  La gestione in Pronto Soccorso  Altri trattamenti

12. Key Points Early treatment is best. Important elements: – A written action plan n Guides patient self-management at home n Especially important for patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations – Recognition of early signs of worsening asthma – Prompt communication between patient and clinician about: n Serious deterioration in symptoms or peak flow, or n Decreased responsiveness to inhaled beta 2 -agonists, or n Decreased duration of beta 2 -agonist effect

13. Risk Factors for Death From Asthma n Past history of sudden severe exacerbations n Prior intubation or admission to ICU for asthma n ≥2 hospitalizations for asthma in the past year n ≥3 ED visits for asthma in the past year n Hospitalization or an ED visit for asthma in the past month n Use of >2 canisters per month of inhaled short- acting beta 2 -agonist

14. Risk Factors for Death From Asthma (continued) n Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids n Difficulty perceiving airflow obstruction or its severity n Comorbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease n Serious psychiatric disease or psychosocial problems

15. Risk Factors for Death From Asthma (continued) n Low socioeconomic status and urban residence n Illicit drug use n Sensitivity to Alternaria

16. Six-part Asthma Management Program Part 5: Establish Plans for Managing Exacerbations Primary therapies for exacerbations:  Repetitive administration of rapid-acting inhaled β 2 -agonist  Early introduction of systemic glucocorticosteroids  Oxygen supplementation Closely monitor response to treatment with serial measures of lung function Primary therapies for exacerbations:  Repetitive administration of rapid-acting inhaled β 2 -agonist  Early introduction of systemic glucocorticosteroids  Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

17. Six-part Asthma Management Program Part 5: Establish Plans for Managing Exacerbations Treatment of exacerbations depends on:  The patient  Experience of the health care professional  Therapies that are the most effective for the particular patient  Availability of medications  Emergency facilities Treatment of exacerbations depends on:  The patient  Experience of the health care professional  Therapies that are the most effective for the particular patient  Availability of medications  Emergency facilities

18. le urgenze pneumologiche in pronto soccorso Pavia, 24 novembre 2006  Premessa  Gestione delle crisi asmatiche  La gestione in Pronto Soccorso  Altri trattamenti

19. Brief Physical Exam n Assess severity: Alertness, distress, accessory muscle use, tachycardia, tachypnea, pulsus paradoxus, cyanosis n Identify complications (e.g., pneumonia, pneumothorax, pneumomediastinum) n Identify diseases that affect asthma (otitis, rhinitis, sinusitis) n Rule out upper-airway obstruction

20. Functional Assessment Measure FEV 1 or PEF: n Upon presentation (begin treatment as soon as asthma exacerbation is recognized) n At intervals depending on response to therapy n Before discharge Monitor SaO 2 in patients with severe distress or with FEV 1 or PEF <50% predicted

21. Brief History (after treatment is initiated) n Time of onset and cause of exacerbation n Severity of symptoms, especially compared to previous attacks n All current medications and time of last dose n Prior hospitalizations and ED visits, especially in past year n Prior episodes of respiratory failure or loss of consciousness due to asthma n Existence of comorbidities

22. Laboratory Assessment n Consider ABG in patients with suspected hypoventilation, severe distress, or with FEV 1 or PEF <30% predicted after initial treatment n CBC may be appropriate in patients with fever or purulent sputum n Serum theophylline concentration n Serum electrolytes, chest x-ray, ECG in special circumstances

23. Emergency Department and Hospital Management: Goals n Correction of significant hypoxemia n Rapid reversal of airflow obstruction n Reduction of likelihood of recurrence

24. Initial Treatment n Oxygen to achieve O 2 saturation >90% n FEV1 or PEF >50%: Inhaled beta 2 -agonist by metered-dose inhaler or nebulizer, up to three treatments in first hour n FEV1 or PEF <50%: Inhaled high-dose beta2-agonist and anticholinergic by nebulization every 20 minutes or continuously for 1 hour n Oral corticosteroids n Repeat assessment (symptoms, physical exam, PEF, O 2 saturation, other tests as needed)

25. Initial Treatment (continued) Impending or Actual Respiratory Arrest n Intubation and mechanical ventilation with 100% O 2 n Nebulized beta 2 -agonist and anticholinergic n Intravenous corticosteroid n Admit to hospital intensive care

26. Treatment After Repeat Assessment Physical exam: moderate symptomsPhysical exam: moderate symptoms FEV 1 or PEF > 50% predicted or personal bestFEV 1 or PEF > 50% predicted or personal best Inhaled short-acting beta 2 - agonist every 60 minutesInhaled short-acting beta 2 - agonist every 60 minutes Systemic corticosteroidSystemic corticosteroid Continue treatment 1 to 3 hours, provided there is improvementContinue treatment 1 to 3 hours, provided there is improvement Physical exam: severe symptoms at rest, accessory muscle use, chest retractionPhysical exam: severe symptoms at rest, accessory muscle use, chest retraction History: high-risk patientHistory: high-risk patient FEV 1 or PEF <50% predicted or personal bestFEV 1 or PEF <50% predicted or personal best No improvement after initial treatmentNo improvement after initial treatment OxygenOxygen Inhaled short-acting beta 2 - agonist hourly or continuously + inhaled anticholinergicInhaled short-acting beta 2 - agonist hourly or continuously + inhaled anticholinergic Systemic corticosteroidSystemic corticosteroid

27. Emergency Department and Hospital Management Not generally recommended: n Methylxanthines n Antibiotics (except for patients with pneumonia, bacterial sinusitis) n “Aggressive” hydration n Chest physical therapy Not recommended: n Mucolytics n Sedation

28. Good Response Incomplete Response Mild-to- moderate symptomsMild-to- moderate symptoms FEV 1 or PEF 50% to 70%FEV 1 or PEF 50% to 70% Individualized decision: hospitalizationIndividualized decision: hospitalization No distressNo distress Physical exam: normalPhysical exam: normal FEV 1 or PEF >70%FEV 1 or PEF >70% Sustained response @ 60 min after last treatmentSustained response @ 60 min after last treatment Discharge HomeDischarge Home Poor Response Physical exam: symptoms severe, drowsiness, confusionPhysical exam: symptoms severe, drowsiness, confusion PCO 2 >42 mm HgPCO 2 >42 mm Hg FEV 1 or PEF <50%FEV 1 or PEF <50% Admit to hospital or intensive careAdmit to hospital or intensive care

29. Hospitalization Consider: n Duration and severity of airflow obstruction n Course and severity of prior attacks n Medication use n Access to care n Home conditions and support n Comorbidities

30. Admit to Hospital Intensive Care Inhaled beta 2 -agonist hourly or continuously + inhaled anticholinergicInhaled beta 2 -agonist hourly or continuously + inhaled anticholinergic IV corticosteroidIV corticosteroid OxygenOxygen Possible intubation and mechanical ventilationPossible intubation and mechanical ventilation Admit to hospital wardAdmit to hospital ward

31. Emergency Department Discharge Criteria n If FEV 1 or PEF  70% predicted and symptoms are minimal, discharge n If FEV 1 or PEF >50% but  70% predicted and symptoms are mild, decision is individualized n If response is prompt, observe for 30 to 60 minutes before discharging

32. Emergency Department and Hospital Discharge Actions n Prescribe sufficient medication and instructions for use n Schedule follow-up or referral visit within 3 to 5 days –Consider referral to specialist if patient has history of life-threatening exacerbations or multiple hospitalizations n Teach correct inhaler use and trigger avoidance

33. Hospital Discharge Actions (continued) n Discharge medications should include: –Short-acting beta 2 -agonist –Sufficient oral corticosteroid to complete course of therapy (3 to 10 days) or to continue therapy until followup appointment –If inhaled corticosteroids are prescribed, start before course of oral corticosteroids is completed

34. le urgenze pneumologiche in pronto soccorso Pavia, 24 novembre 2006  Premessa  Gestione delle crisi asmatiche  La gestione in Pronto Soccorso  Altri trattamenti

35. Intravenous magnesium (MgSO 4 ) n Is effective at improving airflow and reducing admissions in very severe asthma exacerbations (eg, 40% of predicted PEF). n Has few adverse effects, is inexpensive, and is easy to administer. n Rapid adoption of this therapy in North American EDs.

36. Intravenous leukotriene modifiers n Data on intravenous montelukast suggest that leukotriene modifiers have important bronchodilating effects and that this adjunct therapy may prove useful. n The relatively slow onset of action of oral agents will limit their usefulness in the management of truly severe exacerbations.

37. Intravenous epinephrine n In some Australian EDs is commonly used to treat the acute bronchospasm, initiate adequate antiinflammatory treatment, and avoid the risks and complications associated with intubation. n Theoretically it may control airway edema but its use needs to reflect a balance between clinical efficacy and safety. n Evidence on therapeutic safety is difficult to collect and research. n Epinephrine should not be the first step in treating these patients.

39. PEF ~ 70% PEF ~ 50%

40. With frequent admission With one previous admission 40% EMERGENCY VISITS FOR ASTHMA Policlinico San Matteo, Pavia 2002 Cerveri et al. ATS 2004 Without previous admission 60%