Acute Severe Asthma

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Information about Acute Severe Asthma

Published on June 14, 2016

Author: hashu12


1. ACUTE SEVERE ASTHMA Status Asthmaticus

2. Introduction  Status asthmaticus is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators.  Status asthmaticus can vary from a mild form to a severe form with bronchospasm, airway inflammation, and mucus plugging that can cause difficulty breathing, carbon dioxide retention, hypoxemia, and respiratory failure.  Patients report chest tightness, rapidly progressive shortness of breath, dry cough, and wheezing and may have increased their beta-agonist intake (either inhaled or nebulized) to as often as every few minutes.

3. Pathophysiology  The airway obstruction is due to a combination of factors that include  spasm of airway smooth muscle,  edema of airway mucosa,  increased mucus secretion,  cellular (eosinophilic and lymphocytic) infiltration of the airway walls, and  injury and desquamation of the airway epithelium.

4. Risk factors  Genetic predisposition  GERD  Viral infections  Air pollutants - Such as dust, cigarette smoke, and industrial pollutants  Medications - Including beta-blockers, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs)  Cold temperature  Exercise

5.  Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals  Prevalence is increasing in many countries, especially in children  Asthma is a major cause of school and work absence  Health care expenditure on asthma is very high  Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma.  Developing economies likely to face increased demand due to increasing prevalence of asthma  Poorly controlled asthma is expensive  However, investment in prevention medication is likely to yield cost savings in emergency care  The prevalence in Tanzania is 1-8% Burden of asthma GINA 2015

6. Clinical Presentation - History  Presence of current illness, such as upper respiratory tract infection or pneumonia  History of chronic respiratory diseases (eg, bronchopulmonary dysplasia, chronic lung disease of infancy)  History of allergies  Family history of asthma  Known triggering factors – smoke, pets  Home medications - Obtain a detailed list of medications being taken at home and, if possible, their timing and dosage  History of increased use of home bronchodilator treatment without improvement or effect  History of previous intensive care unit (ICU) admissions, with or without intubation and mechanical ventilatory support  Asthma exacerbation despite recent or current use of corticosteroids  Frequent emergency department visits and/or hospitalization (implies poor control)  History of syncope or seizures during acute exacerbation

7. Physical examination  Tachypneic with significant wheezing  Hyperexpanded chest with use of accessory muscles (intercostal and subcostal retratctions)  Pulsus paradoxus  Inability to complete a sentence, sits hunched forward  Tachycardia and hypertension (PR >120 bpm)  O2 saturation (on air) < 90%  PEF ≤50% predicted or best  level of consciousness may progress from lethargy to agitation, air hunger, and even syncope and seizures  Life threatening features – inability to speak, bradycardia, silent chest, normal or reduced respiratory rate, cyanosis, PEF ≤33% predicted or best

8. Laboratory studies  The selection of laboratory studies depends on historical data and patient condition. Tests that should be performed in patients with status asthmaticus include the following:  Complete blood count (CBC)  Arterial blood gas (ABG)  Serum electrolyte levels  Serum glucose levels  Peak expiratory flow measurement  Chest radiographs  Electrocardiogram (in older patients)

9. Management  After confirming the diagnosis and assessing the severity of an asthma attack, direct treatment toward controlling bronchoconstriction and inflammation.  Beta-agonists, corticosteroids, and theophylline are mainstays in the treatment of status asthmaticus

10.  The first line of therapy is bronchodilator treatment with a beta2- agonist. Handheld nebulizer treatments may be administered either continuously (10-15 mg/h) or by frequent timing (eg, q5-20min), depending on the severity of the bronchospasm.  Salbutamol solution 0.5% or 5 mg/mL nebulized by compressed oxygen or Salbutamol via a spacer 2 puffs repeated every 20-30 minutes  Oxygen, via a mask or nasal prongs, oxygen therapy can be easily titrated to maintain the patient's oxygen saturation above 92% (>95% in pregnant patients or those with cardiac disease)  Set up an IV line for rehydration and possible IV medication, Hydration, with intravenous normal saline at a reasonable rate, is essential. Special attention to the patient's electrolyte status is important.  Determine hydration status for amount of fluids required (not <2L/24hrs)  Steroids: Prednisolone orally 40-60mg daily or IV hydrocortisone 200mg 6hry (nebulized: controversial)

11.  Add nebulized ipratropium bromide (500mcg) to B 2 agonist treatment for patients with acute severe or life-threatening asthma or those with a poor initial response to B 2 agonist therapy.  Consider a single dose of IV magnesium sulphate (1.2–2g IVI over 20min) after consultation with senior medical staff, for patients with acute severe asthma without a good initial response to inhaled bronchodilator therapy or for those with life-threatening or near-fatal asthma.  Use IV aminophylline only after consultation with senior medical staff. Some individual patients with near-fatal or life-threatening asthma with a poor response to initial therapy may gain additional benefit. The loading dose of IVI aminophylline is 5mg/kg over 20min unless on maintenance therapy, in which case check blood theophylline level and start IVI of aminophylline at 0.5–0.7mg/kg/hr.  IV salbutamol is an alternative in severe asthma, after consultation with senior staff. Draw up 5mg salbutamol into 500mL 5 % dextrose and run at a rate of 30–60mL/hr.  Avoid ‘routine’ antibiotics.

12. ICU admission criteria Indications for ICU admission include the following: Altered sensorium Use of continuous inhaled beta-agonist therapy Exhaustion Markedly decreased air entry Rising PCO 2 despite treatment Presence of high-risk factors for a severe attack Failure to improve despite adequate therapy

13. Prevention  Compliance with medications  Avoid triggers

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