Updates on Asthma and COPD
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Presented during the 1st Malaysian National Emergency Critical Care Symposium in Ipoh, Perak, Malaysia, Nov 2013.

Presented during the 1st Malaysian National Emergency Critical Care Symposium in Ipoh, Perak, Malaysia, Nov 2013.

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  • 1. Updates  on  Asthma  and  COPD   Keng  Sheng  Chew   School  of  Medical  Sciences   Universi6  Sains  Malaysia   1  
  • 2. Conflict  of  Interest   •  I  declare  I  have  received  educa6onal   grants  from  Astra-­‐Zeneca  (M)  Sdn  Bhd   2  
  • 3. Outlines   •  •  •  •  •  •  •  •  In  asthma:     Con6nuous  neb?   IV  B2-­‐agonist?     IV  steroids?   An6cholinergics?   Magnesium  sulphate?   NIPPV?   When  intubate?  What  to  look  for?   3  
  • 4. Outlines   •  •  •  •  •  •  In  COPD:   Recent  concepts   B2-­‐agonists  vs  an6cholinergics?   NIPPV?   Issues  of  mechanical  ven6la6on   Hypoxic  drive  –how  true  is  this  fear?   4  
  • 5. Updates  on  Asthma   5  
  • 6. Pathophysiology  of  Asthma   6  
  • 7. Pathological  changes   7  
  • 8. “Rules  of  2”  in  asthma   •  AXacks  >2  6mes  per  week  or   •  Needs  rescuer  inhaler  >2  6mes  per   week   •  Awakening  due  to  nocturnal  symptoms   >2  6mes  per  month   •  Use  >2  canisters  of  relievers  per  year   •  If  yes  to  any  =  uncontrolled,  needs   steroids   •  (Adapted  from  GINA  guideline)   8  
  • 9. Con@nuous  neb  vs  intermiCent   neb?   •  “Con6nuous”  neb  =  con6nuous  aerosol   delivery  or  sufficient  frequency  of  at   least  1  neb  q15  min  or  >  4  neb/hour   •  In  a  Cochrane  systema6c  review,   Camargo  et  al  (2009),  8  trials,  n  =  461   •  Con@nuous  neb   –  Benefits  in  severe  disease   –  Significant  lung  improvement  at  2  –  3  hours   –  Similar  side  effects  (tremors,  increased  K+,   HR)   –  Well  tolerated   9  
  • 10. IV  Beta-­‐2  agonists  vs  inhaled   Beta-­‐2  agonists?   •  Travers  et  al  (2001),  in  a  Cochrane   systema6c  review,  15  trials,  n  =  583   •  IV  beta  agonists  offer  no  therapeu6c   advantage  over  inhaled  forms  of  the   drugs.     •  However,  no  difference  in  autonomic   side  effects   10  
  • 11. Early    IV  steroids  use?   •  Rowe  et  al  (2009),  Cochrane  systema6c   review,  12  trials,  n  =  863   •  IV  steroids  given  within  1  hour:   •  significantly  reduced  admission  rates   (OR  =  0.40,  95%  CI:  0.21  to  0.78)   •  Benefits  most  pronounced  among  those   with  severe  asthma  and  in  those  who   have  not  yet  been  on  systemic  steroids   prior  to  ED  presenta6on   11  
  • 12. An@cholinergics   •  An6cholinergics  –  not  to  be  used  alone   •  Teoh  et  al  (2012),  in  a  Cochrane  review,   4  trials,  n  =  171   –  An6cholinergics  alone  less  efficacious  and   more  likely  to  fail   •  An6cholinergics  combined  with  SABA?   –  Griffiths  et  al  (2013),  in  a  systema6c  review,   15  trials,  n  =  2497  (pediatrics),  found   –  combining  an6cholinergic  and  SABA   significantly  reduces  the  risk  for  hospital   admission   12  
  • 13. Magnesium  sulphate   •  Blocks  calcium  channel   •  Relaxes  bronchial  smooth  muscle   •  Inhibits  contrac6le  response  to   endogenous  bronchoconstrictors   •  Rowe  et  al  (2009):   •  7  trials,  n  =  665   •  Overall  no  improvement  in  lung   func6on,  no  improvement  in  adm  rate   •  BUT  reduce  admission  rate  in  severe   asthma  subgroup   13  
  • 14. NIPPV  in  Asthma?   •  Lim  et  al  (2012)  in  a  Cochrane  review,  5   trials,  n  =  206,  preliminary  results  show   NIPPV  has  benefit  of   –  Reduced  hospitaliza6on  rate   –  Reduced  6me  to  discharge  from  ED   –  Improves  lung  func6on   •  But  s6ll  lack  of  good  evidence,  remains   controversial;  NOT  for  rou6ne  use   •  Two  of  the  studies:  2  intuba6ons  needed  in   45  par6cipants  on  NPPV  vs  no  intuba6ons   in  41  control  pa6ents  (risk  ra6o  4.48;  95%   CI  0.23  to  89.13)   14  
  • 15. Mechanical  ven@la@on   •  4  indica6ons  for  intuba6on  (Brenner  et  al,   2009  in  Proceedings  of  the  ATS)   –  cardiac  arrest   –  respiratory  arrest  or  profound  bradypnea   –  physical  exhaus6on   –  AMS  (agitated  pa6ent,  interfering  with  oxygen   delivery)     •  Hypercapnia  per  se  without  evidence  of   physical  exhaus6on  or  mental  changes  IS   NOT  an  indica6on   •  Persistent  hypercapnia  despite  treatment   +/-­‐  AMS  is  an    indica6on  (PaCO2  increase  ~   5mmHg/Hr  or  more  than  55  –  70  mmHg)   15  
  • 16. Mechanical  ven@la@on   •  Permissive  hypercapnia  -­‐  minimize  risk   of  increased  intrathoracic  pressure.   Ini6al  sepng:   –  TV  6  ml/kg   –  Rate  6/min   –  I:E  up  to  1:4   •  Try  keep  Plateau  pressure  below  30  cm   H20.     •  Pplat  (or  lung  distension  pressure)  gives   an  es6mate  of  average  of  end-­‐insp   alveolar  P  (Brenner  et  al,  2009)   16  
  • 17. Induc@on  Agents   Ketamine     releases  of  catecholamines   bronchial  smooth  muscle  relaxa6on   Side  effects  –  hypersecre6on,   hypertension,  arrhythmias,  and   hallucina6ons   •  rela6vely  contraindicated  in  pa6ents   with  ischemic  heart  disease,   hypertension,  increased  intracranial   pressure.   •  •  •  •  17  
  • 18. Updates  on  COPD   18  
  • 19. Reversible Irreversible Source: Peter J. Barnes, MD
  • 20. Basics   •  COPD  is  a  systemic  disease,  not  just   pulmomary  (Agus6,  2005)   –  systemic  inflamma6on,  systemic  oxida6ve   stress,  ac6va6on  of  circula6ng   inflammatory  cells,  e.g.  neutrophils,   macrphages,  and  augmented  levels  of  pro-­‐ inflammatory  cytokines   •  Extrapulmonary  associa6ons:  IHD,   osteopenia,  cachexia,  malnutri6on,   skeletal  was6ng   20  
  • 21. Bronchodilators   •  Cochrane  systema6c  review  by  McCrory  et   al  (2005)   –  No  significant  difference  in  changes  in  FEV1   between  b2-­‐agonists  and  the  an6cholinergic   ipratropium  at  90  minutes  and  24  hours  and     –  no  advantage  combining   •  An6cholinergics  –  slower  onset  (15  min,   peak  60  to  90  min,  and  longer  6  to  8  hrs).   •  General  consensus  (GOLD)  –  SABA  first,   then  an6cholinergics   21  
  • 22. NIPPV  in  COPD   •  Ram  FSF  et  al  (2004)  in  a  Cochrane   systema6c  review,  14  trials  involving  n  =   622  (outcomes  of  treatment  failure),  n  =   541  (mortality)   •  NIPPV  resulted  in   •  decreased  mortality     •  decreased  need  for  intuba6on     •  reduc6on  in  treatment  failure   22  
  • 23. Mechanical  ven@la@ons   •  Issues  with  mechanical  ven6la6on  in   COPD  (BruloXe  et  al,  2012):   •  poorer  prognosis  (mortality  rates   between  20%  and  73%)     •  a  mean  life  expectancy  of  1  year   •  Barotrauma,  infec6ons   •  Discuss  with  family  regarding  pros  and   cons   23  
  • 24. Hypoxic  Drive  in  COPD?   •  How  real  is  this  fear?   •  Started  off  with  a  paper  by  E.J.M  Campbell   in  1960     •  Really  no  science  behind  it!  Consensus   opinion   •  A  Cochrane  review  by  Aus6n  Wood-­‐Baker   (2009)   –  “No  relevant  trials  have  been  published  to   date,  so  there  is  no  evidence  to  indicate   whether  different  oxygen  therapies  in  the  pre-­‐ hospital  se@ng  have  an  effect  on  outcome  for   people  with  acute  exacerbaBons  of  COPD”   24  
  • 25. Hypoxic  Drive  in  COPD?   •  Plant  et  al  (2000)  shows  an  associa6on   between  increased  oxygen  with   hypercapnea,  respiratory  acidosis,  and   ICU  admission  but  this  does  not  occur  in   every  pa6ent  given  increased  FiO2.   •  May  happen   •  Careful  observa6on  of  this  pa6ent   •  BUT  remember:  the  risks  of  withholding   oxygen  are  much  greater  than  giving   them  too  much!   25  
  • 26. Summary   •  •  •  •  •  •  •  •  In  asthma:     Con6nuous  neb?   IV  B2-­‐agonist?     IV  steroids?   An6cholinergics?   Magnesium  sulphate?   NIPPV?   When  intubate?  What  to  look  for?   26  
  • 27. Summary   •  •  •  •  •  •  In  COPD:   Recent  concepts   B2-­‐agonists  vs  an6cholinergics?   NIPPV?   Issues  of  mechanical  ven6la6on   Hypoxic  drive  -­‐  controversials   27  
  • 28. References   •  Camargo  Jr  CA,  Spooner  C,  Rowe  BH.  Con6nuous   versus  intermiXent  beta-­‐agonists  for  acute  asthma.   Cochrane  Database  of  Systema6c  Reviews  2003,   Issue  4.  Art.  No.:  CD001115.  DOI:   10.1002/14651858.CD001115   •  Travers  A,  Jones  AP,  Kelly  K,  Barker  SJ,  Camargo  CA,   Rowe  BH.  Intravenous  beta2-­‐agonists  for  acute   asthma  in  the  emergency  department.  Cochrane   Database  Syst  Rev.2001;(2)  :CD002988   •  Rowe  BH,  Spooner  C,Ducharme  F,  Bretzlaff  J,  BotaG.   Early  emergency  department  treatment  of  acute   asthma  with  systemic  cor6costeroids.  Cochrane   Database  of  Systema6c  Reviews  2001,  Issue  1.  Art.   No.:  CD002178.  DOI:  10.1002/14651858.CD002178.   28  
  • 29. References   •  Griffiths  B,  Ducharme  FM.  Combined  inhaled   an6cholinergics  and  short-­‐ac6ng  beta2-­‐agonists   for  ini6al  treatment  of  acute  asthma  in  children.   Cochrane  Database  of  Systema6c  Reviews  2013,   Issue  8.  Art.  No.:  CD000060.  DOI:   10.1002/14651858.CD000060.pub2.   •  Lim  WJ,  Mohammed  Akram  R,  Carson  KV,   Mysore  S,  Labiszewski  NA,  Wedzicha  JA,  Rowe   BH,  Smith  BJ.  Non-­‐invasive  posi6ve  pressure   ven6la6on  for  treatment  of  respiratory  failure   due  to  severe  acute  exacerba6ons  of  asthma.   Cochrane  Database  of  Systema6c  Reviews  2012,   Issue  12.  Art.  No.:  CD004360.  DOI   10.1002/14651858.CD004360.pub4.   29  
  • 30. References   •  Barry  Brenner,  Thomas  Corbridge,  and   Antoine  Kazzi  "Intuba6on  and  Mechanical   Ven6la6on  of  the  Asthma6c  Pa6ent  in   Respiratory  Failure",  Proceedings  of  the   American  Thoracic  Society,  Vol.  6,  No.  4   (2009),  pp.  371-­‐379.     •  McCrory  DC,  Brown  CD.  An6cholinergic   bronchodilators  versus  beta2-­‐ sympathomime6c  agents  for  acute   exacerba6ons  of  chronic  obstruc6ve   pulmonary  disease.  Cochrane  Database  of   Systema6c  Reviews  2003,  Issue  1.  Art.  No.:   CD003900.  DOI: 10.1002/14651858.CD003900.   30  
  • 31. References   •  Agus6  AG.  Systemic  effects  of  chronic   obstruc6ve  pulmonary  disease.  Proc  Am  Thorac   Soc  2005;  2  (4):367-­‐70;  discussion  71-­‐2.     •  Ram  FSF,  Picot  J,  Lightowler  J,  Wedzicha  JA.   Non-­‐invasive  posi6ve  pressure  ven6la6on  for   treatment  of  respiratory  failure  due  to   exacerba6ons  of  chronic  obstruc6ve  pulmonary   disease.  Cochrane  Database  of  Systema6c   Reviews  2004,  Issue  3.  Art.  No.:  CD004104.  DOI:   10.1002/14651858.CD004104.pub3.     •  BruloXe  CA,  Lang  ES.  Acute  exacerba6ons  of   chronic  obstruc6ve  pulmonary  disease  in  the   emergency  department.  Emerg  Med  Clin  North   Am.  2012;  May;30(2):223-­‐47,  vii.   31  
  • 32. References   •  Teoh  L,  Cates  CJ,  et  al.  An6cholinergic   therapy  for  acute  asthma  in  children.   Cochrane  Database  Syst  Rev  2012,  Issue   4:  CD003797.   •  Plant  PK,  Owen  JL,  Elliot  MW.  One  year   period  prevalence  study  of  respiratory   acidosis  in  acute  exacerba6ons  of  COPD:   implica6ons  for  the  provision  of   noninvasive  ven6la6on  and  oxygen   administra6on.  Thorax  2000;55:550–4.   32  
  • 33. 33