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Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
Acute severe asthma
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Acute severe asthma

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  • 1. Acute Severe Asthma<br />By: Kane Guthrie<br />
  • 2. Objectives<br />Pathophysiology of ASA<br />Assessing the patient with ASA<br />Emergency department management<br />NIV vs Mechanical Ventilation in ASA<br />
  • 3. Case Study<br />
  • 4. Case Study <br />
  • 5. Vital Signs<br />
  • 6. Epidemiology of Asthma<br />Over 2.2 million Aussie’s have asthma<br />Over 400 hundred die each year<br />Highest risk of death >70years<br />Severe acute asthma is a life threatening condition.<br />
  • 7. Pathophysiology<br />
  • 8. Acute Severe Asthma<br />2 distinct phenotypes of ASA identified:<br />
  • 9. Differential Dx:<br />
  • 10. Assessment<br />
  • 11. Assessing Severity<br />
  • 12. Investigations<br />Diagnostic test generally provide limited information, compared to clinical assessment<br />
  • 13. CXR<br />Limited Use<br />Hyperinflation 5-10%<br />Infiltrates 5%<br />PTX <1%<br />Pnemomediastinum <1%<br />
  • 14. Blood Gas<br />Respiratory alkalosis typical<br />Inaccurate predictor of outcome<br />Seldom alters treatment plan<br />Clinical assessment gives better information<br />Painful<br />
  • 15. Pulse Oximetry<br />Simple, less invasive and painful, compared to blo0d gas.<br />Provides continuous o2 measurement<br />Aim >Spo2 94%<br />
  • 16. PEFM<br />Objective measurement of lung function<br />Useful to assess response to treatment<br />Limited role in ASA<br />
  • 17. Complications of ASA<br />
  • 18. ED Management<br />The sick and dying asthmatic!!!<br />
  • 19. Nursing Care<br />Apply o2/neb (humidified)<br />Monitor BP,HR,RR, Spo2, EtCo2, Temp, GCS<br />IVC x2<br />Monitor electrolytes/arrhythmias closely<br />ECG<br />FBC<br />IDC<br />
  • 20. o2<br />Asthmatic die from hypoxia<br />Keep Sp02 > 94%<br />A slight ∧ in Pco2 may occur, (not clinically significant)<br />
  • 21. Bronchodilators<br />Salbutamol<br />First line therapy <br />Nebulizer (back to back nebs)<br />Dose?<br />Not improving consider IV (back door)<br />Monitor K<br />Salbutamol toxicity= ∧Lactic acidosis<br />
  • 22. Anticholinergics<br />Ipratropium bromide<br />Blocks muscarinic receptors in smooth muscle, resulting in bronchodilation<br />Dose: 500mcg<br />Can give up to 3 dose’s initially then ever 4/24<br />
  • 23. Mg<br />Controversial<br />Best evidence is in the sick/dying asthmatic<br />Cause smooth relaxation, inhibits histamine & acetylcholine release from nerve endings<br />Indicated when bronchodilators are failing<br />Dose: 2-4mg over 30-60mins<br />
  • 24. Steroids<br />Prednisolone vs Hydrocortisone<br />Given within 1st hour greatly reduces hospital admission<br />Target airway oedema and secretions via anti-inflammatory role<br />Dose: Pred 50mg PO, Hydrocort 100-200mg IV<br />
  • 25. Adrenaline<br />Given via Neb or IV<br />Alpha effects target ∨ airway oedema<br />Beta effect target ∨bronchodilation<br />Used as a rescue therapy in the hypotensive, poor responding asthmatic<br />Dose: Neb 1-6mg in 3ml Nacl<br />Dose: IV 6mg in 100mls 5% dextrose (1-15mls/Hr), “also push dose’s 0.10-0.50mcg”.<br />
  • 26. AB’s<br />Not routinely indicated<br />Give<br />Underlying pneumonia/bacterial cause<br />Preventing VAP<br />
  • 27. Airway Management<br />
  • 28. NIV<br />Becoming more popular, (research, case reports)<br />Unloads resp muscles, augments alveolar ventilation until asthma resolves.<br />CPAP vs BiPAP<br />Start with low IPAP & EPAP<br />Good indicator which patients need intubating<br />
  • 29. What the literature says on NIV.<br />Clinical Evidence:<br />
  • 30. Mechanical VentilationIndications<br />
  • 31. Intubating<br />Ketamine for bronchodilator effects<br />Use rapid sequence intubation<br />Fluid bolus before (pre-load)<br />Allow permissive hypercapnea<br />
  • 32. Challenges of Mechanical Ventilation<br />Effective pre-oxygenation difficult<br />No margin for error or delay<br />Need to be intubated by most senior person available<br />Develop high Intrathoracic pressure after RSI<br />Intubation causes higher mortality via= lung hyperinflation, VILI, cardiovascular collapse.<br />
  • 33. The BIG issue<br />Asthmatics require prolonged expiratory times<br />Severe asthma pt initiates inspir before expir ceases<br />Results in increase lung volume, auto-peep and hyperinflation<br />Minimizing hyperinflation and avoiding excessive airway pressures are the goals<br />Use low RR and prolonged exhalation times<br />Allow Co2 to rise, but keep pH .7.15 <br />Monitor (P plat) >30 cm H20 against expir time<br />
  • 34. Initial Ventilator Settings<br />Assist control mode<br />Tidal volume 7-8mL/kg (use ideal body weight)<br />RR 10-12bpm<br />Fi02: 100%<br />PEEP: 0cm H20<br />Patients require deep sedation to tolerate the Vent.<br />
  • 35. Crashing Ventilated Asthmatic<br />D.O.P.E.S.<br />
  • 36. Take Home Points<br />Assessment skills are paramount<br />Maximizing therapy to prevent MV is the GOAL!!!<br />Mg works in the sick asthmatic<br />NIV works<br />Experience makes a big difference<br />These patients will challenge you<br />
  • 37. Questions<br />
  • 38. Thank-you<br />

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