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

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