Critical Care management part included

1. ASTHMA IN PREGNANCY
BY
DR MUHAMMAD AKRAM
MATERNITY AND CHILDREN HOSPITAL
MAUSADIA, JEDDAH

2. WHO DEFINITION OF ASTHMA
 "A chronic inflammatory disorder of the airways in
which many cells play a role, in particular mast
cells, eosinophils, and T lymphocytes. In
susceptible individuals this inflammation causes
recurrent episodes of wheezing, breathlessness,
chest tightness, and cough particularly at night
and/or in the early morning. These symptoms are
usually associated with widespread but variable
airflow limitation that is at least partly reversible
either spontaneously or with treatment. The
inflammation also causes an associated increase in
airway responsiveness to a variety of stimuli."

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Pathophysiology

6.  A peak flow meter
 at home
 the convenience and ease of use
 measure the PEFR (peak expiratory
flow rate) by taking a deep breath
and then blowing into a tube on the
meter as hard and as fast as patient
can.
 every day, sometimes several times
a day, and keep track of these rates
over time --are compared with
charts that list normal values for sex,
race, and height.
 A spirometer
 in a doctor's office
 gives a more accurate measure of lung
function
 diagnose asthma, classify its severity, and
help decide what is the best way to treat
asthma
 done periodically
 The total volume patient exhale is called
"forced vital capacity," or FVC
 measures the volume of air patient exhale
in the first second. (This is referred to as
"forced expiratory volume in one second,"
or FEV1.)
 Patient will be given a bronchodilator and
•You would not consider managing hypertension without a sphygmomanometer,
or diabetes without a glucometer –
• accurate and objective assessmentand management of asthma is not possible
without a spirometer or peak flow meter

7.  The Peakflow or Peak Expiratory Flow or PEF
indicates how severe the asthma crisis is:
 PEF values to keep in mind :
 Normal for a man : 600 l/min
 Normal for a woman : 450 l/min
 Values depending on severity (in % of normal value):
Acute asthma Serious crisis Light/moderate
crisis
PEF impossible
or  30%
( 180 l/min)
PEF = 30 to 50%
(180 to 300 l/min)
PEF  50%
( 300 l/min)

8. MANAGING ASTHMA:
PEAK FLOW CHART
People with
moderate or
severe asthma
should take
readings:
 Every morning
 Every evening
 After an
exacerbation
 Before inhaling
certain
medications
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For
Asthma Created and funded by NIH/NHLBI

9. Sputum esinophilia.
Chest X-Ray (For DD , complications).
Skin tests (For Allergen Identification) .
Bronchoprovocation (For Suspected Cases).
Several types of bronchoprovocation testing are available to
assess airway responsiveness in specific patient situations,
including pharmacologic challenge, exercise challenge,
eucapnic voluntary hyperpnea, food additive challenge, and
antigen challenge.
INVESTIGATIONS

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DIFFERENTIAL DIAGNOSIS
All that wheezes is not asthma
 CHF
 COPD
 Upper airway obstruction
 Tumor
 Laryngeal edema ...etc

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Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms Nocturnal
Symptoms
FEV1 or PEF
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent
Continuous
Limited physical
activity
Daily
Attacks affect activity
> 1 time a week
but < 1 time a day
< 1 time a week
Asymptomatic
and normal PEF
between attacks
Frequent
> 1 time week
> 2 times a month
 2 times a month
 60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
 80% predicted
Variability 20 - 30%
 80% predicted
Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.

12. GOALS OF THERAPY
 Minimal or no chronic symptoms day or night
 Minimal or no exacerbations
 No limitations on activities; no school/work missed
 Maintain (near) normal pulmonary function
 Minimal use of short-acting inhaled beta 2 agonist
 Minimal or no adverse effects from medications

13. STEPWISE APPROACH
 Review treatment every 1 to 6 months, and
gradually step down treatment
 If asthma controlled not maintained, then a step up
in treatment may be warranted

14. REASONS FOR POOR ASTHMA CONTROL
 Inhaler Technique
 Compliance
 Environment
 Also assess for an alternative diagnosis
 “All that wheezes is not asthma, and not all asthma
wheezes”

15. FACTORS AFFECTING COMPLIANCE
 Support of health care professional and family
 Route of drug administration (inhaled vs. oral)
 Complexity of drug regimens
 Side effects of medications
 $$ Cost $$

16. • Pregnancy does not increase the frequency or
severity of asthma.
• Progesterone reduces spasm and relaxes smooth
muscle. Bronchi are widened and mucus regulated.
(Progesterone receptors are widely present in
submucosal tissue.)
• Studies suggest that 11-18% of pregnant women
with asthma will have at least one emergency
department visit for acute asthma and of these
62% will require hospitalization1.
• One third of the asthmatic women feel better
during pregnancy.
_______________________________________________________
1. Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, et al.
Perinatal outcomes in the pregnancies of asthmatic women: a prospective
controlled analysis. Am J Respir Crit Care Med 1995;151(4):1170-4

17. PHYSIOLOGICAL CHANGES IN
RESPIRATORY SYSTEM IN PREGNANCY

18. Lung Volumes and Capacities
 Tidal volumes increases gradually(35-50%).
 Total lung capacity is reduced (4-5%) by the elevation of
the diaphragm.
 FRC (Functional Residual Capacity) and RV (Residual
Volume) decrease by about 20%.
Effects of Labour on the Pulmonary System
 There is a further decrease in FRC during the early
phase of each uterine contraction

19. ABG PREGNANT AND NON
PREGNANT

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EFFECT OF ASTHMA ON PREGNANCY
SPECIALLY IF UNTREATED WELL
MATERNAL
  ED visits
  hospitalizations
  hyperemesis
  vaginal hemorrhage
& accidental
haemorrhage due to
severe coughing
  CS
  respiratory failure
  PIH
  death
FETAL
  Oligohydroamnios
  LBW
  premature delivery
  fetal demise
  Meconium staining
NEONATAL
  neonatal hypoxemia
  low newborn
assessment scores
  perinatal mortality

21. DRUG THERAPY IN PREGNANCY
In general, the drugs used to treat asthma are safe in
pregnancy.
 Quick relief medications
 Long-term control medications

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QUICK RELIEF ‘RELIEVER’
MEDICATIONS
 β2-agonists
Salbutamol (Albuterol), terbutaline
 Methylxanthines
Aminophylline, Theophylline
 Anticholinergics
Ipratropium & Tiatropium bromide
 MOA:
Bronchodilators

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LONG TERM ‘CONTROLLER ’ MEDICATIONS
 Corticosteroids
 Leukotriene modifiers
Zafirlukast, Montelukast,Zileuton
 Mast cell stabilisers
Nedocromil/Cromolyn
 Long acting β2-agonists
Salmeterol, Formoterol, Bambuterol
 Methylxanthines
Theophylline
 Anticholinergics
Ipratropium bromide
Bronchodilators
MOA:
Prevent or
reverse
inflammation

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QUICK RELIEF  AGONISTS
 MOA:
1.  receptors  G protein  cAMP  Bronchodilatation
2.  mucociliary transport
3.  release of mediators
 Short acting (30-90 min.) (epinephrine, isoproterenol,
isoetharine)
 Adv: Immediate action
 Disadv: Only by inhalation or parenteral

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 Long acting(4-6 h): Selective 2-agonists terbutaline,
fenoterol, Salbutamol(albuterol)
 Adv: Highly specific, No cardiac side effect except high
doses
Can be given by all routes
 Disadv: Tremors
 Salbutamol: 2-4 mg oral, 0.5 mg im/s.c, 100-200 g/puff
Preferred route inhalation, equivalent to iv in severe asthma
 Terbutaline: 0.25 mg sc or inhalation, 5 mg oral

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 Ultra long(9 to 12 h): Salmeterol & formoterol
 For nocturnal and exercise-induced asthma
 Adv: Anti-inflammatory activities
 Disadv: Not recommended for acute episodes
 Salmeterol: 25 g/puff MDI, 2 puffs BD.
‘SEROFLO’ ROTACAPS (Salm + fluticasone), MDI

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METHYLXANTHINES
Medium potency bronchodilators with ?
anti-inflammatory properties.
2nd line drug
Rarely used in acute condition
Adv: “Controller class”,
Single evening dose  nocturnal
symptoms
Theophylline: 100-300 mg TDS
Aminophylline: Slow iv 250-500 mg

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GLUCOCORTICOIDS
Ind: Acute illness with failure of optimal
bronchodilators
Chronic disease with frequent
recurrence &  severity
Inhaled for long term control of asthma
Adv:
Most potent
Max. antiinflammatory

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 MP
 Dose: 120-180 mg iv QD
 7-60 mg daily OD am as needed for control
 Prednisolone
 Dose: 60 mg QDS. Taper ½ q 5th day after 10-12 days of
acute episode
 S/E:
 Long delay to peak action
 Interrrupted growth, Gastric ulcer.

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 Inhaled steroids
Persistent symptoms & control inflammation
Facilitate the long-term prevention
 need for oral steroids
Minimize acute occurrences & hospitalizations
Beclomethasone: 100,200,250 g
Budesonide: 200, 400 g BD- QID
Fluticasone: 25,50,125 g inhalation, rotacaps
100-250 g BD
 Dose needs to be individually titrated

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LEUKOTRIENE RECEPTOR ANTAGONISTS
Zafirlukast, Montelukast,
 MOA:
 Inhibit or antagonise competitively against LTD4 receptor
 Modest bronchodilator to  asthma
 exercise induced & nocturnal symptoms
 Montelukast: 10 mg OD
 Zafirlukast: 20 mg BD

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 Disadv:
 Hep. Enz. 
 Interact with the drugs metabolised by liver
 +ve responders < 50 %
 No response in 1 month STOP

33. 27-Dec-1533
MAST CELL STABILISERS
Nedocromil Na, Cromolyn Na
 MOA:
 Inhibit degranulation of mast cells
 Reduce symptoms
 Lower airway reactivity
 Ind:
 Atopic patients with seasonal disease
 Exercise or cold induced asthma
 Adv:
 Can be given 15-20 minutes b/f contact as it can abolish
late reaction
 Cromolyn: 1mg/puff, 2 puffs QDS
 Nedocromil: 4 mg or 2 puffs BD

34. Steroid tablets
 Use as normal when indicated. Steroid tablets should
never be withheld because of pregnancy.
 First trimester exposure to oral steroids may slightly
increase the risk of cleft lip/palate2.
 The benefits of treatment outweigh the risks.
_______________________________
____
2.Czeizel AE, Rockenbauer M. Population-based case control study of
teratogenic potential of corticosteroids. Teratology 1997;56(5):335-
40.

35. Treatment Protocol
DIAGNOSIS BASED ON SYMPTOMS & OBJECTIVE ASSESSMENT
ASSESS SEVERITY
MILD MODERATE SEVERE
ENVIRONMENTAL CONTROL AND EDUCATION
ADDITIONAL THERAPY
INHALED CORTICOSTEROIDS
INHALED SHORT-ACTING BETA2-AGONIST PRN

36. New Asthma Treatment Algorithm

39. BREAST FEEDING
 Women with asthma are encouraged to breastfeed.
 Asthma medications are safe to be used as normal
during lactation.

40. SAFETY OF ASTHMA THERAPY DURING
LACTATION(1)

41. SAFETY OF ASTHMA THERAPY DURING
LACTATION(2)

42. MANAGEMENT OF ACUTE ASTHMA IN
PREGNANCY
 Give drug therapy for acute asthma as for the non-
pregnant patient.
 High flow oxygen.
 Acute severe asthma in pregnancy is an
emergency and should be treated vigorously in
hospital.
 Continuous fetal monitoring

43. • For induction of labor, oxytocin is preferred over
various prostaglandin (PG) preparations.
• Intravaginal or intracervical PGE2 gel has not been
reported to cause bronchospasm but IV can cause
• Lumbar epidural analgesia reduces oxygen
consumption and minute ventilation during the first and
the second stages of labor and may considerably
advantageous to patients with asthma
• If general anesthesia is needed:
- Pretreatment with atropine may provide a
bronchodilating effect.
-Ketamine is the agent of choice for anesthesia
induction
• Use of non steroidal may be dangerous

44. • Whenever possible if RA can do, it is preferred to general
• Avoid GA as possible in patients at risk of aspiration of gastric
contents:
 Emergency surgery in non fasting patient
 Gastroesophageal reflux
 Marked obesity
 Bowel obstruction
 Gastroparesis (trauma or diabetes)
 Pregnancy, or other factors increasing intragastric
pressure

46. DURING DELIVERY
 Only about 1 in 10 women with asthma have symptoms during
delivery.
 The increase in plasma epinephrine that occurs during labor
and delivery may contribute to the absence of asthma
symptoms during this critical time period

47. MANAGEMENT DURING LABOUR
 Acute asthma is rare in labour.
 Continue usual asthma medications.
 Avoid general anesthesia if possible.
 Avoid prostaglandin F2α ( Dinoprost for induction ) and
ergometrine (Synto)
 Women receiving steroid tablets at a dose exceeding
prednisolone 7.5mg per day for more than 2 weeks prior
to delivery should receive parenteral hydrocortisone
100mg 6-8 hourly during labour.

48. ADVICE TO MOTHER
 Importance and safety of continuing their asthma
medications during pregnancy to ensure good asthma
control.
 The harm of severe or chronically under-treated asthma
outweighs any small risk from the medications.

49. SELF-MANAGEMENT OF ASTHMA OUTPATIENT
MANAGEMENT OF ASTHMA
 Teach the patient self-management (Level of Evidence=A;
 The patient should have good knowledge of self-management.
 The components of successful self-management are acceptance of
asthma and its treatment effective and compliant use of drugs
 a PEF meter and follow-up sheets at home
 written instructions for different problems
 As a part of controlled self-management the patient can be given
 a PEF follow-up sheet with individually determined alarm limits and the
following instructions (Level of Evidence=B;
 If the morning PEF values are 85% of the patient´s earlier optimal value,
the dose of the inhaled corticosteroid should be doubled for two weeks.
 If the morning PEF values are below 50 - 70% of the optimal value the
patient can start a course of prednisolon 40 mg daily for one week and
contact the doctor by telephone.

50. REFERRENCE
 BRITISH GUIDELINE ON THE MANAGEMENT OF ASTHMA
(UPDATED 2009)
 UptoDate 2011
 Asthma in Pregnancy by Timothy Hoskins, M.D.October 5, 2005