A ppt on acute exacerbation OF Asthma ( Status Asthmaticus) . This presentation basically about the how we cane approach a pt with acute exacerbation of Status asthematicus with sign and Symptoms and what we will do investigation for this pt and what are the management we can do for this patient on Emergency and OPD basis. The main point of this presentation is the CT scan findings in pt with status Asthematicus. There is unique pattern of CT scan Mosaic pattern in lower lobs of lungs of this patient. Also Xrays findings. How it is important to konw about the Respiratory Alkalosis changes into Respiratory acidosis .

1. STATUS
ASTHMATICUS
By Dr. Amir Abbas Rind - House Officer
RMU and Allied

2. DEFINITION:
• Status asthmaticus is a medical emergency,
an extreme form of asthma exacerbation
characterized by hypoxemia, hypercarbia, and
secondary respiratory failure. All patients with
bronchial asthma are at risk of developing an
acute episode with a progressive severity that
is poorly responsive to standard therapeutic
measures, regardless of disease severity or
phenotypic variant. This is also known as
status asthmaticus.

3. ETIOLOGY:
• The time course of progression and the severity
of airway obstruction follow two distinct patterns.
• If appropriately documented, one subgroup
shows a slow subacute worsening of peak
expiratory flow rate (PEFR) over days, known as
"slow onset asthma exacerbation." This
patient subgroup usually has intrinsic patient-
induced predisposition factors, including
inadequate inhaler regimen, suboptimal
compliance, and psychological stressor. (Ref:
• The other phenotype, known as "sudden onset
asthma exacerbation," presents with severe
deterioration within hours. They often correlate
with sudden massive exposure to external
triggers like predisposed allergens, food articles,
sulfites, among others.

4. PAT H O P H Y S I O L O G Y
• At a physiological level, premature
airway closure during exhalation
causes an increase in functional
residual capacity and air trapping.
Heterogeneous distribution of air
trapping results in ventilation-
perfusion mismatch and hypoxemia-
triggering anaerobic metabolism and
lactic acidosis. It is offset initially by
respiratory alkalosis and is
compounded once respiratory
fatigue and respiratory acidosis
ensue.

6. SEVERITY
ASSESSMEN
T:

7. CLINICAL
FINDINGS:
Increasing lethargy
Increasing use of accessory
muscles
Change in posture or speech
Decreasing rate and depth of
respiration
Subcostal retractions
Nasal flaring
Facial grunting

8. EXAMINATION
FINDING
• Hyperresonance on percussion
• Barrel chest
• Pulses paradoxus
• Bilateral diffuse wheezing
• Bilateral crepitations secondary to
pulmonary oedema

9. XRAY
FINDINGS:
 Air-trapping on expiratory scans most
common finding
 Bronchial wall thickening (50-90%)
 Decreased lung attenuation (50%)
 Mosaic lung attenuation
 Degree of mosaic attenuation correlates with
degree of asthma
 Peri bronchial cuffing

11. MOSAIC
ATTENUATION
ON CT CHEST:

13. MANAGEMENT:
• Beta-agonist
• Short-acting inhaled beta-agonists are the
drug of the first choice in acute asthma
• Initial treatment consists of 2.5 mg of albuterol
(0.5 mL of a 0.5% solution in 2.5 mL normal
saline) by nebulization every 20 minutes for
60 minutes (three doses) followed by
treatments hourly during the first several
hours of therapy.

14. MANAGEMENT
• Corticosteroids
• In a meta-analysis of 30 randomized clinical
trials (RCT), concluded that the use
of steroids in the emergency department
significantly reduces rates of admission and
the number of future relapses in subsequent 7
to 10 days due to their anti inflamatory effect.
• Currently available data support the approach
of 60 to 125 mg
methylprednisolone intravenously every 6
hours for the initial 24 hours of treatment of
status asthmaticus. Oral steroids are usually
required for the next 10 to 14 days.

15. MANAGEMENT
• Anticholinergics
• 0.25 mg of ipratropium bromide with 5
mg of albuterol by nebulizer resulted
in greater improvement in FEV1 than
albuterol alone. The response time
was also much faster than
corticosteroids, with a detectable
change in FEV1 within 19 minutes.

16. MANAGEMENT
• Magnesium Sulphate
• Magnesium inhibits calcium-mediated smooth
muscle constriction, decreases acetylcholine
release in the neuromuscular junction, and
affects respiratory muscle force generation.
• Commonly used dose of 2 gm intravenously
(IV) in 2 separate doses over 20 minutes

17. MANAGEMENT
• Heliox and Oxygen
• Heliox is a mixture of 70:30 or 60:40 helium:
oxygen decreases airway resistance and
turbulence and reduces work of breathing and
inspiratory muscle fatigue.

18. MANAGEMENT
Indications of Intubation:
• Coma
• Respiratory arrest
• Deterioration of arterial blood gas tensions
despite optimal therapy:
• PaO2 < 8 kPa (60 mmHg) and falling PaCO2
> 6 kPa (45 mmHg) and rising pH low and
falling (H+ high and rising)
• Exhaustion, delirium, drowsiness

19. THANK YOU