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Approche to acute asthma management

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Approche to acute asthma management

  1. 1. ACUTE ASTHMA MANAGEMENT ANAS SAHLE , MDDAMASCUSE HOSPITAL
  2. 2. Risk factors for death from asthma1. Prior severe exacerbation(eg: ICU admit, intubation).2. 2 or more asthma hospitalization in past year.3. 3 or more ED visit for asthma in past year.4. Hospitalization or ED visit for asthma in prior month.5. Use of >2 SABA canisters per month.6. Difficulty perceiving asthma symptoms or severity of exacerbation.7. Lack of written asthma action plan, sensitve to ALTERNARIA(fungus).8. Other social and comorbidity risks. EPR-3 national heart lung and blood 2007
  3. 3. Risk factors for death from asthma1. Sudden severe attacks2. Recent systemic steroids.3. >2 SABA canisters in prior month.4. HospitalER in last month.5. ≥ 2 ERhospitalization in last year.6. Prior intubationICU stay.7. Illicit drug use.8. Heartpsychiartic disorder.9. Low socioeconomic class. curr Opin pulm med 2008
  4. 4. PEFR≥75% predicted Mild exacerbation Β2 Agonist(neb),(MDI) Check 15-30 min PEFR≥75% and PEFR<75% and clinically stable clinically stable Observe 2H and Treat as moderatedischarge if stable exacerbation
  5. 5. PEFR=50-75% predicted Moderate exacerbation 5 mg SALBUTAMOL(NEB) 30-60 mg PREDNISOLONE Check at 30 min PEFR<50% PEFR=50-75% clinically stable Or clinically deteriorating Repeat 5 mg SALBUTAMOL(NEB) Treat as severe Check at 30 minPEFR<50% or clinically PEFR>50% ,clinically stabledeteriorating Deteriorating : Observe for 2HTreat as severe discharge if stable treat as severe +PEF increasing
  6. 6. PEFR=33-50%predicted , Severe cannot complete sentences , exacerbation RR>25min , HR>110min High flow O2, 5mg salbutamol(neb), 30-60mg prednisolone200mg hydrocortisone(IV) CHECK at 15 min If not improving If improving: admit repeat 5mg salbutamol(neb) every 15-30 min till improvingcontinue 4-6 hourly (neb) 500mcg ipratropium(neb) continue prednisolone consider magnesium(1,2-2)g over 20 min(IV) 40-50mg daily check ABG CHECK at 15 minIF ABG: If improving: admit If not improving continue 2-4 hourly nebsnormalraised PCO2 start aminophylline(IV) dailysevere hypoxia<58 treat as life-threateninglow PH prednisolone or 6 hourly discuss with ICU hydrocortisone
  7. 7. PEFR<33% O2 SAT<92% Silent chest Cyanosis Life-threatening exacerbation Bradycardia Hypotension ExhaustionconfusionREFERTO High flow O2ICU measure ABG 5mg salbutamol (neb) 500mcg ipratropium (neb) hydrocortisone100mg (IV) magnesium 2g(IV) ±250mg aminophylline (IV)
  8. 8. REFERRAL TO INTENSIVE CARE• deteriorating PEF• persisting or worsening hypoxia• Hypercapnea• arterial blood gas analysis showing fall in pH• exhaustion, feeble respiration• drowsiness, confusion, altered conscious state• respiratory arrest
  9. 9. NON-INVASIVE VENTILATION• It is unlikely that NIV would replace intubation in these very unstable patients.• but it has been suggested that this treatment can be used safely and effectively.
  10. 10. DischargeOn dischargeplanning , all patients should have:1. Patients should be on home medication for 24 hours prior to discharge.2. PEF>75% predicted , <25% variability.3. Prednisolone 40mg for at least 5 days.4. Oral antibiotics if confirmed evidence of infection.5. Supply of all inhalers and technique checked.6. PEF meter.
  11. 11. Definition The peak expiratory flow rate is an effort- dependent assessment of a patients ability to forcibly expel air from their lungs Airways Obstruction
  12. 12. Peak Expiratory Flow Rate / PEFR Usually used in children over 5 years Assessment of Reversibility of Airways limitation or Hyperresponsiveness Diurnal variation : Self -Monitoring in asthma
  13. 13. Peak Expiratory Flow Rate / PEFR Usually used in children over 5 years Assessment of Reversibility of Airways limitation or Hyperresponsiveness Diurnal variation : Self -Monitoring in asthma
  14. 14. Peak Expiratory Flow Rate / PEFR Usually used in children over 5 years Assessment of Reversibility of Airways limitation or Hyperresponsiveness Diurnal variation : Self -Monitoring in asthma
  15. 15. Peak expiratory flow rate measurement
  16. 16. Peak expiratory flow rate measurementAsk the patient tostand up & hold the peak flow in ahorizontal position
  17. 17. Peak expiratory flow rate measurementTake care not to place your fingers over the scale
  18. 18. Peak expiratory flow rate measurementAsk the patient now totake a deep breath in & make a tight sealwith their lips around the mouth piece
  19. 19. Peak expiratory flow rate measurementNow ask the patientto blow out as hard & as fast as they can
  20. 20. Peak expiratory flow rate measurement Remember fastblast is better than slow blow
  21. 21. Peak expiratory flow rate measurementNote the numberwhere the sliding pointer has stopped on the scale
  22. 22. Peak expiratory flow rate measurementReset the pointer to zero
  23. 23. Peak Expiratory Flow
  24. 24.  Personal Best PEFR Value Baseline Predicated PEFR Value
  25. 25. Personal Best PEFR Value A baseline measure The baseline values should be obtained when the patient is feeling well after a period of maximal asthma therapy
  26. 26. Personal Best PEFR Value The patient should then record PEFR measurements 2 to 4 times daily for two weeks
  27. 27. Personal Best PEFR Value The personal best is generally the highest PEFR measurement achieved during this post-treatment monitoring period
  28. 28. Personal Best PEFR Value The patients normal PEFR range is defined as 80 and 100 percent of the patients personal best.
  29. 29. Baseline Predicated PEFR Value Tall – 80 X 5 = Prv PEFRExample: 150 – 80 x 5 = 350 L/min
  30. 30. Predicated PEFR value vs Personal Best value of PEFR The patients normal value of PEFR:  Self -Monitoring in asthma
  31. 31. Percentage PEFR VariabilityHighest – Lowest / Highest x 100
  32. 32. Reversibility of PEFInhalation of 200-400 µg of Salbutamol
  33. 33. ReversibilityA 20% improvement in PEF from baseline
  34. 34. L/min PEFR PEFRReversibility PEFR Ventoline Reversibility
  35. 35. 250 – 150 / 250 = 40 % Yes
  36. 36. Self -Monitoring in asthma100 % All clear80 % Caution50 % Medical Alert

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