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Acute asthma management
- 1. Dr Isha Deshmukh Asst Professor Pediatrics Department BJGMC, Pune
- 2. Asthma is associated with bothersome symptoms and worsening QOL Exacerbations – 67% Substantial functional and emotional limitations Acute asthma exacerbations poor asthma control Repeated measurement of lung function is needed T/t initiated after assessment of severity, identification of risk factors and review of therapy
- 3. Symptoms of breath shortness, cough, wheezing Progressive decrease in lung function Common , chronic respiratory distress EarlyT/t of exacerbations Number of ED visits important for treatment initiation.
- 4. Different pathogenesis of both acute and chronic asthma Increased neutrophil count seen in Broncho- alveolar lavage fluid Raised eosinophilia Intense airway inflammation IncreasedT cell markers in the peripheral blood and increased numbers of Activated CD25 to CD8 cells in the tissue.
- 5. Increased oxygen free radical production Oxidation of lipids and proteins Lipid per-oxidation cascade Interleukin 13 and epidermal growth factor receptor activation mucus cell hyperplasia Increased levels of neutrophilic elastase, as well as eosinophil degranulation with high levels of eosinophil cationic protein
- 6. Previous H/o need of MechanicalVentilation Hospital admission / ED visit for asthma care in previous 1 year On Inhaled corticosteriods Recently discontinued gluco-corticoids Use of > 1 canister/ month on inhaled short- acting Beta 2 agonist Need of 3 or more classes of asthma medication Poor adherence to treatment History of psychiatric illness or drug abuse Lack of social support Use of NSAIDs Presence of Co-morbidities
- 7. Componen t Mild exacerbatio n Moderate exacerbatio n Severe exacerbati on Respiratory failure Respiratory status 1.Wheezing 2. Reactive breathing 3.Prolonged expiration 4.Orthopnoea 5. Cyanosis 6. Respiratory Rate Mild None –mild – Can lie down -- Slightly increased Apparent Apparent + Prefers sitting position No cyanosis Increased RR Marked Marked Apparent Bends forward Possibly + Increased Reduced or eliminated Marked Marked Present Undetermined
- 8. Component Mild exacerbatio n Moderate exacerbatio n Severe exacerbatio n Respiratory failure Normal respiratory rate <2 months <60/min 2 to 12 mths <50 / min 1 to 5 years - <40/min 6 to 8 years - <30/min Feeling of dyspnoea During rest During walking --- + when increased activity + Marked with walking Marked Difficulty in walking Marked Cannot walk Daily life Speech Feeding Sleep Pause after one sentence Normal Can sleep Pause after phrases Slight difficult Occ wake up Pause after one word Difficult Disturbed Impossible Impossible Disturbed
- 9. Component Mild Exacerbatio n Moderate Exacerbation Severe Exacerbatio n Respiratory failure Disturbed Consciousn ess Agitation Lowered Level of consciousnes s -- -- Slightly excited --- Excited Slightly lowered Confused +++ PEF Before b2 inhalation After b2 inhalation >60% >80% 30 -60% 50-80% <30% <50% Unmeasureble Unmeasureble SPO2 (Room air) >/=96% 92 to 95% </=91% <91% PACO2 <41 mmHg <41 mmHg <41 to 60 mmHg >60 mmHg
- 10. In child <5 years SCR, Cyanosis, Silent chest Signs of exacerbation severity and vital signs e.g. Level of consciousness,Temp, Pulse rate, RR, BP, Use of accessory muscles, Wheeze Complicating factors E.g anaphylaxis, pneumonia, pneumothorax Signs of alternative conditions CCF, Upper Airway Obstruction, Inhaled FB, Pulmonary Embolism
- 11. Measurement of Lung Function PEF or FEV in 1 second to be recorded without delay before treatment initiation PEF or FEV1 are useful valid measures of airway calibre. Measurements of airway calibre improves recognition of the degree of severity , the appropriateness or intensity of therapy and decisions about Mx in hospital or at home Lung function should be monitored until a clear response toT/t has occurred or a plateau is reached.
- 12. Oxygen saturation To be monitored by Pulse-oximetry When unable to perform PEF SPO2 < 92% -> predictor of hospitalization SPO2 < 90% -> signals need for Aggressive therapy
- 13. For pt with a PEF or FEV1 <50% predicted Respiratory failure if – PaO2 <60 mmHg, PaCO2 > 45 mmHg Respiratory acidosis on ABG Presence of fatigue Presence of lowered level of consciousness
- 14. Suspected Pneumomediastinum Suspected Pneumothorax LRTI ARDS Persistent collapse / consolidation Need of MechanicalVentilation Obstructive Airway disease/ FB
- 15. Foreign body or Obstruction Localized wheezing H/o aspiration of FB No improvement with broncho-dilators Vocal cord dysfunction Wheezing in neck region Stress induced Use of broncho-dilators increase anxiety Frequent Inspiratory wheezing
- 16. Cardiac Dysfunction CCF, Left ventricular dysfunction Auscultatory crackles & rales Pulmonary edema Anaphylaxis More stridor than wheezing H/O exposure to allergen
- 17. Emphysema / COPD Night time symptoms CCAM Early morning brassy Cough Carcinoid Syndrome Flushing, diarrhoea, or right sided heart failure Allergic Broncho-pulmonary Aspergillosis Fever , haemoptysis, expectoration of brown mucus plugs
- 18. Pulmonary Embolism Wheezing, Cyanosis Chest pain Associated DVT, DIC Sudden onset respiratory distress Pneumothorax Respiratory distress Decreased SPO2 Radiology with air pockets
- 22. Thank you for patient listening ...........!!!!!!!!!!!!