How to manage it

1. ASTHMA
DR MALEMBEKA-NG’ONGA

2. What is Asthma?
A condition that
• is chronic
• produces recurring episodes of
breathing problems
• is potentially life-threatening
• can occur at any age
• is not contagious
• cannot be cured, but can be
controlled
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3. Factors that Influence Asthma
Development and Expression
Host Factors
 Genetic
- Atopy
- Airway
hyperresponsiveness
 Gender
 Obesity
Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet

4. Source: Peter J. Barnes, MD

5. • Exercise
• Changes in
weather and
temperature
• Infections in the upper
airways, such as colds
• Physical expressions
of strong feelings
(crying or laughing
hard, yelling)
Common triggers of asthma
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6. Allergens such as
• Furred and feathered
animals
• Dust mites
• Cockroaches
• Pollen
from grass and
trees
• Mold (indoors
and outdoors)
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8. What Happens During an Episode of
Asthma?
•The lining of the airways
become narrow and
easily irritated due to
inflammation
•The airways produce a
thick mucus
•The muscles around the
airways tighten and
make airways narrower
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9. Three things can happen during an asthma episode:
1) Swelling of the airways
2) Clogging- the mucus blocks the airways and thus allows less air to
pass through the airways
3) Squeezing- the air passages are squeezed together by the muscles
that surround the outside of each airway.
•This combination of swelling, clogging, and squeezing dramatically
reduces the size of the airways

10. What are the symptoms of asthma?
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13. How is asthma diagnosed?
• Medical history
• Recurring cough, wheeze, difficulty breathing
• Night cough, chest tightness
• Family history of asthma
• Allergies, eczema
• Physical examination
• Tests
• X-ray
• Test for lung function
• Test for allergies
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Most of the times doctors rely on accurate description of
the symptoms and examination in making the diagnosis.

14. Is it Asthma?
 Recurrent episodes of wheezing
 Troublesome cough at night
 Cough or wheeze after exercise
 Cough, wheeze or chest tightness after
exposure to airborne allergens or
pollutants
 Colds “go to the chest” or take more
than 10 days to clear

15. Important clinical signs to record
. Pulse rate
. Respiratory rate
. Degree of breathlessness
. Use of accessory muscles of respiration
. Amount of wheezing
. Degree of agitation
. Conscious level

16. Acute asthma exacerbations
• Episodes characterized by progressive increase in symptoms
of asthma
• Signifies a change from the patients usual status that requires a
change in treatment
• May occur in known Asthmatics or occasionally as the first
presentation of asthma

17. Management of Asthma in the ED
• A brief focused history and physical examination concurrently
with prompt initiation of treatment
• Time of onset of symptoms
• Cause – if known
• Risk factors for asthma related deaths
• Meds taken, when and doses, devises, any recent dose changes

18. Assessment of Asthma in ER
1. Conscious Level
2. Respiratory Effort
3. Ability to speak
4. Pulse rate
5. Oxygen saturation

19. Severity
CLINICAL FEATURES MILD - MODERATE SEVERE LIFE THREATENING
Conscious level Alert Agitated Confused/ drowsy
Ability to speak in
one breath
Sentences/phrases Words Unable
Use of accessory
muscles of respiration
++ +++ Exhausted/
poor
respiratory
effort
Pulse rate Normal Tachycardia Bradycardia
Oxygen saturation >92% <92% <92%
PEFR >50% 33-50% <33%
ED ED ICU

20. Treatment
• In the first hour - ABC
• Airway – Open and position
• Breathing – Administer oxygen
• Oxygen via facemask or nasal prongs
• Aim for sats 93-95% (94-98% for children 6-11 years) – associated with
better outcomes

21. Treatment continued
• Salbutamol Nebulisation
• 2.5-5mg in normal saline (1:1)
• Repeat every 20-30 mins
• Systemic Steroids – should be given within one hour of presentation
• Speeds exacerbation resolution and prevents relapse
• Route of Delivery - Oral or IV equally effective
• Oral is preferred – less cost, least invasive, quick
• 1-2 mg/KG prednisolone upto 40mg/day, 3-5 days
• Dexamethasone 0.6mg/kg/day OD for 1-2 days
• Hydrocortisone 4mg/kg/4 hourly

22. Other treatments
2nd hour- If no improvement after 1st
hour:
• Ipratropium Bromide
• IV salbutamol
• IV magnesium sulphate
• IV aminophylline
• Adrenaline – history of allergy, angioedema, if inhaled therapy
not available
• Helium Oxygen – expensive, not routinely used in
exacerbations
• Antibiotics – needs strong indication

23. Discharge planning
Discharge when
. Stable on 3-4 hourly inhaled salbutamol
. SaO2 > 94%
Discharge plan
. Inhaler technique
. Need for controller therapy?
. Written action plan for acute exacerbation
. Follow up within 48 hrs
. Referral to paediatric asthma clinic?

24. • If patient improves after the nebulized salbutamol, can start using an
inhaler containing salbutamol 2 puffs when they have symptoms of an
attack
• Additional beclomethasone inhaler every day in the evening 2 puffs
which acts as a controller drug

27. Nebulizer