Pharmaco2 asthma


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Pharmaco2 asthma

  1. 1. MANAGEMENT <ul><li>A&E </li></ul>
  2. 2. 9:30 am <ul><li>BP 140/83, HR 87bpm, spO 2 95%, T 36.4⁰C </li></ul><ul><li>Generalised rhonchi </li></ul><ul><li>Plan </li></ul><ul><ul><li>IV HCT 200mg stat given @ 9:35am. </li></ul></ul><ul><ul><li>Neb. Combivent </li></ul></ul><ul><ul><li>PEFR </li></ul></ul>
  3. 3. 10:10am <ul><li>Speak in full sentence </li></ul><ul><li>PEFR 300L/min, RR 30/min, O 2 sat 98% </li></ul><ul><li>Generalized rhonchi </li></ul><ul><li>Plan </li></ul><ul><ul><li>ABG </li></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>Cont neb </li></ul></ul>
  4. 4. 10:26am <ul><li>VBG? </li></ul><ul><ul><li>pH: 7.377 </li></ul></ul><ul><ul><li>pCO 2 : 42.0mmHg </li></ul></ul><ul><ul><li>pO 2: 30.6mmHg </li></ul></ul><ul><ul><li>Base: -0.4 </li></ul></ul><ul><ul><li>HCO 3 : 22.9mmol/L </li></ul></ul><ul><li>WBC: 8.8x10 9 /L </li></ul><ul><li>Lymph#: 3.2x10 9 /L </li></ul><ul><li>Gran#: 4.8x10 9 /L </li></ul><ul><li>Lymph%: 35.8% </li></ul><ul><li>Gran%: 54.1% </li></ul><ul><li>Hb: 16.5 g/dL </li></ul><ul><li>RBC: 5.13x10 12 /L </li></ul><ul><li>HCT: 47% </li></ul><ul><li>MCV: 91.8fL </li></ul><ul><li>MCH: 32.1pg </li></ul><ul><li>MCHC: 35.1 g/dL </li></ul><ul><li>Plt: 252x10 9 /L </li></ul>
  5. 7. 11:30am <ul><li>BP 140/83; HR 87bpm; T 37⁰C; spO 2 95%↓RA, 98% ↓ NPO 2 3L/min </li></ul><ul><li>O/E generalized rhochi </li></ul><ul><li>Plan </li></ul><ul><ul><li>Admit 7S </li></ul></ul><ul><ul><li>Cont a/b (h/o admission for similar problem 10 days ago) </li></ul></ul><ul><ul><ul><li>T azithromycin 500mg od </li></ul></ul></ul><ul><ul><ul><li>IV claforan 1g tds </li></ul></ul></ul><ul><ul><li>NPO 2 3L/min </li></ul></ul><ul><ul><li>Neb combivent 4hourly </li></ul></ul><ul><ul><li>IV HCT 100mg qid </li></ul></ul><ul><ul><li>ABG ↓ RA </li></ul></ul>
  6. 8. 11:30am <ul><li>ABG </li></ul><ul><ul><li>pH 7.498 </li></ul></ul><ul><ul><li>pCO2: 29.4mmHg </li></ul></ul><ul><ul><li>pO2: 147mmHg </li></ul></ul><ul><ul><li>HCO3: 25.2mmol/L </li></ul></ul><ul><ul><li>Base: -0.3mmol/L </li></ul></ul><ul><li>CXR </li></ul><ul><ul><li>Hyperinflated lungs </li></ul></ul><ul><ul><li>Bilateral lung hazziness </li></ul></ul><ul><li>Coagulation profile </li></ul><ul><ul><li>PT: 13.2s (11.9 – 13.9) </li></ul></ul><ul><ul><li>INR: 1.01 (0.86 – 1.14) </li></ul></ul><ul><ul><li>aPTT: 40.5s (control 37.9) </li></ul></ul><ul><li>BUSE/creat </li></ul><ul><ul><li>Na: 139mmo/L </li></ul></ul><ul><ul><li>K: 4.1mmol/L </li></ul></ul><ul><ul><li>Creat: 106umol/L </li></ul></ul><ul><ul><li>Urea: 2.7mmol/L </li></ul></ul><ul><ul><li>Cl: 108mmol/L </li></ul></ul>
  7. 9. MANAGEMENT <ul><li>Medical ward </li></ul>
  8. 10. 3:20pm <ul><li>Assessment: infective exarcebation COPD </li></ul><ul><ul><li>Partially treated pneumonia </li></ul></ul><ul><ul><li>Haemodynamically stable </li></ul></ul><ul><ul><li>Not in respiratory failure </li></ul></ul><ul><li>Investigations: FBC, BUSE/creat, LFT, aPTT/INR, ESR, ECG, sputum C+S, sputum AFB (D/S x3, C+S) </li></ul>
  9. 11. Plan <ul><li>Strict I/O, encourage orally </li></ul><ul><li>IVD 2 Ѳ NS/24hrs </li></ul><ul><li>Antibiotic </li></ul><ul><ul><li>IV claforan 2g stat & 1g tds </li></ul></ul><ul><ul><li>T azithromycin 500mg stat & OD </li></ul></ul><ul><li>Acute reliever </li></ul><ul><ul><li>Neb combivent hourly x2 then 2hourly x2 then 6hourly </li></ul></ul><ul><ul><li>Monitor BUSE/creat on neb combivent </li></ul></ul><ul><ul><li>PEFR </li></ul></ul><ul><li>Controller </li></ul><ul><ul><li>IV HCT 200mg stat & 100mg qid </li></ul></ul><ul><li>Chest physiotherapy </li></ul><ul><li>Stop smoking education </li></ul>
  10. 12. 11:40pm <ul><li>Plan </li></ul><ul><ul><li>Refer quit smoking clinic </li></ul></ul><ul><ul><li>Increase neb combivent 4hourly </li></ul></ul><ul><ul><li>Continue a/b </li></ul></ul><ul><ul><li>Continue IV hydrocort </li></ul></ul><ul><ul><li>Inhaler technique </li></ul></ul><ul><ul><li>MDI becotide 2puffs bd </li></ul></ul><ul><ul><li>MDI combivent 2puffs tds </li></ul></ul>
  11. 13. PEFR chart L/min Time Day 1 Day 2 day3 day4
  13. 15. <ul><li>Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors. </li></ul>
  14. 16. <ul><li>Symptoms & medical history </li></ul><ul><li>Lung function </li></ul><ul><ul><li>Spirometry </li></ul></ul><ul><ul><li>PEF </li></ul></ul><ul><li>Additional diagnostic tests </li></ul><ul><ul><li>Airway responsiveness </li></ul></ul><ul><ul><li>Skin tests with allergens or measurement of specific IgE in serum </li></ul></ul>
  15. 17. MANAGEMENT <ul><li>Exacerbations </li></ul>
  16. 22. Prompt tx <ul><li>Inhaled rapid-acting β 2 -agonists in adequate doses are essential. </li></ul><ul><ul><li>begin with 2 to 4 puffs every 20 minutes for 1 st hour; </li></ul></ul><ul><ul><li>then mild exacerbations will require 2 to 4 puffs every 3 to 4 hours, and </li></ul></ul><ul><ul><li>moderate exacerbations 6 to 10 puffs every 1 to 2 hours. </li></ul></ul><ul><li>Oral glucocorticoids (0.5 to 1 mg of prednisolone/kg or equivalent during a 24 hr period) introduced early in the course of a moderate or severe attack. </li></ul><ul><li>O 2 is given if patient is hypoxemic (achieve O 2 saturation of 95%). </li></ul>
  17. 23. Prompt tx <ul><li>Combination β 2 -agonist/anticholinergic therapy is associated with lower hospitalization rates. </li></ul><ul><li>Methylxanthines are not recommended if used in addition to high doses on inhaled β 2 -agonists. </li></ul>
  18. 24. <ul><li>Monitor response to tx </li></ul><ul><ul><li>Evaluate symptoms, peak flow, O 2 saturation </li></ul></ul><ul><li>After exacerbations is resolved </li></ul><ul><ul><li>Identify precipitating factors </li></ul></ul><ul><ul><li>Implement avoidance strategies </li></ul></ul><ul><ul><li>Review pt’s medication </li></ul></ul>
  19. 25. MANAGEMENT <ul><li>Ward </li></ul>
  20. 26. <ul><li>Continue oxygen > 40% </li></ul><ul><li>IV HCT 100-200 mg 6 hourly or prednisolone 30-60 mg daily. </li></ul><ul><li>Neb β 2 -agonist 2-4 hourly preferably in combination with anticholinergic. </li></ul><ul><li>If patient is still not improving, commence aminophylline infusion (0.5-0.9 mg/kg/hour); monitor blood levels if aminophylline infusion is continued for more than 24 hours. </li></ul><ul><li>Terbutaline or salbutamol infusion at 3-20 mcg/min after an initial IV bolus dose of 250 mcg over 10 mins can be given as an alternative. </li></ul><ul><li>In cases where response to the above treatment is inadequate, IV MgSO 4 2 g in 50 ml NS infused over 10-20 mins may be given. </li></ul>
  21. 27. Monitoring the response to treatment <ul><li>Repeat measurement of PEF 15-30 minutes after starting treatment. </li></ul><ul><li>Aim to maintain arterial oxygen saturation above 92%. </li></ul><ul><li>Repeat arterial blood gas measurements if initial results are abnormal or if patient deteriorate. </li></ul><ul><li>Monitor PEF at least 4 times daily throughout the hospital stay. </li></ul><ul><li>Other I(x): </li></ul><ul><ul><li>BUSE </li></ul></ul><ul><ul><li>ECG if indicated </li></ul></ul>
  22. 28. Transfer pt to ICU or prepare to intubate if there is: <ul><li>Deteriorating PEF </li></ul><ul><li>Worsening hypoxaemia, or hypercapnia </li></ul><ul><li>Exhaustion or feeble respiration </li></ul><ul><li>Confusion or drowsiness </li></ul><ul><li>Coma or respiratory arrest </li></ul>
  23. 29. MANAGEMENT <ul><li>ICU </li></ul>
  24. 30. <ul><li>Cont O 2 </li></ul><ul><li>Cont IV HCT </li></ul><ul><li>If the patient is mechanically ventilated, administer neb β 2 - agonist with anticholinergic via the ETT. This can be given up to every 15-30 min. </li></ul><ul><li>IVI aminophylline or terbutaline or salbutamol should be continued </li></ul><ul><li>IVI MgSO 4 may be added. </li></ul>
  25. 31. DISCHARGE PLAN FOR HOSPITALISED PATIENT <ul><li>Before discharge, the patient should be: </li></ul><ul><ul><li>started on inhaled steroids for at least 48 hours in addition to a short course of oral prednisolone and bronchodilators </li></ul></ul><ul><ul><li>Stable on the medications he is going to take outside the hospital for at least 24 hours </li></ul></ul><ul><ul><li>Having PEF of > 75% of predicted or best value and PEF diurnal variability of < 20% </li></ul></ul><ul><ul><li>Able to use the inhaler correctly and if necessary, alternative inhaler devices could be prescribed </li></ul></ul><ul><ul><li>Educated on the discharge medication, home peak flow monitoring and self </li></ul></ul><ul><ul><li>Management plan (for selected, motivated patients), and the importance of regular follow up </li></ul></ul><ul><ul><li>Given an early follow-up appointment within 2-4 weeks for reassessment of the condition and for adjustment of the medicines </li></ul></ul>
  26. 32. MANAGEMENT <ul><li>Chronic asthma </li></ul>
  27. 33. Assessing asthma control
  28. 34. Mx approach based on control (>5 y/o)
  29. 35. Tx steps
  30. 36. Monitoring <ul><li>At each visit: </li></ul><ul><ul><li>Control </li></ul></ul><ul><ul><li>Technique </li></ul></ul><ul><ul><li>Compliance & avoiding risk factors </li></ul></ul><ul><ul><li>Concerns </li></ul></ul><ul><li>Adjusting medication: </li></ul><ul><ul><li>Not controlled -> step up, TCA 1/12 </li></ul></ul><ul><ul><li>Partly controlled -> consider step up </li></ul></ul><ul><ul><li>Control at least 3 months -> step down </li></ul></ul>
  31. 37. CONTROLLERS <ul><li>Medications </li></ul>
  32. 41. RELIEVER <ul><li>Medications </li></ul>
  33. 45. <ul><li>Per inhalation </li></ul><ul><li>Ipratropium Br monohydrate 21 mcg, salbutamol sulphate 120 mcg </li></ul>Per UDV Ipratropium Br 0.5 mg, salbutamol sulfate 2.5 mg
  34. 46. <ul><li>Seretide 50/100 Accuhaler Salmeterol 50 mcg, fluticasone propionate 100 mcg. </li></ul><ul><li>Seretide 50/250 Accuhaler . </li></ul><ul><li>Seretide 50/500 Accuhaler </li></ul><ul><li>Seretide 25/50 Evohaler </li></ul><ul><li>Seretide 25/125 Evohaler </li></ul><ul><li>Seretide 25/250 Evohaler </li></ul>
  35. 47. Per 160/4.5 mcg inhalation <ul><li>Budesonide 160 mcg, formoterol 4.5 mcg </li></ul>
  36. 48. Identify & reduce exposure to risk factors <ul><li>Tobacco smoke </li></ul><ul><li>Drugs, foods, and additives </li></ul><ul><li>Occupational sensitizers </li></ul><ul><li>House dust mites </li></ul><ul><li>Animals with fur </li></ul><ul><li>Cockroaches </li></ul><ul><li>Outdoor pollens and mold </li></ul><ul><li>Indoor mold </li></ul>