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Acute severe Asthma case
presentation
February 2016
SIGN 141 • British guideline on the
management of asthma 2014
By Rania elashkar
Queens Belfast university
History
Patient 30 years old female own pets ,diagnosed with asthma since she was 8 years old
medication history : an inhaled corticosteroid in combination with a LABA , theophylline, an anticholinergic agent and an inhaled short-acting β2 agonists. patients best peak flow at the clinic is 405 L/minute. admitted to hospital with an acute asthma exacerbation. had two other admissions for asthma in the last few months
Symptoms increasing wheeze, cough, yellow sputum and chest tightness. PF 150 L/minute,.
Examination on admission at hospital
HIGH respiratory rate of 30/min HIGH pulse rate of 145/ minute
(60 pulse) peak flow of 100 L/minute. LOW PO2 of 8.4kPa (12-14
kPa) HIGH PCO2 of 7.2kPa (4.5-6.0
kPa) decreased pH 7.29 Normal
(7.35-7.45)
Features of acute severe asthma
• Peak expiratory flow (PEF) 33-50% of best (use % predicted if recent best unknown)
• Can’t complete sentences in one breath
• Respirations ≥25 breaths/min
• Pulse ≥110 beats/min
• Blood gas markers of a life threatening attack:
• ‘Normal’ (4.6-6 kPa, 35-45 mmHg) PaCO2
• Severe hypoxia: PaO2 <8 kPa
• Low PH
IMMEDIATE TREATMENT
• ƒOxygen to maintain SpO2 94-98%
• ƒSalbutamol 5 mg or terbutaline 10 mg via an oxygen-driven nebuliser
• Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser
• Prednisolone tablets 40-50 mg or IV hydrocortisone 100 mg
IMMEDIATE TREATMENT
IF LIFE THREATENING FEATURES ARE PRESENT:
• Discuss with senior clinician and ICU team
•Consider IV magnesium sulphate 1.2-2 g infusion over 20 minutes (unless already given)
• Give nebulised β2 agonist more frequently e.g. salbutamol 5 mg up to every 15-30 minutes or 10 mg per hour via continuous nebulisation (requires special nebuliser)
SUBSEQUENT MANAGEMENTIF PATIENT IS IMPROVING continue:•Oxygen to maintain SpO2 94-98% •Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6 hourly •Nebulised β2 agonist and ipratropium 4-6 hourly
IF PATIENT NOT IMPROVING AFTER 15-30 MINUTES:
•Continue oxygen and steroids•use continuous nebulisation of salbutamol at 5-10 mg/hour if an appropriate nebuliser is available. Otherwise give nebulised salbutamol 5 mg every 15-30 minutes •Continue ipratropium 0.5 mg 4-6 hourly until patient is improving
SUBSEQUENT MANAGEMENT
IF PATIENT IS STILL NOT IMPROVING:
•Discuss patient with senior clinician and ICU team �
•Consider IV magnesium sulphate 1.2-2 g over 20 minutes (unless already give
• Senior clinician may consider use of IV β2 agonist or IV aminophylline or progression to mechanical ventilation
MONITORING• Repeat measurement of PEF 15-30 minutes after starting
treatment • Oximetry: maintain SpO2 >94-98% • repeat blood gas measurements within 1 hour of starting
treatment if: - initial PaO2 92% - PaCO2 normal or raised - patient deteriorates
• Chart PEF before and after giving β2 agonists and at least 4 times daily throughout hospital stay
Transfer to ICU accompanied by a doctor prepared to intubate if:
Deteriorating PEF, worsening or persisting hypoxia, or hypercapnea �Exhaustion, altered consciousness Poor respiratory effort or respiratory arrest
DISCHARGE• discharge medication for 12-24 hours and
inhaler technique checked and recorded
• PEF >75% of best or predicted and PEF diurnal variability
• Treatment with oral & inhaled steroids &bronchodilators.
• Own PEF meter & written asthma action plan
• Follow up within 2 days & 4 weeks RC
Features that increase the probability of asthma
symptoms: wheeze, breathlessness, chest tightness and cough,
symptoms worse at night / in the early morning , exercise, allergen exposure and cold air , taking aspirin or beta blockers
History of atopic disorder , Family history of asthma and/or atopic disorder
low FEV1 or PEF
Factors that Exacerbate Asthma
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
© Global Initiative for Asthma
Patients at risk of developing near-fatal or fatal asthma
• previous near-fatal asthma
• previous admission for asthma
• requiring three or more classes of asthma medication
• heavy use of β2 agonist
• adverse behavioural or psychosocial features
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
Asthma Diagnosis
History and patterns of symptoms Measurements of lung function - Spirometry - Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify risk
factors
Typical Spirometric (FEV1) Tracings
11Time (sec)22 33 44 55
FEV1
Volume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
Measuring Variability of Peak Expiratory Flow
Measuring Airway Responsiveness
VIDEO ON HOW TO USE peak flow and spirometry
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and PreventionProgram: Five Components
Asthma Management and Prevention Program
Goals of Long-term Management
Achieve and maintain control of symptoms Maintain normal activity levels, including
exercise Maintain pulmonary function as close to
normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
Asthma Management and Prevention Program
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
.
Asthma Management and Prevention Program
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma Management and Prevention Program
Part 1: Educate Patients to Develop a Partnership
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Example Of Contents Of An Action Plan To Maintain Asthma ControlYour Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.
HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.
Asthma Management and Prevention Program
Factors Involved in Non-Adherence
Medication Usage Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Distance to pharmacies
Non-Medication Factors
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma
development, especially in children and young infants
Asthma Management and Prevention Program
Asthma Management and Prevention Program
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
Levels of Asthma Control(Assess patient impairment)
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
Assess Patient Risk
Features that are associated with increased risk of adverse events in the future include:
Poor clinical control
Frequent exacerbations in past year
Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke, high dose medications
Assessment of Future Risk Risk of exacerbations, instability, rapid decline
in lung function, side effects
Features that are associated with increased risk of adverse events in the future include: Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthmaLow FEV1, exposure to cigarette smoke, high dose medications
Any exacerbation should prompt review of maintenance
treatment
preventer Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in combination
with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE
Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (µg) Medium Daily Dose (µg) High Daily Dose (µg)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200
600-1000 >200-400 >1000 >400
Budesonide-Neb Inhalation Suspension
250-500
500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750
>1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200
>250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200
> 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800
>1000-2000 >800-1200 >2000 >1200
Reliever Medications
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists
Shaded green - preferred control ler options
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest controlling step
consider stepping up to gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1STEP
2STEP
3STEP
4STEP
5
RE
DU
CE
INC
RE
AS
E
© Global Initiative for Asthma
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular preventer treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single preventer
A low-dose inhaled glucocorticosteroid is recommended as the initial preventer treatment for patients of all ages (Evidence A)
Alternative preventor medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two preventer
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline (Evidence B)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more preventer
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)
Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control
© Global Initiative for Asthma
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
Treating to Maintain Asthma Control
When control as been achieved, ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored by the health care professional and by the patient
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)
When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)
If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.
Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)
Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)
Severe exacerbations are potentially life-threatening and treatment requires close supervision
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for
the particular patient Availability of medications Emergency facilities
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled β2-agonist
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serialmeasures of lung function