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مقاربة نوبة الربو الحادة
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ACUTE ASTHMA MANAGEMENT
ANAS SAHLE , MDDAMASCUSE
HOSPITAL
Risk factors for death from asthma
1. 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
Risk factors for death from asthma
1. Sudden severe attacks2. Recent systemic steroids.3. >2 SABA canisters in prior month.4. Hospital\ER in last month.5. ≥ 2 ER\hospitalization in last year.6. Prior intubation\ICU stay.7. Illicit drug use.8. Heart\psychiartic disorder.9. Low socioeconomic class.
curr Opin pulm med 2008
PEFR≥75% predicted
Β2 Agonist(neb),(MDI)PEFR≥75% and clinically stable
Observe 2H and discharge if stable
PEFR<75% and clinically stable
Treat as moderate exacerbation
Check 15-30 min
Mild exacerbation
PEFR=50-75% predicted
5 mg SALBUTAMOL(NEB) 30-60 mg PREDNISOLONE
PEFR=50-75% clinically stableRepeat 5 mg SALBUTAMOL(NEB)
PEFR<50% or clinically deteriorating
Treat as severe
PEFR>50% ,clinically stable
Deteriorating: treat as severe Observe for 2H discharge if stable +PEF increasing
PEFR<50% Or clinically deteriorating
Treat as severe
Check at 30 min
Check at 30 min
Moderate exacerbation
PEFR=33-50%predicted, cannot complete sentences , RR>25\min , HR>110\min
High flow O2,5mg salbutamol(neb),
30-60mg prednisolone\200mg hydrocortisone(IV)
If improving: admit continue 4-6 hourly (neb)
continue prednisolone 40-50mg daily
If not improving repeat 5mg salbutamol(neb) every 15-30 min till
improving 500mcg ipratropium(neb)
consider magnesium(1,2-2)g over 20 min(IV) check ABG
If improving: admit continue 2-4 hourly nebs daily
prednisolone or 6 hourly hydrocortisone
If not improving start aminophylline(IV) treat as life-
threatening discuss with ICU
CHECK at 15 min
CHECK at 15 min
IF ABG:normal\raised PCO2severe hypoxia<58 low PH
Severe exacerbation
PEFR<33% O2 SAT<92%
Silent chest Cyanosis
Bradycardia Hypotension
Exhaustion\confusion
High flow O2measure ABG
5mg salbutamol (neb) 500mcg ipratropium (neb) hydrocortisone100mg (IV)
magnesium 2g(IV)250mg aminophylline (IV)؟؟±
REFER TO ICU
Life-threatening exacerbation
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
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.
Discharge planningOn discharge , 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.
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Definition
The peak expiratory flow rate is an effort-dependent assessment of a patients ability to forcibly expel air from their lungs
Airways Obstruction
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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
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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
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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
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Peak expiratory flow rate measurement
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Peak expiratory flow rate measurement
Ask the patient to stand up & hold
the peak flow in a horizontal position
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Peak expiratory flow rate measurement
Take care not to place your fingers
over the scale
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Peak expiratory flow rate measurement
Ask the patient now to take a deep breath in & make a
tight seal with their lips around the mouth piece
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Peak expiratory flow rate measurement
Now ask the patient to blow out as hard & as fast as they can
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Peak expiratory flow rate measurement
Remember fast blast is better than slow blow
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Peak expiratory flow rate measurement
Note the number where
the sliding pointer has
stopped on the scale
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Peak expiratory flow rate measurement
Reset the pointer to 'zero'
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Peak Expiratory Flow
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Personal Best PEFR Value Baseline Predicated PEFR Value
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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
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Personal Best PEFR Value
The patient should then record PEFR measurements 2 to 4 times daily for two weeks
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Personal Best PEFR Value
The personal best is generally the highest PEFR measurement achieved during this post-treatment monitoring period
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Personal Best PEFR Value
The patient's normal PEFR range is defined as 80 and 100 percent of the patient's personal best.
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Baseline Predicated PEFR Value
Tall – 80 X 5 = Prv PEFRExample: 150 – 80 x 5 = 350
L/min
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Predicated PEFR value vs Personal Best value
of PEFR
The patient's normal value of PEFR:
Self -Monitoring in asthma
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Percentage PEFR Variability
Highest – Lowest /
Highest x 100
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Inhalation of 200-400 µg of Salbutamol
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01تمرين
عمره لديه 10مريض أن أشتبه سنوات،الصدر/ إصغاء عند منتشر وزيز ربو
PEFR : المتوقعL/min 300كان فحصه 150المقاس PEFRعندفحص له Reversibilityأجري
250المقاس PEFRكان Ventolineبعد هناك ؟Reversibilityهلربو؟ لديه هل
36
التمرين 01حل
250 – 150 / 250 = 40 %Yes
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Self -Monitoring in asthma
100 %
80 %
50 %
All clear
Caution
Medical Alert