Acute Asthma in Adults

Krit Kuruchaiyapanich, MD 3/20/13

Definition
Asthma

is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role.

This inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. Associated with widespread but National Asthma Education and Prevention Program, EPR3: variable airflow obstruction that is 3/20/13
Guidelines for the

Definition
Status

asthmaticus

severe bronchospasm that does not respond to aggressive therapies within 30 to 60 minutes. respiratory arrest or evidence of respiratory failure (Paco2 > 50 mm Hg).

Near-fatal

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Definition

National Asthma Education and Prevention Program, EPR3: 3/20/13 Guidelines for the

Severe/Refractory asthma

American Thoracic Society workshop consensus for definition of severe/refractory asthma (requires one or both major and two minor criteria and that other conditions 3/20/13 have been excluded, exacerbating factors have been treated, and patient is generally compliant).

Pathophysiology
Hallmark

reduction in airway diameter caused by

smooth muscle contraction vascular congestion bronchial wall edema thick secretions

Bronchoconstriction

occurs due

to

1. allergic mediators and 3/20/13

Pathophysiology

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Pathophysiology

National Asthma Education and Prevention Program, EPR3: 3/20/13 Guidelines for the

Pathophysiology
Early

asthmatic response

Release of preformed histamine from mast cell granules bronchial smooth muscle and airway edema wheezing and airflow obstruction (resolves within an hour )

Late

asthmatic response

cytokines generated and released by mast cells and other local and recruited inflammatory cells 3/20/13 prolonged airflow obstruction and

Pathophysiology
Eosinophils Airway

are major effector cells in asthma epithelial cells : produced Nitric oxide (NO) potent vasodilator and may reflect the presence of inflammation in asthma remodeling : Inflammation, mucus hypersecretion , subepithelial 3/20/13fibrosis airway

Airway

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Aspirin-exacerbated respiratory disease (AERD) Triad

aspirin sensitivity, asthma, and nasal polyps

NSAIDs also precipitate AERD (but not reported after administration of COX2 inhibitors ) common

precipitant of lifethreatening asthma

Symptoms
3/20/13 occur within 3 hoursprofuse

Aspirin-exacerbated respiratory disease (AERD)

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Exercise-induced asthma (EIA)

Etiology Atopy

is unclear

is strongly associated with EIA, and up to 40% of patients with allergic rhinitis have EIA

Symptom

occur 3-8 min of exercise, peak 8-15 min after exercise, spontaneous recovery occurs within 60 min

Prophylaxis

: warm-up and a 3/20/13 short-acting inhaled beta2-

Menstruationassociated asthma
Perimenstrual

reductions in PEFR

of 35 to 80%
Estradiol

inhibits eosinophil degranulation and suppresses LT activity. have bronchodilator and anti-inflammatory activity. : LT antagonists, LABA , estradiol, progesterone, and 3/20/13 gonadotropin-releasing hormone

Progesterone Tx

CLINICAL FEATURES
Classification

1. Type 1 (Slow onset> 6 hr) 80-90%

Female>male Etiology:

URI less severity than type 2

Inflammation slower

response to therapy

2. Type 2 (Sudden onset< 6 hr) 1020%

Male>female

3/20/13 Etiology: allergen, a exercise, Picado C. Classification of respiratory severe asthma exacerbations: proposal. Eur

CLINICAL FEATURES
Symptom

: Triad

dyspnea, wheezing, and cough

Early

chest constriction and

cough
Exacerbation

progresses wheezing, prolonged expiration and accessory muscle used(indicates diaphragmatic fatigue)
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Tachypnea

and tachycardia >120

CLINICAL FEATURES

bronchiolar smooth muscle tone airway resistance, pulponary infiltration, V/Q missmatch hyperinflation autoPEEP pulsus paradoxus, diastolic LV dysfn hypercapnia+ intrathoracic pressure ICP

Dynamic

Acute

(1) National Asthma Education and Prevention Program, EPR3: 3/20/13 Signs of impending respiratory Guidelines for the

SEVERITY OF ASTHMA EXACERBATIONS

National Asthma Education and Prevention Program, EPR3: 3/20/13 Guidelines for the

Risk factors for death from asthma

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DIAGNOSTIC STRATEGIES
Pulmonary

Function Studies

FEV1 or PEFR the best of 3 consecutive values should be recorded

Indicati on

Arterial

Blood Gas (mild to moderate

hypoxemia with resp. alkalosis)

1. predicted PFTs of < 30%

2. clinical course is perplexing 3. capnography is not available. acute ventilatory failure

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DIAGNOSTIC STRATEGIES
CXR

suspected

pneumonia, pneumothorax, ateltctasis, pneumomediastinum, or CHF

ECG should not be routinely obtained,

except

patients >40 yr, a separate complaint (e.g., chest pain), Hx of significant CVD severe asthma: a RV strain pattern
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Assessment Summary
The

severity of airflow obstruction cannot be accurately judged by patients symptoms, PE , and laboratory tests. Serial measurements of airflow obstruction (FEV1 or PEFR) are key components of disease assessment and response to therapy .
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Peak Flow Meter

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Management

Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

3/20/13

Management

Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

3/20/13

Management

Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

3/20/13

Management

Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

3/20/13

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Medicatio n

The goal of treatment of acute asthma in the ED is to reverse airflow obstruction rapidly by repetitive or continuous administration of inhaled B 2agonists, ensure adequate oxygenation, and relieve inflammation
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Medication
1. Relievers - B2-adrenergic , Anticholinergics, Theophyline 2. Controller - Glucocorticoids, Leukotriene modifiers, Cromones, Anti-IgE

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2-Adrenergic Agonists
Relaxation

of bronchial smooth muscle, inhibit mediator release and promote mucociliary clearance. common side effect: skeletal muscle tremor.

Most

others: nervousness, anxiety, insomnia, headache,

hyperglycemia, palpitations,
3/20/13 tachycardia, and hypertension.

2-Adrenergic Agonists
SABA

(Solution=MDI)

First line drug

Nebulization = MDI + spacer (prefer nebulization) Salbutamol 2.5 5 * 3 time/hr MDI with spacer 4 8 puffs q 20 min up to 4 h, then q 14 h as needed.

3/20/13

2-Adrenergic Agonists
IV

form (not recommened in USA)

severe nonresponsive acute asthma. albuterol loading dose 4 g/kg for 25 min then infusion of 0.1 to 0.2 g/kg/min Epinephrine IV titrated to effect (average 1.5 g/min with a range of 0.513.3 g/min)

SC

form

may be used in pt who cannot 3/20/13

Corticosteroids
Action

in the airways

inhibition of recruitment of inflammatory cells and inhibition of release of proinflammatory mediators and cytokines from activated inflammatory and epithelial cells, activate cytoplasmic glucocorticoid receptors to regulate directly or indirectly the transcription of certain target genes resulting in the synthesis of new proteins.

Two forms

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Corticosteroids
1.

Systemic (IV and oral)

speeds the resolution of airflow obstruction, reduces the rate of relapse and may decrease admissions in severe, but not in mild to moderate attacks. Prednisone 40-60 mg oral loading Methylprednisolone 4080 mg/day in one dose or two divided doses Demethasone 5 mg
3/20/13

Corticosteroids
IV

= oral effects

Side

short-term (hours or days) reversible increases in glucose (important in diabetics) and decreases in potassium, fluid retention with wt gain, mood alterations including rare psychosis, hypertension, peptic ulcers, aseptic necrosis of the femur
3/20/13

Corticosteroids
2.

Inhaled

ICS

+ SABA NB: reducing airway reactivity and edema more effectively rates of hospitalization effect : Dysphonia, Reflex cough and bronchospasm, Oral candidiasis

reduce Side

Discharged
Prednisone ICS

40-60 mg oral for 7 day

high-dose budesonide (400 g, two puffs twice per day)

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Anticholinergic Agents

Atropa Belladonna Leave

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Anticholinergic Agents
Block

smooth muscle constrictor and secretory consequences of the PNS, blocking reflex bronchoconstriction and reversing acute airway obstruction. large, central airways, but adrenergic drugs dilate smaller airways. effect 3/20/13

affect

Side

Anticholinergic Agents
Inhaled-ipratropium

bromide

Nebulizer solution (0.25 mg/ml) 0.5 mg q 20 min for 1 hr (three doses), then as needed; MDI (18 g/puff) 8 puffs q 20 min as needed, for up to 3 hr not recommended as monotherapy in ED slow onset of action added to SABA for a greater and longer-lasting bronchodilator effect, 3/20/13 Emergency Treatment ofof Asthma, N ENGL J MED 363;8 nejm.org reduce rates hospitalization by

Magnesium Sulfate
relaxes I/C

bronchial smooth muscle and dilates asthmatic airways. (recommended IV > NB)
severe asthma attacks (FEV1 < 25% predicted) improves airflow obstruction and decreases the need for hospital admission MgSO4 2 -3 g IV over 20 min or at rates of up to 1 g/min to patients with severe refractory asthma
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Treatments That Are Not Recommended

1.

Methylxanthines

lack of demonstrated efficacy and increases in adverse events

2.

Antibiotics

should be reserved for pt with bacterial infection (e.g., pneumonia or sinusitis) seems likely.

3. 4.

Aggressive hydration Mucolytic agents

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Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

Leukotriene Modifiers
non-beta-mediated

bronchodilating effects
Zafirlukast

(20 mg twice a day)

Montelukast

(10 mg daily)

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Pregnancy
The

principles of managing acute asthma in pregnancy and during lactation are similar to those for the nonpregnant state. intervention during acute exacerbation is key to the prevention of impaired maternal and fetal oxygenation. <70 mm Hg severe hypoxemia 3/20/13

Early

PaO2

NPPV
BiPAP

well tolerated by children , decrease the need for intubation and mechanical ventilation. Consider for pt. who decline intubation and pt. who cooperate with mask therapy but more data are needed to recommend this approach

Patient

must be alert mental 3/20/13 Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org status and intact airway reflexes

Ketamine
potent no

bronchodilator effects

randomized trials have been conducted. recommended for therapy of acute asthma in the nonintubated patient 12 mg/kg IV effect

not

Ketamine Side

increased airway secretions and 3/20/13

Intubation and Ventilator Strategy Avoid nasotracheal route

Intubate

before the crisis of respiratory arrest largest ET-tube as soon as possible.

Selected

Pretreatment

Lidocaine 1.5 mg/kg IV Midazolam 1 mg IV q 2-3 min

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Induction

Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adult: a review. Chest

Intubation and Ventilator Strategy

Ventilator

strategy

adequate oxygenation and ventilation, minimizing high airway pressure, barotrauma, and systemic hypotension

Permissive

hypercapnia technique

TV 68 mL/kg, MV 6-8 LPM I:E > 1:3, RR 11-14 /min End-inspiratory pressure < 35 cmH2O pH maintained at 7.157.2
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Intubation and Ventilator Strategy

Complications

of mechanical

ventilation

Hypotension and barotrauma Pneumothorax !!!

sudden

clinical deterioration

hypotension significant

rise in peak inspiratory ventilator pressures and falling oxygen saturation.

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External

lateral chest

Cardiopulmonary arrest
May

result from unrecognized barotrauma.

Empirical bilateral tube thoracostomy should be performed if unexplained cardiac arrest occurs, especially in the context of dramatic increases in peak inspiratory pressure. IV epinephrine has both cardiostimulatory and bronchodilatory properties. 3/20/13

DISPOSITION
When

11

should be discharged

FEV or PEF after treatment is >= of the personal best or predicted value Improvements in lung function and symptoms > 60 min

Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

3/20/13

DISPOSITION

Emergency Treatment of Asthma, N ENGL J MED 363;8 nejm.org

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THANK

YOU

3/20/13