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exacerbation of
asthma in adult
.
August 2015
Asthma
early morning.
These episodes are usually associated with
widespread, but variable, airflow
GINA 2015
Asthma is a heterogeneous disease, usually
characterized by chronic airway
inflammation. It is defined by the history of
respiratory symptoms such as wheeze,
shortness of breath, chest tightness
and cough that vary over time and in
intensity, together with variable
expiratory airflow limitation.
Asthma is usually associated with airway
hyperresponsiveness to direct or indirect stimuli, and
with chronic airway inflammation
Asthma Pathophysiology
On-and-Off
Symptoms
Variable airflow limitation
Bronchial hyperresponsive
Inflammation
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
PEF (L/min)
Exacerbation
AM
PM
AM
PM
AM
PM
AM
PM
GINA 2015
Add tiotropium
Acute asthmatic
attack
Spasm
Swelling
Secretion
http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/
Pathophysiology of
asthmatic
acute asthmaEarly
attack :
Airway obstruction
Hypoxemia (V/Q
Uneven
distribution of
mismatch)
Hyperinflation
Increased wasted
Ventilation
ventilation
Increased work of breathing
V/Q mismatch
Late :
Hypercarbia /
Ventilatory
failure
Mx of asthma
exacerbation
Differential diagnosis
Is it asthma?
Asthma mimicker
COPD exacerbation
Congestive heart failure
Anaphylaxis
Foreign body obstruction
Not all wheezing is asthma!
Vocal cord dysfunction
Is it Asthma?
History
Age : Onset at young age (Some
exception Late onset asthma)
History of allergy : Allergic rhinitis,
Sinusitis, Allergic dermatitis
Hx of aggravating factors : Cold air, Dust
mites, Smokes / air pollution
Family history of asthma
Physical examination
Is it Asthma?
History
Physical examination
Signs of allergic rhinitis :
Allergic shiner, Nasal crease
No obvious sign of chronic airtrapping (EXCEPT in uncontrolled
long standing asthma)
Lab
Is it Asthma?
History
Physical examination
Lab
PEF variation
Spirometry : bronchodilator
response
Bronchial hyperresponsive test
BUT !!!
Evaluation of severity
History (Indicate more
severe disease)
Hx previous intubation
Hx admission from asthma
within 1 year
Use of B2 agonist > 1
canister / mo
Current steroid use
Meta-analysis
Patients with history of
mechanical ventilation
use
increase risk of nearfatal asthma
OR 4.738 [2.49-9.03]
Physical
Signsexam
of impending
respiratory failure
Unable to supine
Incomplete
sentences
Accessory muscle
use
Abdominal
paradox
More severe /
respiratory
failure
Unconscious
Air-hunger
RR < 12 /
min
BP drop
Immediat
e
Intubatio
n!
Signs of severe
exacerbation
GINA 2015
Reported
dyspnea
score
40% of patients
PEF
60% of patients
Perception of dyspnea
is generally poor
Kendrick AH. BMJ. 1993 Aug 14;307(6901):422-4.
Pts with
poor
perception
visit ER
more
frequent!
Predicted PEF
ATS scale
EU scale
UpToDate
accessed 11 Jul
2015
Chest radiography
Routine chest
radiography is not
required
Performed if Findley
failure
to 1981; 80:535LJ. Chest
response
Unrecognized
pneumothoraxGershel JC. N Engl J Med 1983; 309: 336pneumomediastinum
Severe airflow
obstruction required
Goal of treatment
1 Correction of arterial hypoxemia
2 Reversal of airflow obstruction
with minimal side effect
Supportive Rx
Oxygen supplement
Bronchodilator
Ventilatory support
Other adjunctive Rx
Oxygen supplement
Keep Sat O2
just 90% (up
to 95%)
Low-flow O2
and titrate
against pulse
oximeter
Bronchodilator
(parenteral or
inhaled?)
MDI spacer small volume
nebulizer
continuous intermittent
nebulization
Terbutaline SC, IM or IV
Salbutamol NB
Nebulized
bronchodilator
Theophylline /
Aminophylline
(parenteral or
inhaled? )
MDI spacer small volume
nebulizer
continuous intermittent
nebulization
Beta-2 agonist
5 mg / mL
Salbutamol (Ventolin)
Usual dose of
Beta2 agonist
Anticholinergic
Increased vagal tone in
asthmatic airway
Role of anticholinergic is less well
defined (than B2A)
Beta-2 agonist
anticholinergic
combination
Adding IB to SABA
in mod-severe asthma
Decrease
hospitalization
Improvement of FEV1
Compare to SABA
alone
(parenteral or
inhaled? )
MDI spacer small volume
nebulizer
continuous intermittent
nebulization
Volumetric
spacer
MDI bronchodilator
Equally effective delivery of aerosolized
medication or MDI
(with spacer)
MDI therapy is at least effective as nebulized form
Turner M. Arch Intern Med 1997:
158:1736-44.
MDI bronchodilator
(parenteral or
inhaled? )
MDI spacer small volume
nebulizer
continuous intermittent
nebulization
Continuous
nebulization
Frequent refill of normal nebulizer
Nebulizer with infusion pump
Large-volume nebulizer with high-output
extended aerosol respiratory therapy
Ventilatory support
Ventilatory failure (Late consequence)
from respiratory muscle fatigue
ETT is recommended
Non-invasive ventilator (CPAP, BiPAP) is
risky due to the flip-flop nature of asthma
(Pt can get worse all of a sudden)
NIV may be considered case-by-case by
an expert under close monitoring!
BiPAP improves
outcome
BiPAP use in
asthma:
Improve lung function
Reduce the need for
hospitalization
CHEST 2003; 123:10181025
IV trial
N
r
o
f
ded
e
e
n
s
i
toring
i
n
o
m
lose
c
/
e
v
i
Intens
Adjunctive therapy
Inhaled corticosteroid
Magnesium
Adrenaline
2 g IV drip in 20 min
GINA
2015
Specific Rx
Systemic corticosteroid *****
Reduce admission and relapse
rate
IV or Oral corticosteroids
IV dexamethasone
4-10 mg IV q 6h
Oral prednisolone
50 mg/day
Systemic corticosteroid
Early corticosteroid administration
Within 1 hour of presentation to the ER
prevent hospitalization
Systemic corticosteroid
administration prevent
relapse, NNT = 10
Effects up to 3 weeks
Corticosteroid
Systemic corticosteroid should be considered in
management of almost all asthma exacerbation
ESPECIALLY
Initial SABA fails to achieve lasting improvement
Patient taking oral corticosteroid (OCS)
A history of previous exacerbations requiring
OCS
Oral and IV corticosteroid are equivalent
GINA 2015
Systemic
corticosteroid
Duration of systemic corticosteroid
Thai asthma CPG 2012
Systemic
corticosteroid
Inhaled corticosteroid
Effect
Systemic anti-inflammation
Topical
Time delay
Late improvement in
outcome (>6 h)
Early improvement in
outcome
Mechanism
Corticosteroid induce
transcriptional effect :
synthesis new protein
Corticosteroid up-regulate
receptor
Mucosal vasoconstriction
Decongestion
Administration
Oxygen
2-agonist
Corticosteroid
Summary of dosages
Agents
Administration
Anticholinergic
Magnesium sulfate
Adrenaline
Intravenous 2 agonist
Aminophylline
Summary of dosages
Admit
What to be
considered
GINA 2015
When to discharge
GINA 2015
Ramathibodi CPG
Conditions to be considered
Unconscious
Air hunger
RR< 12/min
Unstable
hemodynamic
Hx of
intubation
Hx of steroid
(ICS, oral)
Admission in 1
y
Salbutamol >1
History
canister/month
PR > 130
RR > 30
Wheezing
+
PEF
Emergency Intubation
Incomplete
sentence
Accessory
muscle use
Abdominal
paradox
Unable to lie
Physical exam
down
Severity Steroid
Incomplete
Continue treatment
resolution
Acute asthma
A
Unconscious
Air hunger
RR< 12/min
Unstable
hemodynamic
B
Hx of intubation
Hx of steroid
(ICS, oral)
Admission in 1 y
Salbutamol >1
canister/month
Assessment 1
Intubation
Initial PEFR
Assessment 2
PR > 130
RR > 30
Wheezing
PEF
Incomplete
sentence
Accessory
muscle use
Abdominal
paradox
Unable to lie
down
PR > 130
RR > 30
Wheezing
Assessment 3
A+C+D+PEF
PEF
Incomplete
sentence
Accessory
muscle use
Abdominal
paradox
Unable to lie
down
Assessment 4
PEF>70%
PEF>70%
+any C
PEF 50-70%
+any of C
A+C+D+PEF
PEF 50-70
+any A,D
PEF <50%
Unconscious
Air hunger
RR< 12/min
Unstable
hemodynamic
PR > 130
RR > 30
Wheezin
g
Assessment 4
PEF>70%
PEF>70%
+any C
PEF 50-70%
+any of C
Incomplete sentence
Accessory muscle
use
Abdominal paradox
Unable to lie down
PEF
A+C+D+PEF
PEF 50-70
+any A,D
PEF <50%
Discharge
PEF 50-70%
+any of C
Admit ward
Initial PEF
After D/C
Follow-up at OPD
Within 5-7 days after D/C
Asthma
reading
Further
Thai asthma
guidelines (2555)
Thank you
for your attention