Asthma

Dr Vincent Chan

Overview

Definition

Abnormally increased responsiveness of the bronchi to a variety of stimuli that is reversible May co-exist with chronic bronchitis, emphysema, bronchiectasis

Epidemiology

Effects 5% of adults 25% of children Increasing in prevalence for all age groups Most cases develop before age 40 years Asthma incidence in children

25% in Australia 17% in UK 7% in Europe 2% in China 0.6% in PNG

Acute Exacerbating Factors

Viral respiratory infection

By far the most common

Allergic Reaction Change in temperature and humidity (cold, dry air) Strong odours (perfume) Drugs (aspirin, beta blockers, NSAIDS) Chemical (tartrazine dye) Pollutants, dust, fumes Sinus infections Exercise Emotional Stress

Pathophysiology

Bronchial smooth muscle contraction Mucous hypersecretion Inflammation and bronchial wall oedema

Assessment

Symptoms may correlate poorly with objective measurements of severity

Assessment

History

Past history

Intubation Hypercapnoea Pneumomediastinum/pneumothorax Hospitalisation despite chronic steroid use Medical non-compliance Underlying psychiatric illness

Assessment

History

Current attack

Long duration of symptoms Late presentation Extreme fatigue Altered mental state Sleep deprivation Deterioration despite optimal therapy (including oral steroids) Accelerated use of inhaled beta agonists

Assessment

Examination

Colour Pulse Speech

None, words, phrases, sentences May be absent in severe asthma

Presence of generalised wheeze

Prolonged expiratory phase Oxygen saturation PEFR

Assessment

Severe

Colour Posture (upright) Pulse >120 Respiratory rate >30 min Pulsus Paradoxus )12 mmHg Speech words PEFR <40 of predicted or patients best PO2 hypoxaemia PCO2 hypercapnoea (occurs when FEV1 <25% predicted) Metabolic acidosis

Feature
Altered Consciousness Physical Exhaustion Talks in

Mild
No No Sentences

Moderate
No No Phrases

Severe
Drowsy Yes/Paradoxical chest wall movement Words

Extreme
Coma Respiratory rate may be low/agonal Unable to speak

Pulse Rate
Pulsus Paradoxus Central Cyanosis Wheeze intensity Peak expiratory flow (% predicated) FEV1 (% predicated) Oximetry on presentation Arterial Blood gases

<100
Absent Absent Variable >60% >60% >94% Not Needed

100-120
Possible Possible Moderate-loud 40-60% 40-60% 94-90% Only if poor initial response

>120
Palpable Likely Often Quiet <40% <40% <90% Yes

Usually >140 may become bradycardic

Palpable Very common Usually Quiet Unable to perform Unable to perform <80% Yes

Complications of Acute Asthma

Pneumothorax Pneumomediastinum Subcutaneous emphysema Pneumopericardium Mucous Plugging Segmental Atelectasis Nosocomial Pneumonia Respiratory Failure Dug toxicity

Complications of Acute Asthma

Electrolyte disturbance

Hypokalaemia Hypophosphataemia Hypomagnesaemia Rarely of clinical significance

Myocardial infarction Hyperglycaemia Lactic Acidosis Anoxic Brain injury Death

Risk Factors for Death in Asthma

Labile asthma History in the past one year of any of:

>3 ED visits >2 hospitalisation ICU admission Endotracheal intubation Recent withdrawal from corticosteroids Current use of systemic corticosteroids Co-morbid conditions e.g. cardiac disease, HIV Psychiatric Disease

Differential Diagnosis of Asthma

Anaphylaxis Bronchiolitis (children) Foreign body ingestion

Paediatric Neurologically impaired adult

Upper airways obstruction Endobronchial Disease

Foreign body Neoplasm Stenosis Always consider this in older patients without a previous history of bronchospasm

Acute LVF

Carcinoid tumours Recurrent PE Chronic Bronchitis Eosinophilic Pneumonias Systemic vasculitis involving lungs

Chronic Poor Control Vs. Acute Exacerbation

Regular high volume use of bronchodilators is a sign of poor asthma control Diurnal PEF variability
= maximum daily PEF minimum daily PEF/mean PEF 20% during periods of poor asthma control 5% during stable asthma control In acute exacerbations

Linear decline in PEF over several days Diurnal variability does not differ significantly from stable control

Investigations

In the majority of cases PEFR/Spirometry and SpO2 are the only investigations required

Investigations

CXR

Over utilised in most hospitals Clinically significant findings rare

First presentation of asthma Temperature >37.8 Focal chest findings Pleuritic chest pain (to exclude pneumothorax / Pneumomediastinum) On long term maintenance steroids Failure to respond to aggressive therapy To search for alternative diagnosis e.g. CCF

Indications

Investigations

Common Findings

Normal appearance Hyperinflation Mediastinal emphysema Pneumothorax Areas of atelectasis Broncocoeles

Finger shaped hilar shadows consisting of mucous filled bronchi

Investigations

ABGS

Over utilised in most hospitals Only indicated in severe asthma Clinical findings usually provide adequate information Criteria for intubation and mechanical ventilation in asthma are clinical rather than based on ABG findings Of use in severe asthma to monitor respiratory fatigue and response to treatment when clinical evaluation difficult Findings

May be within normal limits Respiratory alkalosis Hypercapnoea Hypoxaemia

Investigations

UEC

Hypokalaemia may be present, but rarely of clinical significance Inhaled beta agonists reduce serum potassium by an average of 0.4 mmol Only indicated in severe/life threatening asthma

Investigations

FBE

Of no value in the acute management of asthma WCC often non-specifically elevated (stress, steroids, catecholamines)

Discharge from ED

Consideration for discharge should be based on: Clinical assessment of severity following treatment

Mild severity grading usually required Percent of previous best Percent of predicted or absolute value Poor social situation Poor compliance Smoking Availability of medications Technique of administration of medications

Spirometric test results

Assessment of clinical risk factors for relapse

Lower threshold for admission should be used for patients with high risk profile

PEFR and Admission

Pre-treatment PEFR <25% previous best or predicated usually require admission Post-treatment PEFR <40% previous best or predicated usually require admission Post-treatment PEFR 40-60% previous best or predicated are possible candidates for discharge Post-treatment PEFR >60% previous best or predicated are likely candidates for discharge

Discharge Instructions in Asthma

A discharge plan and clear instructions for follow up should be given to all patients Self-management education of asthma in adults is associated with reduced

hospital admission, ED and unscheduled LMO visits Days of work or school Nocturnal Asthma Consider specialist referral (respiratory physician)

Asthma Management

Monitoring

Oxygen saturations Spirometry = PEFT Cardiac Monitor, BP as indicated

Asthma Management

Therapeutic Options

Oxygen Beta Agonists Anticholinergics Methylxanthines Ketamine Isoflurane/Sevoflurane Heliox

Asthma Management

Preventers

Steroids Sodium Chromoglycate Leukotriene receptor antagonists

Oxygen

Improves oxygen delivery to tissues including respiratory muscles Reverses hypoxic pulmonary vasoconstriction Reverses airway bronchoconstriction Protects against fall in PO2 after beta agonist administration Administer only as much oxygen as is required to achieve desired arterial oxygen tension Aim is to maintain oxygen saturation >92%

Short Acting Beta 2 Agonists

First line therapy in management of acute attacks in the ED Reserve for intermittent symptoms relive rather than regular treatment of asthma Usually administered by the inhaled route rather than parenterally Objective and clinical measures of airflow limitation should be used to guide dose and frequency Severity of airflow limitation should be determined by FEV1 or PEFR Long acting drugs not recommended for emergency treatment Chronic use may increase the severity of asthma in allergic patients with reversible obstruction Use during acute attacks has not been associated with worsening of asthma

Anticholinergics

Should be added to beta agonist therapy in severe asthma

Repeated dose may confer additional benefit (especially in children) Multiple doses indicated in severe asthma Most consistent efficacy in children and smokers May also be helpful in mild to moderate asthma

Corticosteroids

All patient treated in the ED for an acute episode of asthma should be considered candidates for oral or IV steroid Benefits

May reduce admission rates and the number of relapses in the first 7-10 days Failure to treat with steroids may contribute to asthma deaths

Corticosteroids

Oral vs. IV administration

Oral and IV routes have equivalent effects on pulmonary function No evidence suggests one route improves function more than the other

Methylxanthines

Indications

Insufficient evidence to support the routine use of aminophylline in acute asthma when adequate beta agonist therapy has been provided In acute asthma IV aminophylline does not result in any additional bronchodilation compared to standard care with betaagonists Possible roles Hospitalised patients not responding to maximal initial therapy Young asthmatics not responding to standard therapy Patients with pre-existing respiratory muscle failure e.g. COPD

Anaesthetic Agents

Ketamine Dissociative anaesthetic agent PCP derivative Bronchodilator effects

Directly relaxes smooth muscle Causes catecholamines to accumulate at the beta receptors Decreases peak inspiratory pressure in status Reduces PCO2 Improves pH

In Status Asthmaticus

Sevoflurane/Isoflurane At 1-2% inspired concentration Moderate effects on bronchial muscle relaxation and cause bronchodilation

Heliox

Lack of evidence to support first line use in asthma Evidence to support its use in parallel with conventional forms of treatment in asthma Impact on asthma modest at best Consider in patient s with severe refractory asthma who have failed standard treatment and still have respiratory muscle reserve Consider with initiating intubation and mechanical ventilation of patient not responding to standard treatment

Antibiotics

No role for routine use Indicated if clinical suspicion of pneumonia or acute sinusitis Consider if mycoplasma or Chlamydia infection is suspected Discolouration of sputum is most commonly caused by eosinophils produced by the asthma attack, rather than bacterial process The most common infective precipitant URTIs are viral