MANAGEMENT OF SEVERE EXACERBATION IN ASTHMA

DR.RABIA SALEEM SAFDARPOST GRADUATE TRAINEEPAEDIATRICS UNIT 1,NHM.

DEFINITION:

acute episode of• airflow obstruction• airway hyperresponsiveness

occurs on a background of chronic airway inflammation

DEFINITION:

Acute severe asthma, formerly known as status asthmaticus, is defined as: Severe asthma unresponsive to repeated courses of ß2 agonist therapy.

Medical emergency

Requires immediate recognition and treatment

TRIGGERS

Viral infection of the upper respiratory tract

Bacterial infection

Inhaled allergens. Environmental irritants

Emotions

Exercise

Medications

Poor asthma control

Risk factors for potentially fatal asthmaPrevious near-fatal asthmaPrevious admission to a PICU for asthmaAdmission for asthma in the last year

Excessive use of or overdependence on ß2 agonistsCurrent use or recent use of oral corticosteroids

Repeated attendances at emergency unit for asthma treatment, especially if in the last year

‘Brittle’ asthma (sudden onset of acute severe asthma attacks)

Poor adherence to medication

Psychosocial and/or family problems

Assessment

pulse rate

respiratory rate and degree of breathlessness (ability to complete sentences in one breath or to feed)

use of accessory muscles of respiration\amount of wheezing

degree of agitation and level of consciousness

PEFR

Initial and first-line management of acute asthma

Oxygen

Short-acting beta-2 (β2)-agonist bronchodilators

Steroid therapy

Ipratropium bromide

Additional therapy for acute asthma

Magnesium sulphate

Intravenous salbutamol infusion

Intravenous aminophylline

Child with asthma exacerbation

Clinical assessment,ABG’s,CXR,pulse

oximetry

Initial therapy in first hour of management

OxygenWhen spO2 <92 % via nasal cannula or face mask

B2-agonists:Nebuliser: salbutamol 0.5-0.6mg/kg+ saline. Repeat at 20 - 30-minute intervals

Steroid therapy:Hydrocortisone10 mg/kg IV statThen 5 mg/kg IV q 6 hrMP 2 mg/kg 8hour IV loading then0.5mgLkg IV every 6hrs Dexa 0.6 mg/kg IV

Iptatropium Bromide:Add 250 μg IB/dose to 2.5 - 5.0 mg of salbutamol with saline to make a total volume of 4 ml* in the same nebuliser and administer every 20 - 30 minutes initially then 4 - 6-h

Repeat assessment after 1hr

ModeratePEF < 60-80%Moderate symptoms

SevereHigh risk ptPEF<60%Severe symptoms

Treatment•Oxygen•B2-agonist nebulizatiion and IB every 60mins•Oral steroids•Continue 1-3 hrs until improvement

Treatment•Oxygen•B2-agonist and IB nebulization•Systemic steroids•A single dose of intravenous magnesium sulphate 25 - 75 mg/kg over 20 mins

Reassess after 1-2 hrs

Good responseResponse sustained 60mins after last treatmentNo distressSpO2 >90%PEFR>70%

Incomplete response Mild to

moderate Symptoms

PEFR <60%

SpO2 not improving

Poor responseHigh risk ptSevere symptomsPEFR <30%PCO2>45mHgPO2<60mm HgPlan for

discharge

Admit in ward

Admit to ICU

WARD CAREOxygenInhaled B2-agonists + IBSystemic corticosteroidsMonitoring PEFR,SpO2,pulse,K level

ICUOxygenInhaled B2agonists + IBSystemic corticosteroidsConsider iv *terbutaline infusion*IV loading dose of terbutaline(5 - 10 μg/kg iv in 10minz followed by continuous infusion (0.4-4ug/kg/min)Consider iv aminophylline infusionA 6 mg/kg loading dose of aminophylline should be given over 20 minutes under continuous ECG monitoring, followed by a continuous infusion at 0.5 - 1 mg/kg/h

Improved

Plan discharge

Improved

Poor response

Poor response

Reassess at intervals

Possible intubation &Mechanical ventilation

Criteria for DischargePEFR>60%Sustained on oral/inhaled medicationHome treatmentInhaled beta-agonistsOral steroidsCombination inhalersPatient education1. Take

medicine correctly

2. Review action plan

3. Close medical follow up

Criteria for ventilation: � Severe hypoxia � Depressed level of consciousness � Obvious life-threatening respiratory distress not responding to bronchodilatorImpending respiratory failure � Hemodynamic compromise, including bradycardia,pulsus paradoxus � Lactic acidosis associated with increased work of breathing � Apnea or near-apnea � Peak flows <40% of predicted

General guidelines for mechanical ventilation management:

1. Start with low tidal volume• Tidal volume 4-7 ml/kg • Low Ventilatory rate 10-14 breaths per minute• I:E ratio 1:4 to 1:6 • Tolerate hypercapnia• Goal pH>7.25• Peak pressures <30-35

2. Keep well sedated – consider ketamine

3. Prevent bronchoconstriction with suctioning by providing adequate sedation

4.Limit use of paralytics

NEED PRAYERS FOR MY FATHER’SHEALTH

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