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1Acute Asthma
Management
Module 6
Training of Inhalation Therapy
& Pediatric Asthma Management
Departemen IKA FKUI-RSCM
UKK Respirologi PP IDAI
2Prof. Dr. Mardjanis Said, Sp.A(K)Prof. Dr. Mardjanis Said, Sp.A(K)
Born: Born: Payakumbuh, 1 September 1945Payakumbuh, 1 September 1945
Education:Education:
1.1. Faculty medicine, University Indonesia, 1970Faculty medicine, University Indonesia, 1970
2.2. Medical Post Graduate (Pediatrics), Faculty of Medical Post Graduate (Pediatrics), Faculty of
Medicine Universitas Indonesia, 1976Medicine Universitas Indonesia, 1976
3. Pediatric Pulmonology Subspecialty, Faculty of Indonesia 19871987
Recent position :Recent position :
Staff member of Division of Respirology
Lecturer on Pediatric Pulmonology and Respirology,Dept of Child Health, Faculty of Medicine University of Indonesia
Asthma : chronic respiratory disease that can have acute attack (two in one disease)
AsthmaAcute Asthma
Chronic Asma
Asthma, 2 aspects
Classification of pediatric asthma
Chronic asthma
1. Infrequent episodic asthma
2. Frequent episodic asthma
3. Persistent asthma
Acute asthma
1. Mild attack
2. Moderate attack
3. Severe attack
Asthma managements
Chronic asthma
Long term management
Algorithm diagnosis
& treatment
Acute asthma
Attack
management
Algorithm attack
management
Asthma managements
Chronic asthma
Long term management
Reliever &
Controller
Acute asthma
Attack
management
Reliever
Asthma medication
Controller
drug to control asthma ie attack or symptom not easily emerge
Inhaled steroid
LABA, ALTR
Reliever
drug to relieve asthma attack or symptoms
-agonist Xanthine
anticholinergic
Definition
Acute asthma = asthma attack = asthma excacerbation
Rapid progressive worsening episode of cough, dyspnea, wheezing, chest tightness etc
84.4%
3.9%11.7%
Mild
Moderate
Severe
Type of asthma attacks
in Cipto Mangunkusumo hospital
AsthmaTriggers
Acute attacks
Inhalant house dustmite Smoke Food
Failed of long term management
triggers
bronchoconstriction, edema, secretion
Airway obstruction
non-uniformventilation
Lung hyperinflation
Ventilation-perfusionmismatch
Compliance disturbances
Atelectasis
Alveolar hypoventilation work of breathing
surfactant
PaCO2 PaO2
acidosis
Pulmonaryvasoconstriction
Pathophysiology of acute asthma
Michael Sly. Nelson Textbook, 1996
Respiratory track of healthy children
Triggers(dust, animal danders, smoke, etc)
Bronchus Bronchus
Keep on wide, opened(not hypersensitive,
not easily constricted)
Respiratory track of asthmatic children
triggers(dust, animal danders, smoke, etc)
Bronchus
no symptoms attack
muscle spasmwall oedema
hyper secretions
Bronchus
very fragilevery sensitive
constrict easily
Triggers of asthma Respiratory infection (viral, mycoplasma)
Exercise
Allergens : - inhaled
- ingested (rare)
Irritants (cigarette smoke, air pollution)
Weather changes
Medications (ASA)
Chemical (tartrazine, sulfites, menosodium glutamate)
Emotional stress
Gastroesophageal reflux
Symptoms of asthma attack:
Rigorous cough/without stopping
Dyspnea, difficult breathing
Wheezing
Tachypnea, fast breathing
Chest pain
Difficult to speak
Cyanosis
20
Asthma management principles
1.Avoidance
2.Avoidance
3.Avoidance
4.Drugs inhalation therapy
Goal of acute asthma management
Rapid resolution of acute symptoms
To reduce hypoxemia
Normal lung function as soon as possible
Reevaluation to prevent asthma attacks
Lenfant C et al, GINA 2002
22
Acute asthma management
Asthma attack / symptoms present:
First line therapy
-agonist : terbutaline, salbutamol anticholinergic: ipratropium bromida
Chronic asthma (long term management)
First line therapy
Inhaled steroid
Long-acting beta-2 agonist (LABA)
Assessment of severity
Mild Moderate SevereRespiratory
arrest imminent
Breathless Walking
Can lie down
Talking
Infant-softer
Shorter cry
Difficult feeding
Prefers sitting
At rest
Infant stops feeding
Hunched forward
Talks in Sentences Phrases Words
Alertness Maybe agitated
Usually agitated
Usually agitated
Drowsy or confused
Respiratory rate
Increased Increased Often >30x/min
Normal rates of breathing in awake children:
Age Normal rates
Pulsus paradoxus
Absent
Acute asthma algorithm
Clinic/ERAsses attack severity
1st management nebulitation -agonis 3x, 20 min interval
3rd nebulitation + anticholinergic
Moderate attack(nebulization 2-3x, partial response)
give O2 asses: Moderate
ODC IV line
Mild attack(nebulization 1x,
complete response)
persist 1-2 hr:discharge
symptom reappear:Moderate attack
Severe attack(nebulization 3x,
no response) O2 from the start IV line asses: Severe -
hospitalized CXR
One Day Care (ODC) Oxygen therapy Oral steroid Nebulized / 2 hour Observe 8-12 hours,
if stable discharge Poor response in 12h,
admission
Admission room Oxygen therapy Treat dehydration and
acidosis Steroid IV / 6-8 hours Nebulized / 1-2 hours Initial aminophylline IV,
then maintenance Nebulized 4-6x
good response per 4-6 h If stable in 24 hours discharge
Poor response ICU
Discharge give -agonist
(inhaled/oral) routine drugs viral infection:
oral steroid Outpatient clinic in
24-48 hours
Notes: In severe attack, directly use -agonist + anticholinergic If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
At home
Known of asthma symptoms
Nebulized 2 agonist
If not available: MDI with/without spacer or orally
In Indonesia: not popular
Be careful with OTC
Early management
Initial assessment of severity asthma attacks
Nebulized 2-agonist, interval 20 minute
3rd nebulization: anticholinergic agent
Severe attacks: directly with anticholinergic agent
If nebulizer not available:
MDI with Spacer
Adrenalin SC
MDI with Spacer Vs Nebulizer
2 agonist: bronchodilator
Mild-moderate attacks
MDI with spacer: as effective as nebulizer
Severe attacks:
Nebulizer is recommended
MDI with spacer vs nebulizer
Take less time
Fewer side effects
More portable
Cheaper
Easier use
2 agonist + ipratropium bromide.
Symptoms score decrease
Lung function better than alone
Hospitalized
Activity: longer
Mild attacks
Good response post nebulization
Observe: 1-2 hours
Discharge if the response is good
Treat as moderate attacks if symptoms still remain
Use routine drugs
Out patient clinics
Management of asthma attacks
Mild
NebulizationNebulizationNebulizationNebulization
Observe 1Observe 1Observe 1Observe 1----2 hours2 hours2 hours2 hours
DISCHARGE
Moderate
Routine drugsOutpatient clinic
Moderate attacks
Partial response post nebulization
ODC admission
Oxygen therapy
Oral steroid
IV line
Repeated nebulization
Good response: discharge
Poor response: admission
Management of Asthma Attack
MILDMILDMILDMILD
Nebulization
Observe: 1-2 hours
DISCHARGEDISCHARGEDISCHARGEDISCHARGE
MODERATEMODERATEMODERATEMODERATE
OxygenOxygenOxygenOxygen
NebulizationNebulizationNebulizationNebulization
IVFDIVFDIVFDIVFD
Oral steroidOral steroidOral steroidOral steroid
ODCODCODCODC SEVERESEVERESEVERESEVERE
???
Why is not response?
Dehydration
Metabolic acidosis
Atelectasis
Severe attacks
Poor response postnebulization
Oxygen therapy
IV line: rehydration and treat acidosis
Corticosteroids (IV)
Initial Aminophylline (IV), then maintenance
Repeated nebulization
Chest X-ray
Good response : Discharge
Poor response : Intensive care
Management of asthma attack
MILDMILDMILDMILD
Nebulization
Observe 1-2 hours
DISCHARGEDISCHARGEDISCHARGEDISCHARGE
MODERATEMODERATEMODERATEMODERATE
Oxygen
Nebulization
IVFD
Oral steroid
ODCODCODCODC SEVERESEVERESEVERESEVERE
OOOO2222, steroid, steroid, steroid, steroid
NebulizationNebulizationNebulizationNebulization
HydrationHydrationHydrationHydration
AminophyllineAminophyllineAminophyllineAminophylline
RRRR
ICU (?)ICU (?)ICU (?)ICU (?)
Others drugs (asthma attacks)
Adrenalin: maximal dose, and b effects
Salbutamol SC: be careful
MgSO4: not significant
Inhaled steroid : high dose (1600 mg)
Asthma attacksAsthma attacksAsthma attacksAsthma attacks
Stable asthmaStable asthmaStable asthmaStable asthma
(No attack)(No attack)(No attack)(No attack)
Infrequent Infrequent Infrequent Infrequent
episodicepisodicepisodicepisodic
Frequent Frequent Frequent Frequent
episodicepisodicepisodicepisodicPersistentPersistentPersistentPersistent
Reliever (+)Reliever (+)Reliever (+)Reliever (+)
Controller (Controller (Controller (Controller (----))))
Reliever (+)Reliever (+)Reliever (+)Reliever (+)
Controller (+)Controller (+)Controller (+)Controller (+)
Reliever (+)Reliever (+)Reliever (+)Reliever (+)
Controller (+)Controller (+)Controller (+)Controller (+)
Assess the severity Assess the severity Assess the severity Assess the severity
of attacksof attacksof attacksof attacks
Assess class of Assess class of Assess class of Assess class of
diseasediseasediseasedisease
Educations and AVOIDANCE
Acute asthma attacks
Nebulization 1-2 x
Good response
Discharge
Bronchodilator
Partially response
One Day CareOxygenNebulizationOral steroid IVFD
Good response Poor response
Discharge
Hospitalization
OxygenNebulizationIVFD: rehydrationSystemic steroid Aminophylline
-Agonist
Oxygen therapy
Reduce hypoxemia
To achieve saturation > 95%
Should be titrated according to oximetry
Inhalation therapy
2 agonist and ipratropium bromide Vs 2 agonist alone:
Hospitalization
Symptoms score
Lung function
Duration of action:
Mucolytics: worsen
Schuh et al. J Pediatr 1995; 126:639-45.
IVFD
Replacement therapy for dehydration
Intake because dyspnea
Vomiting
Treat acid-base and electrolyte imbalance
Parenteral medications
Steroids
Intravenous or oral
Anti-inflammations
Inhaled steroids: controversial
Aminophylline
Initial: 6-8 mg/kgBW IV in 10-20 minute
Maintenance dose 0.5 - 1 mg/kgBW/hour
Monitoring: aminophylline serum level
Narrow safety margin
National guidelines for childhood asthma, 2004
Other drugs
Adrenalin: maximal dose !!!, and effects Salbutamol SC: be careful
MgSO4: not significant than salbutamol
Inhaled Steroid : high dose (1600-2000 mg)
LABA: Nocturnal asthma, EIA
Antibiotics: Not necessary except sinusitis
Lenfant C et al, GINA 2002Lenfant C et al, GINA 2002Lenfant C et al, GINA 2002Lenfant C et al, GINA 2002
Inhaled steroid
Controversial (limited literature)
High dose (1600-2000 mg)
Reduced asthma attacks
Not effective in severe attacks
Alternative therapy
Management of acute asthmaMILDMILDMILDMILD
Nebulization
Observe 1-2 hours
DISCHARGEDISCHARGEDISCHARGEDISCHARGE
MODERATEMODERATEMODERATEMODERATE
Oxygen
Nebulization
IVFD
Oral steroid
ODCODCODCODC SEVERESEVERESEVERESEVERE
OOOO2222, steroid, steroid, steroid, steroid
NebulizationNebulizationNebulizationNebulization
HydrationHydrationHydrationHydration
AminophyllineAminophyllineAminophyllineAminophylline
RRRR
ICU (?)ICU (?)ICU (?)ICU (?)
Severe acute asthmaNo response after initial serial nebulization
Oxygen
IV line: dehydration and acidosis
Systemic steroid: oral or IV
Frequent nebulization
Aminophylline IV drip: initial + maintenance
Chest X ray
Non responsive
Dehydration: inadequate intake, the longer the more
evaluate: clinically, laboratory; overcome
Acidosis: correction
Atelectasis & mucus plug: CXR mandatory; physiotherapy
Monitoring
Vital sign: consciousness, RR, HR, temperature
Cyanosis, retraction, wheezing
Hydration state and acid base, electrolite
Complication: pneumothorax, atelectasis, encephalopathy
Nonresponsive
Excessive use of -agonist down regulation of -agonist receptors tachyphylaxis, subsensitivity
Systemic steroid
reduce the edema
up regulates more -agonist receptors sensitive again to -agonist drugs
Conclusion Asthma labelling
Acute asthma: mild, moderate, and severe
Avoidance is a very important prevention
Initial management is important to prevent mortality
Nebulisation in severe acute asthma: agonist + ipratropium bromida
Pedoman Nasional Asma Anak
56
Thanks for
your attention