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ASTHMA IN THE PICUASTHMA IN THE PICU
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EpidemiologyEpidemiology
• 14-15 million Americans14-15 million Americans• Nearly 5 million childrenNearly 5 million children• 5,000 people (mostly adults) die each year5,000 people (mostly adults) die each year• Incidence, hospitalization rate, and death Incidence, hospitalization rate, and death
rate is increasing each year.rate is increasing each year.• 15-24 year-olds are at higher risk of dying 15-24 year-olds are at higher risk of dying
from asthma than are 0-4 year olds.from asthma than are 0-4 year olds.• Prior asthma episode requiring mechanical Prior asthma episode requiring mechanical
ventilation is strong predictor of ventilation is strong predictor of subsequent asthma death.subsequent asthma death.
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PathogenesisPathogenesis
• Asthma is a chronic inflammatory disease of Asthma is a chronic inflammatory disease of the airways.the airways.
• Asthma is characterized by bronchospasm, Asthma is characterized by bronchospasm, airway edema, and mucus productionairway edema, and mucus production
• Asthma has several components:Asthma has several components:– CellularCellular– CytokinesCytokines– NeurologicNeurologic
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PathophysiologyPathophysiology
• Asthma is an obstructive pulmonary disease.Asthma is an obstructive pulmonary disease.• Air-trapping and over-expansion of alveoli is a Air-trapping and over-expansion of alveoli is a
hallmark of asthma.hallmark of asthma.• Air-trapping may lead to air-leak, which can be Air-trapping may lead to air-leak, which can be
fatal.fatal.• In addition, active expiration may be required In addition, active expiration may be required
to return the lung volume to FRC.to return the lung volume to FRC.• Muscles of expiration are not designed for Muscles of expiration are not designed for
active expiration and quickly become fatigued, active expiration and quickly become fatigued, leading to respiratory failure and death.leading to respiratory failure and death.
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TriggersTriggers
• Numerous things can trigger asthma attacks:Numerous things can trigger asthma attacks:– AllergensAllergens– ExerciseExercise– StressStress– VirusesViruses– MedicinesMedicines– Noxious stimuliNoxious stimuli
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Cellular componentCellular component
• Numerous cells involved:Numerous cells involved:– Mast cellsMast cells– EosinophilsEosinophils– Lymphocytes (TH-2 cells)Lymphocytes (TH-2 cells)– NeutrophilsNeutrophils– Epithelial cellsEpithelial cells
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CytokinesCytokines
• Numerous soluble products of the cells Numerous soluble products of the cells exacerbate asthma:exacerbate asthma:– InterleukinsInterleukins– BradykininsBradykinins– HistamineHistamine
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NeurologicNeurologic
• ParasympatheticParasympathetic– Stimulation via the vagus leads to airway Stimulation via the vagus leads to airway
constriction.constriction.• SympatheticSympathetic
– Plays little role in humans since only Plays little role in humans since only pulmonary vasculature, not airway smooth pulmonary vasculature, not airway smooth muscle, is innervatedmuscle, is innervated
• Non-adrenergic non-cholinergic (NANC)Non-adrenergic non-cholinergic (NANC)– Role in humans not determined.Role in humans not determined.– Vasoactive intestinal polypeptide, Substance Vasoactive intestinal polypeptide, Substance
P, NOP, NO
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ReceptorsReceptors• BetaBeta
– 3 subtypes3 subtypes 22 is common in airway smooth muscle is common in airway smooth muscle– Activation leads to increase in cAMPActivation leads to increase in cAMP
• Alpha: little roleAlpha: little role• CholinergicCholinergic
– Muscarinic receptors: Muscarinic receptors: •MM22 receptor inhibits acetylcholine release, receptor inhibits acetylcholine release,
leading to bronchodilation.leading to bronchodilation.•MM33 receptor cause bronchoconstriction receptor cause bronchoconstriction
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Physical ExamPhysical Exam
• Respiratory RateRespiratory Rate• Work-of-BreathingWork-of-Breathing• Breath SoundsBreath Sounds• Inspiratory:Expiratory PhaseInspiratory:Expiratory Phase• CyanosisCyanosis• Mental statusMental status
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Respiratory rateRespiratory rate
• NormalNormal– Infants: <40Infants: <40– Toddlers: <30Toddlers: <30– Preschoolers: <30Preschoolers: <30– Elementary School: low 20sElementary School: low 20s– High school: upper teensHigh school: upper teens
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Work-of-breathingWork-of-breathing
• Nasal FlaringNasal Flaring• RetractionsRetractions
– SupraclavicularSupraclavicular– IntercostalIntercostal– SubsternalSubsternal
• Paradoxical BreathingParadoxical Breathing
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Breath soundsBreath sounds • Lung FieldsLung Fields• Air flowAir flow
– Good, fair, poorGood, fair, poor• Expiratory WheezeExpiratory Wheeze
– Polysyllabic vs. MonosyllabicPolysyllabic vs. Monosyllabic• Inspiratory WheezeInspiratory Wheeze
– Common, even in non-diseased statesCommon, even in non-diseased states
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PhasesPhases
• Normally, expiratory phase is the same as, Normally, expiratory phase is the same as, or shorter than the inspiratory phase.or shorter than the inspiratory phase.
• In asthma, the expiratory phase is prolonged In asthma, the expiratory phase is prolonged as airway collapse and air-trapping occur.as airway collapse and air-trapping occur.
• Intrathoracic pressure becomes higher than Intrathoracic pressure becomes higher than the large airway pressure, leading to the large airway pressure, leading to collapse of the airways.collapse of the airways.
• Airway edema, bronchospasm, and mucus Airway edema, bronchospasm, and mucus impede air movement.impede air movement.
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CyanosisCyanosis
• Need 5gm/dl of unoxygenated hemoglobin Need 5gm/dl of unoxygenated hemoglobin before cyanosis presentbefore cyanosis present
• Cyanosis will be more pronounced in Cyanosis will be more pronounced in children with high hematocrits: dehydrated, children with high hematocrits: dehydrated, cyanotic heart diseasecyanotic heart disease
• Cyanosis can be a sign of impending Cyanosis can be a sign of impending respiratory failure….or not.respiratory failure….or not.
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Mental StatusMental Status
• Hypoxia and hypercarbia can lead to mental Hypoxia and hypercarbia can lead to mental status changes.status changes.
• Fatigue can, too.Fatigue can, too.• Improvement can, too.Improvement can, too.• Watch for agitation, delirium, Watch for agitation, delirium,
unresponsiveness, especially to pain.unresponsiveness, especially to pain.
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Laboratory testsLaboratory tests
• PEFRPEFR• PFTsPFTs• Asthma ScoresAsthma Scores• IgEIgE• Allergy testsAllergy tests• Blood gasBlood gas• CXRCXR
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TreatmentsTreatments• OxygenOxygen• SteroidsSteroids
– InhaledInhaled– SystemicSystemic
• Beta AgonistsBeta Agonists– Short-actingShort-acting– Long-actingLong-acting
• AnticholinergicsAnticholinergics• Leukotriene InhibitorsLeukotriene Inhibitors• MethylxanthinesMethylxanthines• MagnesiumMagnesium
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Oxygen/FluidOxygen/Fluid
• Ventilation/perfusion mismatch can be quite Ventilation/perfusion mismatch can be quite highhigh
• Oxygen lends to patient comfortOxygen lends to patient comfort• In absence of chronic pulmonary disease, i. e., In absence of chronic pulmonary disease, i. e.,
COCO22 retention, supplemental oxygen will not retention, supplemental oxygen will not suppress the respiratory drivesuppress the respiratory drive
• Most patients with asthma are dehydrated Most patients with asthma are dehydrated (increased insensible losses, decreased intake)(increased insensible losses, decreased intake)
• Overhydration can exacerbate pulmonary Overhydration can exacerbate pulmonary edema.edema.
• Watch for SIADH.Watch for SIADH.
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SteroidsSteroids
• Only drug that addresses the underlying Only drug that addresses the underlying pathophysiologypathophysiology
• SolumedrolSolumedrol– 2mg/kg/day divided q6hr2mg/kg/day divided q6hr– Max is 60mg/day “kids,” 180mg/day “adults”Max is 60mg/day “kids,” 180mg/day “adults”– IVIV
• Prednisone or PrednisolonePrednisone or Prednisolone– OralOral
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SteroidsSteroids
• No difference between IV and poNo difference between IV and po• Usually give IV in severe attack because of Usually give IV in severe attack because of
nausea and high respiratory rate increases nausea and high respiratory rate increases risk of aspirationrisk of aspiration
• 5 day course of therapy won’t suppress 5 day course of therapy won’t suppress adrenal systemadrenal system
• Start to work in 8-12 hoursStart to work in 8-12 hours
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SteroidsSteroids
• ComplicationsComplications– HypertensionHypertension– HyperglycemiaHyperglycemia– HypokalemiaHypokalemia– GastritisGastritis
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Inhaled SteroidsInhaled Steroids
• For long term controlFor long term control• Fewer side effects than systemic steroids, Fewer side effects than systemic steroids,
but may be associated with long-term but may be associated with long-term growth suppression.growth suppression.– BeclomethasoneBeclomethasone– BudenosideBudenoside– FlunisolideFlunisolide– FluticasoneFluticasone– TriamcinoloneTriamcinolone
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Beta-agonistsBeta-agonists
• Work via the Work via the 22 receptor to bronchodilate receptor to bronchodilate
• AlbuterolAlbuterol• TerbutalineTerbutaline• Can cause hypokalemia, tremors, nausea, Can cause hypokalemia, tremors, nausea,
vomiting, tachycardiavomiting, tachycardia
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Beta-agonistsBeta-agonists• Give via MDI or nebsGive via MDI or nebs• Dose:Dose:
– Depends upon size, severity of disease, Depends upon size, severity of disease, and delivery device. Titrate to heart rate and delivery device. Titrate to heart rate and responseand response
– Usual neb dose:Usual neb dose:•<10kg: 2.5mg/hr<10kg: 2.5mg/hr•10-20kg: 5mg/hr10-20kg: 5mg/hr•20-30kg: 10mg/hr20-30kg: 10mg/hr•>30kg: 15mh/hr>30kg: 15mh/hr
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Anti-cholinergicsAnti-cholinergics
• Atropine and atroventAtropine and atrovent• Bronchodilate and decrease mucus Bronchodilate and decrease mucus
productionproduction• Additive effect with beta-agonists.Additive effect with beta-agonists.• Use for beta-blocker induced asthmaUse for beta-blocker induced asthma• Complications include drying of the airways Complications include drying of the airways
and rarely, increased wheezingand rarely, increased wheezing• Atrovent dose: 250-500mcg/dose up to q Atrovent dose: 250-500mcg/dose up to q
20min, usually q2-4hrs.20min, usually q2-4hrs.
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Leukotriene inhibitorsLeukotriene inhibitors
• Block the actions of leukotrienesBlock the actions of leukotrienes• Zafirlukast and zileutonZafirlukast and zileuton• Used for long-term controlUsed for long-term control• Little use in acute attacksLittle use in acute attacks• May be as effective as inhaled steroidsMay be as effective as inhaled steroids• Rare side effects (liver damage)Rare side effects (liver damage)
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MethylxanthinesMethylxanthines
• Theophylline and aminophyllineTheophylline and aminophylline• Actions are several:Actions are several:
– Phosphodiesterase inhibitor (increases cAMP)Phosphodiesterase inhibitor (increases cAMP)– Stimulates catecholamine releaseStimulates catecholamine release– DiueresisDiueresis– Augments diaphragm contractilityAugments diaphragm contractility– Prostoglandin antagonistProstoglandin antagonist
• May be of little benefit in routine use for acute May be of little benefit in routine use for acute asthmaasthma
• High risk of side effects: N/V, tachycardia, High risk of side effects: N/V, tachycardia, agitation, cardiac arrythmias, hypotension, agitation, cardiac arrythmias, hypotension, seizures, deathseizures, death
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MagnesiumMagnesium
• Mechanism unclear, but may be a direct Mechanism unclear, but may be a direct bronchodilator through blocking calciumbronchodilator through blocking calcium
• Raising the Mg levels up to 2-4 mg/dL Raising the Mg levels up to 2-4 mg/dL significantly improved expiratory air flow in significantly improved expiratory air flow in adultsadults
• One study in children showed that MgSOOne study in children showed that MgSO44 25mg/kg over 20 minutes significantly 25mg/kg over 20 minutes significantly improved PFTs, but did not change improved PFTs, but did not change hospitalization rate or length of stay in the hospitalization rate or length of stay in the ED.ED.
• Relatively safe. Levels >12 can cause Relatively safe. Levels >12 can cause weakness, areflexia, respiratory depression, weakness, areflexia, respiratory depression, and cardiac arrhythmiasand cardiac arrhythmias
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Weaning protocolWeaning protocol
• Patients selected by attending/residentPatients selected by attending/resident• Physician writes orderPhysician writes order• Physician writes initial dose and frequency Physician writes initial dose and frequency
of bronchodilatorof bronchodilator• Respiratory therapist evaluates patient and Respiratory therapist evaluates patient and
changes therapy in accordance with protocolchanges therapy in accordance with protocol
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Treatment levelsTreatment levels• Level 1: Continuous albuterol at Level 1: Continuous albuterol at >> 0.6 mg/kg/hr 0.6 mg/kg/hr• Level 2: Continuous albuterol at 0.3 mg/kg/hr Level 2: Continuous albuterol at 0.3 mg/kg/hr – (Max 15 mg/hr)(Max 15 mg/hr)
• Level 3: Continuous albuterol at 0.15mg/kg/hr Level 3: Continuous albuterol at 0.15mg/kg/hr • Level 4: Albuterol at about 0.3mg/kg q2hoursLevel 4: Albuterol at about 0.3mg/kg q2hours– Infants <5kg use 1.0 mgInfants <5kg use 1.0 mg– Infants 5 - 10 kg use 2.5 mgInfants 5 - 10 kg use 2.5 mg– Children 10 - 20 kg use 5.0 mgChildren 10 - 20 kg use 5.0 mg– Children > 20 kg round to closest multiple of Children > 20 kg round to closest multiple of
2.5 mg (2.5, 5.0, 7.5, etc)2.5 mg (2.5, 5.0, 7.5, etc)
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Treatment levelsTreatment levels• Level 5 : Albuterol q3 hours at same dose as Level 5 : Albuterol q3 hours at same dose as
level 4level 4– When the patient has been stable on q3 hour When the patient has been stable on q3 hour
treatments for 2 treatment intervals, therapist is treatments for 2 treatment intervals, therapist is to call the physician to evaluate for possible to call the physician to evaluate for possible transfer out of the PICU (anytime of day or night). transfer out of the PICU (anytime of day or night).
– If the patient is also receiving intermittent If the patient is also receiving intermittent Atrovent nebulizations q2 or q4 hours, the Atrovent nebulizations q2 or q4 hours, the therapist should make these q3 to coincide with therapist should make these q3 to coincide with the albuterol treatments.the albuterol treatments.
• Level 6 : Albuterol q4 hours, same dose as level Level 6 : Albuterol q4 hours, same dose as level 4 and 54 and 5
• Level 7 : Albuterol q4 hours at about 0.15mg/kg Level 7 : Albuterol q4 hours at about 0.15mg/kg if dose for previous levels is above 2.5 mgif dose for previous levels is above 2.5 mg
• Level 8 : Albuterol q6 hours, same doseLevel 8 : Albuterol q6 hours, same dose
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Acute Asthma ScoreAcute Asthma Score Modified from Woods, et al, AJDC, 1972Modified from Woods, et al, AJDC, 1972
Variable 0 1 2
Pulse Oximetry >93% in RA <94% in RA<94% with 40% FiO2
Cyanosis None In RA In 40% FiO2
Inspiratory Breath Sounds Normal Unequal
Decreased to Absent
Accessory Muscles Used None Moderate Maximal
Expiratory Wheezing None Moderate Marked
Cerebral Function Normal
Depressed or Agitated Coma
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Weaning criteriaWeaning criteriaA. Respiratory therapist has evaluated patient A. Respiratory therapist has evaluated patient
and feels the patient is not acutely distressed, and feels the patient is not acutely distressed, ANDAND
B. The asthma score is less than or equal to 3, B. The asthma score is less than or equal to 3, ANDAND
C. If the patient is over 6 years and C. If the patient is over 6 years and cooperative, the peak flows are cooperative, the peak flows are >> 70% of 70% of predicted, predicted, ANDAND
D. The patient must be stable at these criteria D. The patient must be stable at these criteria for 3 hours or for two treatment intervals, for 3 hours or for two treatment intervals, whichever is longer.whichever is longer.
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Failure criteriaFailure criteria
A.A. The therapist (or nurse) judges the The therapist (or nurse) judges the patient to be in increased distress, but patient to be in increased distress, but notnot severe distress. severe distress.
OROR
B. The asthma score increases to greater B. The asthma score increases to greater than 3 but less than 5. than 3 but less than 5.
OROR
C. The PEFR drops to less than 70% C. The PEFR drops to less than 70% predicted but greater than 50% of predicted but greater than 50% of predicted.predicted.
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Ped
iatr
ic R
esid
en
t C
urr
icu
lum
for
the P
ICU
Ped
iatr
ic R
esid
en
t C
urr
icu
lum
for
the P
ICU
Deterioration criteriaDeterioration criteria
A. The respiratory therapist (or nurse) A. The respiratory therapist (or nurse) judges the patient has developed severe judges the patient has developed severe distress. distress.
OROR
B. The asthma score increases to more B. The asthma score increases to more than or equal to 5. than or equal to 5.
OROR
C. The PEFR drops to less than 50% of C. The PEFR drops to less than 50% of predicted.predicted.
