Acute severe Asthma case presentation

Acute severe Asthma case

presentation

February 2016

SIGN 141 • British guideline on the

management of asthma 2014

By Rania elashkar

Queens Belfast university

History

Patient 30 years old female own pets ,diagnosed with asthma since she was 8 years old

medication history : an inhaled corticosteroid in combination with a LABA , theophylline, an anticholinergic agent and an inhaled short-acting β2 agonists. patients best peak flow at the clinic is 405 L/minute. admitted to hospital with an acute asthma exacerbation. had two other admissions for asthma in the last few months

Symptoms increasing wheeze, cough, yellow sputum and chest tightness. PF 150 L/minute,.

Examination on admission at hospital

HIGH respiratory rate of 30/min HIGH pulse rate of 145/ minute

(60 pulse) peak flow of 100 L/minute. LOW PO2 of 8.4kPa (12-14

kPa) HIGH PCO2 of 7.2kPa (4.5-6.0

kPa) decreased pH 7.29 Normal

(7.35-7.45)

Features of acute severe asthma

• Peak expiratory flow (PEF) 33-50% of best (use % predicted if recent best unknown)

• Can’t complete sentences in one breath

• Respirations ≥25 breaths/min

• Pulse ≥110 beats/min

• Blood gas markers of a life threatening attack:

• ‘Normal’ (4.6-6 kPa, 35-45 mmHg) PaCO2

• Severe hypoxia: PaO2 <8 kPa

• Low PH

IMMEDIATE TREATMENT

• ƒOxygen to maintain SpO2 94-98%

• ƒSalbutamol 5 mg or terbutaline 10 mg via an oxygen-driven nebuliser

• Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser

• Prednisolone tablets 40-50 mg or IV hydrocortisone 100 mg

IMMEDIATE TREATMENT

IF LIFE THREATENING FEATURES ARE PRESENT:

• Discuss with senior clinician and ICU team

•Consider IV magnesium sulphate 1.2-2 g infusion over 20 minutes (unless already given)

• Give nebulised β2 agonist more frequently e.g. salbutamol 5 mg up to every 15-30 minutes or 10 mg per hour via continuous nebulisation (requires special nebuliser)

SUBSEQUENT MANAGEMENTIF PATIENT IS IMPROVING continue:•Oxygen to maintain SpO2 94-98% •Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6 hourly •Nebulised β2 agonist and ipratropium 4-6 hourly

IF PATIENT NOT IMPROVING AFTER 15-30 MINUTES:

•Continue oxygen and steroids•use continuous nebulisation of salbutamol at 5-10 mg/hour if an appropriate nebuliser is available. Otherwise give nebulised salbutamol 5 mg every 15-30 minutes •Continue ipratropium 0.5 mg 4-6 hourly until patient is improving

SUBSEQUENT MANAGEMENT

IF PATIENT IS STILL NOT IMPROVING:

•Discuss patient with senior clinician and ICU team �

•Consider IV magnesium sulphate 1.2-2 g over 20 minutes (unless already give

• Senior clinician may consider use of IV β2 agonist or IV aminophylline or progression to mechanical ventilation

MONITORING• Repeat measurement of PEF 15-30 minutes after starting

treatment • Oximetry: maintain SpO2 >94-98% • repeat blood gas measurements within 1 hour of starting

treatment if: - initial PaO2 92% - PaCO2 normal or raised - patient deteriorates

• Chart PEF before and after giving β2 agonists and at least 4 times daily throughout hospital stay

Transfer to ICU accompanied by a doctor prepared to intubate if:

Deteriorating PEF, worsening or persisting hypoxia, or hypercapnea �Exhaustion, altered consciousness Poor respiratory effort or respiratory arrest

DISCHARGE• discharge medication for 12-24 hours and

inhaler technique checked and recorded

• PEF >75% of best or predicted and PEF diurnal variability

• Treatment with oral & inhaled steroids &bronchodilators.

• Own PEF meter & written asthma action plan

• Follow up within 2 days & 4 weeks RC

Features that increase the probability of asthma

symptoms: wheeze, breathlessness, chest tightness and cough,

symptoms worse at night / in the early morning , exercise, allergen exposure and cold air , taking aspirin or beta blockers

History of atopic disorder , Family history of asthma and/or atopic disorder

low FEV1 or PEF

Factors that Exacerbate Asthma

Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

© Global Initiative for Asthma

Patients at risk of developing near-fatal or fatal asthma

• previous near-fatal asthma

• previous admission for asthma

• requiring three or more classes of asthma medication

• heavy use of β2 agonist

• adverse behavioural or psychosocial features

Is it Asthma?

Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after

exposure to airborne allergens or pollutants

Colds “go to the chest” or take more than 10 days to clear

Asthma Diagnosis

History and patterns of symptoms Measurements of lung function - Spirometry - Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify risk

factors

Typical Spirometric (FEV1) Tracings

11Time (sec)22 33 44 55

FEV1

Volume

Normal SubjectNormal Subject

Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)

Note: Each FEV1 curve represents the highest of three repeat measurements

Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness

VIDEO ON HOW TO USE peak flow and spirometry

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

Asthma Management and PreventionProgram: Five Components

Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms Maintain normal activity levels, including

exercise Maintain pulmonary function as close to

normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality


Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

.


Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control


Part 1: Educate Patients to Develop a Partnership

Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams

Clear communication between health care professionals and asthma patients is key to enhancing compliance


Component 1: Develop Patient/Doctor Partnership

Educate continually

Include the family

Provide information about asthma

Provide training on self-management skills

Emphasize a partnership among health care providers, the patient, and the patient’s family

Example Of Contents Of An Action Plan To Maintain Asthma ControlYour Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.

HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.


Factors Involved in Non-Adherence

Medication Usage Difficulties associated

with inhalers

Complicated regimens

Fears about, or actual side effects

Cost

Distance to pharmacies

Non-Medication Factors

Misunderstanding/lack of information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma

development, especially in children and young infants



The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional

Levels of Asthma Control(Assess patient impairment)

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

Assess Patient Risk

Features that are associated with increased risk of adverse events in the future include:

Poor clinical control

Frequent exacerbations in past year

Ever admission to critical care for asthma

Low FEV1, exposure to cigarette smoke, high dose medications

Assessment of Future Risk Risk of exacerbations, instability, rapid decline

in lung function, side effects

Features that are associated with increased risk of adverse events in the future include: Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthmaLow FEV1, exposure to cigarette smoke, high dose medications

Any exacerbation should prompt review of maintenance

treatment

preventer Medications

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in combination

with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (µg) Medium Daily Dose (µg) High Daily Dose (µg)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200

600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation Suspension

250-500

500-1000 >1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750

>1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200

>250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200

> 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800

>1000-2000 >800-1200 >2000 >1200

Reliever Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Shaded green - preferred control ler options

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROLLEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTIONTREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

RE

DU

CE

INC

RE

AS

E


Step 1 – As-needed reliever medication

Patients with occasional daytime symptoms of short duration

A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)

When symptoms are more frequent, and/or worsen periodically, patients require regular preventer treatment (step 2 or higher)

Treating to Achieve Asthma Control

Step 2 – Reliever medication plus a single preventer

A low-dose inhaled glucocorticosteroid is recommended as the initial preventer treatment for patients of all ages (Evidence A)

Alternative preventor medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids


Step 3 – Reliever medication plus one or two preventer

For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)

Inhaled long-acting β2-agonist must not be used as monotherapy


Additional Step 3 Options for Adolescents and Adults

Increase to medium-dose inhaled glucocorticosteroid (Evidence A)

Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline (Evidence B)


Step 4 – Reliever medication plus two or more preventer

Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3

Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma


Step 4 – Reliever medication plus two or more controllers

Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)

Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)




Step 5 – Reliever medication plus additional controller options

Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)

Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

Treating to Maintain Asthma Control

When control as been achieved, ongoing monitoring is essential to:

- maintain control

- establish lowest step/dose treatment

Asthma control should be monitored by the health care professional and by the patient


Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)

When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)


Stepping down treatment when asthma is controlled

When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)

If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)


Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.

Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy


Stepping up treatment in response to loss of control

Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)

Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)


Component 4: Manage Asthma Exacerbations

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision



Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for

the particular patient Availability of medications Emergency facilities



Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled β2-agonist

• Early introduction of systemic glucocorticosteroids

• Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Health & Medicine

Acute severe Asthma case presentation