acute attack asthma
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Managing acute episodes
Some pharmacology
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Relievers
Short-acting 2-agonists
Salbutamol
Terbutaline
Non selective -agonist
Adrenaline
Anticholinergics
Ipratropium bromide
Steroids
Theophylline
(Select situations)
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Oxygen
Hypoxia due to V / Q mismatch.
agonists may paradoxically worsen hypoxia
Maintain SaO2 > 92%.
Use oxygen to nebulise 2agonists
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Inhaled 2-agonists
Drugs of choice.
Salbutamol / Terbutaline are similar.
Severe acute episodenebuliser preferred
Dose- < 6 months-0.25 ml of respirator soln,
> 6 months- 0.5-1ml of respirator soln
Dilute in salineonly, NEVER distilled water
Beware of hypokalemiawith high dose nebulization.
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Rescue steroids
Early usage- reduces morbidity/ hospitalization
Oral prednisolone1-2 mg/kg for 3-7 days.
No tapering needed / No adverse effects
Injectablesdo not confer quicker benefit.
Hydrocortisone( 5-10 mg/kg) q 6hr or
IV Methylprednisolone (1-2 mg/kg) q6hr
IV / IM Dexamethasone (0.10.2 mg / Kg) q 6 hr
if patient unable to take orally (drowsy/distressed/vomiting)
High dose inhaled / nebulised steroids not proven
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Aminophylline
Retains its role as reliever in acute severe attacks
improves diaphragmatic contractility
mucociliary function
inflammatory modulation
Dose: Loading dose 5 mg/kgslow diluted IV bolus
(Avoid if patient on SR theophylline)
Followed by 0.51.0mg/kg/hr as infusion
(Avoid subsequent bolus doses)
Toxicity
Gl , Cardiac, CNS
Monitor levels if possible
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Oral 2agonists for mild intermittent airflow
obstruction.
Oral prednisolone for rescue therapy
Oral drugs as relievers
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Managing acute episodes
Back to Arpit and his friends
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Case..
Arpit decides to help his mother with Diwali cleaning. He starts
coughing continuously and his mother rushes him to the
clinic
What questions will you ask the mother?
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During an acute attack
Enquire
Duration ?
Relievers taken? - Response?
Brittleness (Rapid worsening)
Precipitant / trigger factors
On regular preventers?
Number and severity of previous attacks
Last theophylline dose (if relevant)
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Case contd
On examination, Arpit has a respiratory rate of 40 per minute
and a mild increase in accessory muscle activity. He
appears comfortable and is able to talk in sentences.
Auscultation reveals a wheeze towards the end of
expiration.
How will you grade Arpits acute attack and
manage him?
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Grading severity
Over a period of time-
helps to decide regarding need and choice of preventer drugs
At a point in time -
helps to decide regarding the level and drugs for acute
care.
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Quick assessment
Respiratory rate
Too breathless to feed / sleep
Talking words, not sentences
Poor or only transient (< 2hr) response to bronchodilator
Worsening despite 23 recent doses of inhaled 2agonistsat
15 minute intervals
SaO2< 92%
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Pulmonary score index
Score Respiratory Rate Wheezing* Accessory muscle6 years Sternomastoid activity
0 < 30 < 20 None No apparent activity
1 3145 2135 Terminal Questionable increaseexpiration with
stethoscope2 4660 3650 Entire expiration Increase apparent
with stethoscope
3 > 60 > 50 During inspiration Maximal activityand expirationwithout stethoscope
Score 03 Mild *If no wheezing due to minimal air exchange, score>346 Moderate
> 6 SevereThose children whose score is > 6 should be admitted to a pediatric ICU
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Home managementPS < 3 (mild grade)
SA 2agonist: 2 - 4 puffs through MDI + spacer +
mask
Repeat every 15 - 20 mins for max 3 times
If response ill sustained (< 4 hrs), start 1st
dose of
rescue steroid
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Case..
Sanjana calls you in the middle of the night. She is
proceeding to the casualty once again. You rush in
to see her and find her to have a respiratory rate
of 40 per min. She is wheezing audibly.
Assess her severity and manage her
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E Room planPS 4-6(moderate)
O2 SA 2agonist
Nebulised q 20 min x 3
or
MDI + spacer + mask 2 puffs q 2 min increasing by 2 puffs till10 puffs reached / 10 puffs q 20 min x 3
or (if inhaled therapy not available)
Adrenaline / Terbutaline 0.01mg/kg sc q 20 min x 3
Commence / Continue rescue steroid
Continuous assessment
SA 2agonist neb hourly p.r.n.
If good response(PS
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Sanjana does not respond to this treatment. One hour later, her
respiratory rate has gone up to 50 per minute. You decide to
admit her to the ward.
What do we do next? asks your resident doctor
Outline your plan to him
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Ward plan
Continue oxygen,
Start IV fluids, IV/oral steroid
SA 2nebulization - hourly/ back-to-back
Ipratropium neb q 30 min x 3 and then q 6 hours
Aminophyllinebolus and IV infusion
Monitor SaO2and serum K+
CBC, X-Ray chest to identify complications
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Intensify if not better
Pulmonary score q 15-30 minutes
Consider blood gas studies if SaO2< 92%
Terbutaline continuous iv infusion.
Magnesium sulfate iv infusion over 30 mins
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Your resident doctor is new but means well. What
complications should I expect? he asks and Sir/Madam, no
antibiotics? he continues with a bewildered look.
What will you teach this young lad?
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Complications
Pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Atelectasis
Secondary infection
Therapy related
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Role of antibiotics
Consider only in those with poor response, purulent
secretions and radiological evidence of infection.
Bacterial infections seldom trigger asthma
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Case
36 hours later Sanjana is showing signs of improvement. On your
morning round, you find her sitting up comfortably sipping her tea.
She says she slept well through the night. On examination she is
mildly tachypnoeic and her wheeze is now only in the terminal phase
of respiration.
Can I go home? she asks
How will you reduce her medication and when will you
decide to discharge her?
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Stepping down acute care
Follow the principle last in first out
Discontinue terbutaline /aminophylline drip in 24
hours
Discontinue ipratropium neb in 24-48 hours
Reduce SA 2agonist to q 2-4 hrly and then q 4-
6hrly
Replace iv steroid with oral steroid
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Discharge criteria
Pulmonary score < 3
Slept well at night
Feeding well
Appears comfortable.
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Cases. contd
What will you advise Arpit and Sanjana when they areready to go home?
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Discharge plan
Inhaled SA 2agonist MDI + spacer + mask q 4-6 hour till
symptoms
Continue course of rescue steroid for 3-7 days (Tapering not
necessary)
Review compliance, trigger elimination, preventer regime
Educate regarding home plan / long term strategy
Plan follow up visit within 7-14 days
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If a child requires
rescue steroids / 2 - agonists frequently,
explore reasons for poor control.
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Case.
Meanwhile, Raju, a 8 year old with asthma is brought to the hospital in an
ambulance with oxygen by mask. He is too breathless to speak, is
sweating and quite agitated. On examination his nails are dusky and on
auscultation you hardly perceive any air entry. He has shown no
response to 3 doses of nebulized bronchodilator given while he was
rushed in with sirens blaring.
ACT FAST beg the parents.
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AsthmaRed flagsigns
Unable to talk or cry
Cyanosis
Feeble chest movements Absent breath sounds
Fatigue or exhaustion
Agitated
Altered sensorium
Oxygen saturation < 92%
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ICU plan
Continue / initiate intensified ward plan
Blood gas studies
Possible intubation and mechanical ventilation withketamine and midazolam / fentanyl iv infusion
Paralysis with vecuronium, if required
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To summarize
Asthma is an inflammatory illness
Diagnosis of asthma is clinical, and relies on history
All asthma does not wheeze
In children < 3 yrs, WALRI is an important differential diagnosis
2 out of 3 children outgrow their asthma
A family history of asthma / atopy increases risk of asthma
Diagnosis
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To summarize
Patient education is a very important part of asthma management
Drugs control, but do not cure asthma
Clinical grading over time, decides long term management plan
Mild intermittent asthma does not merit preventers
Inhaled steroids are mainstay of long term asthma management
Treatment should be stepped up or stepped down depending upon patient
response
Long term management
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To summarize
Grading at a point in time decides management
SA inhaled 2agonists are used to manage acute exacerbations
Frequent use of SA 2agonists indicate poor control of asthma
Taking care of the home environment reduces exacerbations of asthma
MDI should always be used with spacer
Acute management
Devices
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