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• PRESENTATIONANDDIAGNOSIS
• CLASSIFICATIONOFASTHMABYLEVELOFCONTROL
• ASSESSMENTOFASTHMACONTROLUSINGTHEASTHMACONTROLTEST
• ASTHMAMANAGEMENTBASEDONLEVELSOFCONTROL
• MANAGEMENTOFASTHMAEXACERBATIONS:-HOWSEVEREISTHEASTHMAATTACK?
• MANAGEMENTOFACUTEASTHMAEXACERBATIONSINCHILDREN
• MANAGEMENTOFACUTEASTHMAEXACERBATIONSINADULTS
• WHENTOREFER
Bronchial asthma
Contributors: DrChongPhuiNahDrTangWernEe
Advisors: ProfLimTowKeangA/ProfJohnAbisheganadenA/ProfDanielGohYamThiamA/ProfLynetteShek
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PRESENTATION AND DIAGNOSIS
57
Bronchial asthma
Adult:
•Calung,bronchiectasis
•COPD,emphysema
•Pulmonarytuberculosis
•Suppurativelungdisease
•Pulmonaryoedema
•Upperairwayobstruction/
inhaledforeignbody
•Vocalcorddysfunction
Reversible episodic wheeze and cough
Nocturnal symptoms
YES YES
Features supportive of diagnosis of asthma
•Frequentepisodesof wheeze(morethanoncea month)
•Activityinducedcoughor wheeze
• Nocturnalcoughinperiods withoutviralinfections
•Symptomspersistafterage3
Children
•Recurrentviralinfectionswith wheezing
•Chronicrhino-sinusitis
• Gastro-oesophagealreflux
•Bronchopulmonarydysplasia
•Chroniclungdiseaseof prematurity
•Aspirationsyndromes includingforeignbody aspiration/recurrentsilent aspiration
•Congenitalmalformationsof lung
•Congenitalheartdisease
Supportive Evidence
• Atopicfeatures • Familyhistoryofasthma/atopy
*Home PEF Variability (PEFdiary) >20%diurnalvariation
*Reversible airway obstruction Bronchodilatorresponse: >20%FEV1&≥200ml increaseinFVCorFEV1after bronchodilatorchallenge
*Bronchial provocation
•Exercise •Methacholine • Histamine
<5yearsold
Exclude Alternative Diagnosis
≥5yearsold
*Eitherofthesetestscanbeused
• PEFistheleastreliableasPEFis highlyeffortdependent
• Officespirometrymaybeusedto assessbronchodilatorresponse
Do CXR if other diagnosis suspected or consider
other diagnostic tests in the presence of:
•Neonatal/earlyonset
•Failuretothrive,LOW
•Frequentvomiting/choking
•Focallungsigns,haemoptysis
•Vocalcorddysfunction
Commence on trial of asthma therapy
Review diagnosis if response is poor
BronchialAsthma
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BronchialAsthma
Notes
1. Investigations
Investigationsareusuallynotnecessaryexceptinsevereoratypicalcases,andinpatientswhodonotrespondtotherapy.
Someinvestigationswhichmaybeconsideredare
(i) ChestX-raytoexcludeforeignbodyorchronic chestinfectionortoexcludecomplicationsin severeacuteepisodes.
(ii) PulmonaryFunctionTests-Peakexpiratory flowrate(PEFR)/Spirometry.
• Thedemonstrationofdiurnalvariation ofPEFR≥20orbronchodilatorresponse resultinginimprovementofFEV1(Forced expiratoryvolumeinonesecond)by≥12% isindicativeofairwayhyper-responsiveness andairflowreversibility.
(iii) SkinPrickTest:
• Thisisusefulforthedemonstrationofatopy, especiallyinpatientswithnoclinicalsignsof eczemaorfamilyhistoryofatopy.
• Skinpricktestsmaybeusefulinguiding patientadviceonenvironmentalcontrol.
• Otherallergytestssuchasantigenspecific IgG,IgG4,intradermalskintestsarenot useful.Foodallergytestingisalsonotuseful forevaluationofasthmaperse.
(iv) Exhalednitricoxide
• Thisprovidesanon-invasiveassessmentof airwayinflammationthatisnotspecificbut usefulformonitoringofdiseaseand compliancetoinhaledcorticosteroids.
(v) AirwayChallengeTests–usingexerciseorwith inhalationofmethacholineorhistamine.
• Exercisechallengeisalsousefulforevaluation ofexercise-inducedasthma.
(vi) Otherteststoexcludeothermedicalconditions
• Mantouxtest–toexcludeMycobacteria infection
• Otolaryngologicevaluationofthesinusesand/ orCTscanofthesinuses
• Gastroesophagealrefluxstudies,e.g. esophagealpHmonitoring
• Bronchoscopytoexcludestructuralanomalies
• Immunologicalinvestigations,e.g.HIV,Serum Immunoglobulintitres
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2. Other Modes of Presentation
• Coughvariantasthmawithoutwheezing Maybethegroupover-diagnosedasasthma. Ruleoutrhinitisandsinusitis
• ‘Hypersecretoryasthma’–Coughandexcessive secretions.Usuallyyoungpatients;more crepitationsthanwheezing
• ‘Firstacutewheeze’–Excludeinfections,foreign bodyaspiration
• Recurrentviralwheezingin0-2yearagegroup withoutatopymaynotrespondtoasthma treatment
• Incigarettesmoker,considerCOPDwithasthma
• Exercise-inducedbronchoconstruction
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Bronchial asthma
3. Asthma Management should include:
• Gooddoctor-patientrelationship
• Identificationandreductionofexposuretorisk factorssuchasdustmites,molds,pets,pollen andcigarettesmoke
• Assessment,treatmentandmonitoringof Asthma
• Manageasthmaexacerbations
• PatienteducationincludingWrittenAsthma ActionPlan
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CLASSIFICATION OF ASTHMA BY THE LEVEL OF CONTROL
TheGlobalInitiativeforAsthma(GINA)guidelinesdefinethecontrolofasthmainto3categories:
• Controlled
• PartlyControlledand
• Uncontrolled
* Anyexacerbationshouldpromptreviewofmaintenancetreatmenttoensurethatitisadequate.† Bydefinition,anexacerbationinanyweekmakesthatanuncontrolledasthmaweek.‡ Lungfunctionisnotareliabletestforchildren5yearsandyounger
Bronchial asthma
Level of Asthma Control
High Risk Patients are patients who:
• Have2ormoreexacerbationspermonthrequiringacutecare
• Have2ormorehospitalizationsforasthmain3months
• Requiretheuseofrescuemedication3ormoretimesaweek
• HavehistoryofsevereasthmaexacerbationsrequiringcareintheHighDependencyorIntensiveCareUnit
CHARACTIERISTIC
Daytimesymptoms
Limitationsofactivities
Nocturnalsymptoms/awakening
Needforreliever/rescuetreatment
Lungfunction(PEForFEV1)‡
Exacerbations
CONTROLLED(All of the following)
None(twiceorless/week)
None
None
None(twiceorless/week)
Normal
None
PARTLY CONTROLLED(Any Measure Present In Any Week)
Morethantwice/week
Any
Any
Morethantwice/week
<80%predictedorpersonalbest(ifknown)
oneormore/year*
UNCONTROLLED
Threeormorefeaturesofpartlycontrolled
asthmapresentinanyweek
Oneinanyweek†
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Thisisa5-item,patient-administeredquestionnaireforassessingasthmacontrol(Figure1).Itisasimple,objective,robustandvalidatedmethodformonitoringcontrolbydoctors(andpatients),whichisbeingusedinternationally.AmanagementplanbasedonACTassessmentisprovidedbelow(Figure3).
Thereisalsoa7-itemAsthma Control Test For Children Aged 4-11 Years Old©(Figure2).
Figure1:AsthmaControlTest(ACT)©foradultsandchildrenaged12andabove
Asthma Control Test (ACT)
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Bronchial asthma
ASSESSMENT OF ASTHMA CONTROL USING THE ASTHMA CONTROL TEST
© 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated.
© 2001 - 2005, GlaxoSmithKline Group of Companies. All Rights Reserved.
Basedonafive-pointscoringsystem,amaximumscoreof25willindicate‘totalcontrol’ofasthma.‘Wellcontrolled’asthmaisdefinedasascoreof20-24,andascoreoflessthan20willimply‘poorcontrol’.
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BronchialAsthma
Figure 2: Asthma Control Test For Children Aged 4-11 Years Old©
© 2001 - 2005, GlaxoSmithKline Group of Companies. All Rights Reserved.
Ascoreof19orlesssuggestspoorasthmacontrol.Ascoreof20orabovesuggeststhechild’sasthmamaybeundercontrol.Ascoreof27indicates‘Totalcontrol’ofasthma.
Bronchial asthma
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*ICS(inhaledglucocorticosteroids) **Receptorantagonistorsynthesisinhibitors ***Preferredcontrolleroptionsareshowninshadedboxes
Alternativerelievertreatmentsincludeinhaledanticholinergics,short-actingoralβ2-agonists,somelong-actingβ2-agonists,andshort-actingtheophylline.
Regulardosingwithshortandlong-actingβ2-agonistisnotadvisedunlessaccompaniedbyregularuseofaninhaledglucocorticosteroid.
Bronchial asthma
Management Approach Based on Control For Children Older Than 5 Years, Adolescents and Adults
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Level of Control
Step 1 Step 2 Step 3 Step 4 Step 5
Controlled
TreatmentSteps
Maintainandfindlowestcontrollingstep
Considersteppinguptogaincontrol
Stepupuntilcontrolled
Treatasexacerbation
ACTscore<20ACTscore>20
PartlyControlled
Uncontrolled
Exacerbation
Treatment Action
Red
uce
Incr
ease
IncreaseReduce
AsthmaEducationEnvironmentalControl
ControllerOptions***
Selectone
Low-doseinhaledICS*
Leukotrienemodifier**
Medium-orhigh-doseICS
Leukotrienemodifier
Anti-IgETreatment
Selectone Addoneormore Addoneorboth
Low-doseICSplusleukotrienemodifier
Sustainedreleasetheophylline
Low-doseICSplussustainedreleasetheophylline
Figure3:ManagementofAsthmatoAchieveControl
Oralglucocorticosteroid
(lowestdose)
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ASTHMA MANAGEMENT BASED ON LEVELS OF CONTROLManagement in Adults, Adoloscents and Children Older Than 5 Years
Thepatient’scurrenttreatmentandlevelofcontroldeterminetheselectionofpharmacologictreatment.Ifasthmaisnotcontrolledonthecurrenttreatment,treatmentshouldbesteppedupuntilcontrolisachieved.Controlisusuallymaintainedforatleast3monthsbeforeanattemptismadetostepdownthetreatment,withtheaimtoestablishtheloweststepanddoseoftreatmentthatmaintainscontrol.
Figure3showsthesteps1-5forachievingcontrol. Eachsteprepresentstreatmentoptionsinstepsofincreasingefficacy.InthemanagementschemedescribedinFigure3,thedoseofdailyasthmamedicationisadjustedaccordingtheACTscoresevaluatedateachclinicvisit.
Patients who do not achieve good asthma control despite Step 4 levels of treatment have refractory asthma and should be reviewed by a specialist. Management at Step 5 should be supervised directly by specialists.
PatientsshouldalsobetaughthowtoimplementaWrittenAsthmaActionPlanforself-managementofexacerbationsbetweenvisits.Patientsmayalsobeadvisedtoperformmonthlyself-monitoringusingtheACTbetweenclinicvisits.
Management in Children aged 5 and younger
• Theavailableliteratureontreatmentofasthmainchildrenaged5andyoungerprecludesdetailedtreatment recommendations.
• Thebestdocumentedtreatmentisinhaledglucocorticosteroids.
• ConsiderreferraltoPaediatricspecialistifthepatient’sresponsetotreatmentisnotasgoodasexpectedorif thechildremainssymptomatic.
Recommended inhaler devices for children
<4years MDIwithspacer+afacemask
4-6years MDIwithspacerwithmouthpiece
>6years MDIwithspacerwithmouthpieceoraccuhaler
>9years MDIwithspacerwithmouthpieceorturbuhaler
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Addontherapy:
• Tobeconsideredifnotachievingadequatecontroldespite:
i. goodcompliance;and
ii. satisfactoryinhalertechnique;and
iii. propertriggeravoidance
• Alternativesasadd-ontherapyinclude:
i. Inhaledlongactingβ2-agonists(LABA)
ii. Leukotrienemodifier
Note: LABAs should NOT be used without concomitant inhaled corticosteroids.
Indications for referral to the Paediatric specialist for further evaluation and management:
1. Patientswithhighriskasthmawithpoorcontrol
2. Patientsagedlessthan3yearsoldrequiringhighdosesofinhaledsteroids
3. Patientswhoremainsymptomaticdespitesuboptimalresponsetotherapy
4. PatientsrequiringhighdosesofinhaledsteroidsBDP/BUD≥400mcg/day
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Bronchial asthma
Management in Children Aged 5-12
EstimatedEquipotentDailyDosesofInhaledGlucocorticosteroidsforChildren
Drug
Beclomethasone Diproprionate 100-200 >200-400 >400
>400
>500
>200-400
>200-500
100-200
100-200
Budesonide
Fluticasone
Low Daily Dose (mcg) Medium Daily Dose (mcg) High Daily Dose (mcg)
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BronchialAsthma
MANAGEMENT OF ASTHMA EXACERBATIONS: HOW SEVERE IS THE ASTHMA ATTACK?
*Thepresenceofseveralparameters,butnotnecessarilyall,indicatethegeneralclassificationoftheattacks.Notealsoanypriorusageof bronchodilatorasthismayalterthepresentingclinicalpictures.Please refer to the Guide to Normal Respiratory and Pulse Rates in Infants and Children, found on the last page of this Bronchial Asthma chapter.
Bronchial asthma
SEVERITY
SYMPTOMS
Breathless
Feeding(infant)
Talksin….
Alertness
SIGNS
Respiratoryrate*
Useofaccessorymuscles/suprasternalretractions
Wheezes
Pulserate*
FUNCTIONAL ASSESSMENT
PEF
PulseOximetryPaO2(onair)
MILD
Whilewalking
Canliedown
Feedsnormally
Sentences
Maybeagitated
Increased
Usuallynot
Moderate,oftenonlyendexpiratory
<100/min(adults
>80%
>95%
MODERATE
Whiletalking(infant-softer,shortercry)
Prefersitting
Difficultyfeeding
Phrases
Usuallyagitated
Increased
Usually
Loud
100-200/min(adult)
Approx.60%-80%
91%-95%
RESPIRATORY/ASSEST IMMINENT
Drowsyorconfused
Paradoxicalthoraco–abdominalmovement
Absenceofwheeze Bradycardia
SEVERE
Whileatrest
Hunchedforward
Stopsfeeding
Words
Usuallyagitated
Often>30/min(inadults)
Usually
Usuallyloud,throughoutinhalationandexhalation >120/min(adults)
<60%predictedorpersonalbestinservreasthmaexacerbation
<90%
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Assess Severity Assessmentintheveryyoungmaybedifficult.Childrenwithsevereattackmaynotappeardistressed.
Bearinmindforeignbodyaspiration.
1.HighflowO2viamask(6-10L/min)toachieveSaO2>95%2.IVaccess3.IVhydrocortisone4mg/kgstat(max100mg)4.Nebulizedsalbutamolwithipratropiumevery20minuteswhileawaitingtransfertohospital
Neb: Salbutamol: Ipratropium: Normal Saline:Weight≤10kg: 0.5mls0.5mls 3mlsWeight>10kg: 1ml1ml 2mls
s/corETTadrenaline1:10000.1-0.3ml(0.01ml/kg)onlyforthoseabove2yrold
Using a spacer with a metered-dose inhaler has been shown in clinical studies to be as effective as using a nebulizer in the delivery of a bronchodilator in the treatment of an acute asthma exacerbation.
*Ashortcourseoforalsteroidsshouldbeconsideredifthechildmeetsoneofthefollowingcriteria:1. requiresfrequentβ2–agoniststherapy(morefrequentlythan4hourly)2. hasapasthistoryoflife-threateningasthmaexacerbation3. isonhighdoseinhaledsteroidorlowdoseoralmaintenancesteroidtherapy.For patients with moderate to severe exacerbations, a dose of prednisolone 1-2 mg/kg/day [max 40mg] can be given for 3 to 5 days without a need to taper the dose. Paediatric patients requiring prolonged or repeated courses of oral steroid to control their asthma should be referred to a specialist for further evaluation and management.
Life-threatening Asthma Exacerbation
Respiratory:Cyanosis/Tachypnea,Exhaustion/ SilentChest/SaO2<91%
Neurological:Confusion/drowsiness
Cardiovascular:Pulsusparadoxus
Deteriorationinconditiondespitemaximaltherapy
Mild / Moderate Asthma Exacerbation
Mild/modtachypnea,no/minimumchestretractions,
No/minimumuseofaccessorymuscles,SaO291-95%
Arrange transfer to Hospital immediately
Severe Asthma Exacerbation
Tachypneic+,chestretractions,
Useofaccessorymuscles++,SaO2<91%
Bronchial asthma
Neb: Salbutamol : Ipratropium : Normal Saline Weight≤10kg: 0.5mls 0.5mls 3mlsWeight>10kg: 1ml 1ml 2mls
1. Repeatx1-2cyclesasneeded2. Oralprednisolone1mg/kg(max40mg)stat3. HighflowO2viamask(6-10L/min)toachieve SaO2>95%4. Reviewafter1-2cycles,refertohospitalA&Eifno improvement/deterioration
Improved
Improved
Improved
No improvement
Some improvement
Reassess after 15 min – 30min
Discharge with appropriate advice and follow-up*
CheckMDItechniqueKIVspacerandsetaTCUdate Repeat salbutamol MDI via
spacer or Neb
No improvement
Refer to Hospital A&E
No improvement
1.Weight≤10kg:SalbutamolMDI5puffsx2cyclesat15minintervalsWeight>10kg:SalbutamolMDI10puffsx2cyclesat15minintervals
2.Formoderateexacerbation: a. Oralprednisolone1mg/kg(max40mg)stat b. AddIpratropium(Atrovent®)2puffs
3.KeepSaO2>95%,addO2@4L/minvianasalprongsifnecessary
4.Reviewafter2cycles
5.ConverttoNebulizerifchildisfatigued
Neb: Salbutamol : Ipratropium : Normal Saline Weight≤10kg: 0.5mls 0.5mls 3mlsWeight>10kg: 1ml 1ml 2mls
MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN CHILDREN
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Mild / Moderate Asthma ExacerbationMild/modtachypnea,
No/minimumuseofaccessorymuscles,SaO291-95%
1.MDIbronchodilatorviaSpacersteps#*:
4puffsSalbutamol+ i.e.8puffsevery10-15minutes
4puffsIpratropium Patienttoinhale2-3xviathemouth/lipsafterevery2puffs.Repeat2-4cyclesasneeded
2.Doctortoreviewafterevery2ndor3rdcycle
3.Maystopbefore4thcycleifpatientisnolonger symptomatic
4.Torepeatcyclesasneeded5.Oralprednisolone30-60mgstat
6.TorefertohospitalA&Eifnoimprovementafter8 cycles(orearlierasclinicallyindicated)
*Converttonebulizerifpatientisfatigued:Neb Salbutamol : Ipratropium : Normal Saline
1ml 2mls 1ml
RefertoA&Eifnoimprovementafter2roundsofnebulizationorequivalent
1. HighflowO2viamask6-10L/mintoachieveSaO2>95%2. IVaccess3. IVhydrocortisone200mgstat4. Nebulizedsalbutamolwithipratropiumevery15-20 minutes whileawaitingtransfertohospital5. Neb Salbutamol : Ipratropium : Normal Saline 1ml 2mls 1ml
6.Considers/cadrenaline1:10000.5ml(0.01ml/kg)
ArrangetransfertoHospitalimmediately
Severe Asthma ExacerbationCan’tcompletesentences,TachypneicPulse>110/minRespRate>25/minPEF<50%predictedorbestSaO2<91%
Life-threatening Asthma Exacerbation
Respiratory:Cyanosis/Tachypnea,Exhaustion/ SilentChest/SaO2<91%
PEF<33%predictedorbestNeurological:Confusion/drowsinessCardiovascular:PulsusparadoxusDeteriorationinconditiondespitemaximaltherapy
1. HighflowO2viamask6-10L/mintoachieveSaO2>95%
2. IVaccess
3. IVhydrocortisone200mgstat
4. Neb Salbutamol : Ipratropium :NormalSaline 1ml 2mls 1ml
5. Torepeatabovenebulizationifindicated
6. Reviewafter30minutes
7. RefertoA&Eifnoimprovementafter2roundsof nebulization.
#Clinicalequivalencetosingle“round”ofnebulisation(neb):
1“round”ofneb=3-4cyclesofthefollowingtreatment:
4puffssalbutamol+4puffsIpratropium i.e.8puffsevery10-15minutes
MDI+SpacerMethod
a. Primethespacerwith8to10puffsofSalbutamol
b. Loadthespacerwith2puffseachtime,patienttoinhale2–3times(tidal breaths)afterevery2puffs(ifpatientcancooperate,deepbreathswithbreath holdingrecommended).
c. Oxygencanbeadministeredconcurrentlyvianasalprongsifrequired– maintainSAO2>95%forpatientswithasthma.
d. Nursetoadministerpuffs,ensureinhalationviathemouth/lips
e. Patientcanself-administerbronchodilatortreatmentwithsupervisionby medicalstaff
Bronchial asthma
Assess Severity of Asthma Exacerbation
MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN ADULTS
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Clinical Assessment after Bronchodilator TreatmentSymptoms,physicalexamination,O2saturation,PEF,othertestsasneeded
Good Response
•Responsesustained60minutesafterlasttreatment•Physicalexaminationisnormal•PEF>70%predicted•Nostress•O2saturation>90%
Historyofhigh-riskpatientPhysicalexamination:•Mildtomoderatesymptoms•PEF>50%-70%•O2saturationnotimproving
Historyofhigh-riskpatientPhysicalexamination:• Symptomssevere, drowsiness,confusion•PEF<30%•pCO2>45mmHg•O2saturation<90%
Action:
•RefertoHospitalA&E
•O2viamask6-10L/mintoachieveSaO2>95%
•Nebulizedsalbutamolwithipratropiumevery 15-20minuteswhileawaitingtransfertohospital
•i/vHydrocortisone200mgstatifnotalreadyadministeredearlier
Incomplete Response Poor Response
Action:
•Discharged
•Continuetreatmentwithinhaledβ2–agonists
•Considercourseofprednisolone30mgomfor5-7daysinmostcases
•Initiateorcontinueinhaledglucocorticosteroids
•Reinforcepatienteducation,actionplanandclosefollow-up
Action:
•ARRANGEURGENTTRANSFERTOHOSPITALviaambulanceimmediately
•HighflowO2viamask6-10L/mintoachieveSaO2>95%
•Nebulizedsalbutamolwithipratropiumevery15-20minuteswhileawaitingtransfertohospital
•i/vHydrocortisone200mgifnotalreadyadministeredearlier
•Considers/cadrenaline1:10000.5ml(0.01ml/kg)
•Possibleintubation&mechanicalventilation
Bronchial asthma
MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN ADULTS (Continued)
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Risk factors for death from asthma
• Priorintubationandmechanicalventilation forasthma
• Hospitalizationoremergencycarevisitfor asthmainthepastyear
• Currentuseofsystemiccorticosteroidsorrecent withdrawalfromsystemiccorticosteroids
• Notcurrentlyusinginhaledcorticosteroids
• Useof>1canisterofinhaledshort-acting β2–agonistswithin1month
• Historyofpsychiatricdiseaseor psychosocialproblems
Patients at high risk of dying with asthma require special attention, monitoring and care, particularly intensive education, including advice to seek medical care early during an exacerbation.
Bronchial asthma
WHEN TO REFERAcute Asthma – Severe or Frequent Exacerbations
1. Alife-threateningasthmaexacerbation.
2. Frequentexacerbations: • acuteexacerbations2-3timesayear,or • morethanonceeverysixmonths,despite compliancewithmedicationsandgood inhaler(orinhaleranddevice)technique
3. Needforcontinuousoralcorticosteroid therapyorStep5therapy
Chronic Asthma – Difficult or Poor Control
1. Failinggoalsoftherapyafter3to6monthsof treatment.
2. UncontrolledAsthma
3. Underage3andrequiringstep3or4care.
4. Steroiduse: • continuousoralcorticosteroidtherapy,or • requiremorethantwoburstsoforal corticosteroidsin1year,or • high-doseinhaledcorticosteroids
Diagnosis
1. Atypicalsignsandsymptoms.
2. Otherconditionscomplicateasthmaorits diagnosis,e.g.heartfailure,COPD,unsure ofdiagnosis.
3. Additionaldiagnostictestingisindicated.
4. Suspicionofoccupationalasthma.
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Abbreviations < Lessthan ≤ Lessthanorequalto> Morethan ≥ MorethanorequaltoBDP Beclomethasonediproprionate BUD BudesonideCa Carcinoma COPD ChronicobstructivepulmonarydiseaseCXR Chestx-ray ETT Endotrachealtube FEV1 Forcedexpiratoryvolumein1second
References1. MinistryofHealth,Singapore.MOHClinicalPracticeGuidelinesManagementofAsthma,January20082. GlobalInitiativeforAsthma.Globalstrategyforasthmamanagementandprevention,Updated2009.3. NathanRA,SorknessCA,KosinskiM,SchatzM,LiJT,MarcusP,etal.DevelopmentoftheAsthmaControlTest:asurveyforassessing asthmacontrol.JAllergyClinImmunol2004;113:59-65.4. CatesCC,BaraA,CrillyJA,RoweBH.Holdingchambersversusnebulisersforbeta-agonisttreatmentofacuteasthma.Cochrane DatabaseSystRev.2003;(3):CD000052.5. TurnerMO,NoertjojoK,VedalS,BaiT,CrumpS,FitzGeraldJM.Riskfactorsfornear-fatalasthma.Acase-controlstudyinhospitalized patientswithasthma.AmJRespirCritCareMed1998;157(6Pt1):1804-9.6. SuissaS,BlaisL,ErnstP.Patternsofincreasingbeta-agonistuseandtheriskoffatalornear-fatalasthma.EurRespirJ1994;7(9):1602-9.7. ErnstP,SpitzerWO,SuissaS,CockcroftD,HabbickB,HorwitzRI,etal.Riskoffatalandnear-fatalasthmainrelationtoinhaled corticosteroiduse.JAMA1992;268(24):3462-4.5. SuissaS,BlaisL,ErnstP.Patternsofincreasingbeta-agonistuseandtheriskoffatalornear-fatalasthma.EurRespirJ1994;7(9):1602-9.6. JosephKS,BlaisL,ErnstP,SuissaS.Increasedmorbidityandmortalityrelatedtoasthmaamongasthmaticpatientswhousemajor tranquillisers.BMJ1996;312(7023):79-82.
i/v Intravenous LOW Lossofweight MDI Metereddoseinhaler mths Month(s) O2 Oxygen PEF Peakexpiratoryflow s/c Subcutaneous TCU To-see-you(i.e.reviewappointment)Yr Year(s)
Guide to Normal Respiratory and Pulse Rates in Infants and Children
AGE
<2months <60
<50 <1602-12months 2-12months
<40 <1201-5years 1-2years
<30 <1106-8years 2-8years
RESP RATE (MIN) PULSE RATE (MIN)AGE
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