Acute severe asthma Acute severe asthma who is

Acute severe asthma

Acute severe asthma : who is at most risk ? l Previous life-threatening attacks l Severe disease (3 or >3 drugs for control; emergency steroid in past ; ever admitted in last 1 year) l Psychiatric morbidity l Non-compliance l Requiring 2 or > 2 Bronchodilator inhalers monthly

Near fatal episodes l l l l l Misuse of drugs/alcohol Psychiatric illness Denial Non compliance Learning difficulties Previous admission to ICU for asthma Brittle asthma Social isolation, income and employment difficulties Previous self discharge from hospital Br Med J 2005; 330585 -9

What is acute severe asthma ? ANYONE OF: l PEF 33 -50% best or predicted l RR 25/min l Heart rate 110/min l Inability to complete sentences in one breath

What is life threatening asthma ? ANYONE OF: l PEF < 33% best or predicted l Sat O 2 < 92% l Pa. O 2< 55 mm Hg l Normal Pa. CO 2 l Silent chest l Cyanosis l Feeble respiratory effort

Contd……. l Bradycardia l Dysrhythmia l Hypotension l Exhaustion l Confusion l Coma

What is near fatal asthma? l Increased Pa. CO 2 l Requiring mechanical ventilation

What is brittle asthma? l Type 1… > 40% diurnal variability in PEF for > 50% of the time over a period > 150 days despite intense therapy l Type 2 … sudden severe attacks on a background of apparently well controlled asthma

Criteria for hospital admission ADMIT IN ICU l Near fatal attack l Life threatening attack ADMIT IN ICU l Severe attack persisting after initial treatment l Previous near fatal or brittle attack l Concerns about compliance l Living alone l Psychological problems l Physical disability / learning difficulty l Pregnancy l Presentation at night

Hospital Treatment – Immediate action l l l l CBC (to r/o infection) Chest X-ray (to r/o pneumothorax) Oxygen (40 -60%) β 2 agonist –nebulised or MDI + spacer Inhaled Ipratropium can be added if required Systemic steroid (Prednisolone / Hydrocortisone) Inhaled steroids to be continued or started as soon as posible Avoid sedation

Nebulised salbutamol 5 mg or 0. 15 - 0. 3 mg/kg salbutamol hourly (to a maximum of 10 mg per hour have been used in trials so far) Nebulised Ipratropium bromide 250 -500 mcg 6 hourly

Acute severe asthma…continues l Oxygen continues l Nebulised ß 2 -agonist (5 mg salbutamol every 20 minutes or continuously at 5 -10 mg/hr) l Nebulised ipratropium bromide (500 mcg 4 -6 hrly ) l Combination of above two

Acute severe Asthma Treatment (Contd. ) l Obtain IV access l Start steroids (4 mg/kg hydrocortisone loading dose, then 100 mg 6 hrly) l Antibiotics ( not routinely ) l Adequate hydration l Still deteriorating - Start Aminophylline infusion (0. 5 - 0. 7 mg/kg/hr)

Acute severe Asthma Treatment (Contd. ) l Adrenaline (0. 1 mg sc) l Cautious CPAP (ideally Bi. PAP) l Mechanical ventilation – 6 - 10 RR – Low TV (6 - 10 ml / kg) – I: E ratio 1: 3 or longer – Maintain Pa. O 2 > 60 mm. Hg – Allow Pa. CO 2 to rise, provided p. H > 7. 2 – Adequate sedation and paralysis

Management of acute severe Asthma in children > 2 years l High O 2 concentrations l β 2 agonist –nebulised or MDI + spacer l Systemic steroids ( Oral / IV ) l IV Bronchodilators ( Salbutamol 15μg/kg bolus or continuous infusion of 1 -2μg/kg/min upto 5μg/kg/min in PICU)

Treatment (general practice) l Oxygen (Check Room air O 2 saturation if available) l Nebulised salbutamol 5 mg l Prednisolone (30 -60 mg) or IV Hydrocortisone 200 mg l Nebulised Ipratropium Bromide (500 mcg) l SC Terbutaline / IV Aminophylline (5 mg/kg bolus over 20 mins. ) l Arrange for ambulance

Emergency Department Management Acute Asthma Initial Assessment History, Physical Examination, PEF or FEV 1 Initial Therapy Bronchodilators , O 2 if needed Good Response Incomplete/Poor Response Observe for at least 1 hour Add Systemic Glucocorticosteroids If Stable, Discharge to Home Good Response Poor Response Discharge Admit to Hospital Respiratory Failure Admit to ICU

Instructions / points on discharge l Been on discharge medication for 24 hours l Inhaler technique checked l PEFR diurnal variability < 25% l Oral + inhaled steroids / bronchodilators l ? PEFR meter l Follow-up appointment < 48 hrs with GP

‘Treat acute severe asthma at least 4 days before it occurs’ Thomas Petty

PREVENT ACUTE ATTACKS OF ASTHMA BY TAKING REGULAR INHALED CORTICOSTEROID TREATMENT