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MANAGEMENT OF SEVERE EXACERBATION IN ASTHMA
DR.RABIA SALEEM SAFDARPOST GRADUATE TRAINEEPAEDIATRICS UNIT 1,NHM.
DEFINITION:
acute episode of• airflow obstruction• airway hyperresponsiveness
occurs on a background of chronic airway inflammation
DEFINITION:
Acute severe asthma, formerly known as status asthmaticus, is defined as: Severe asthma unresponsive to repeated courses of ß2 agonist therapy.
Medical emergency
Requires immediate recognition and treatment
TRIGGERS
Viral infection of the upper respiratory tract
Bacterial infection
Inhaled allergens. Environmental irritants
Emotions
Exercise
Medications
Poor asthma control
Risk factors for potentially fatal asthmaPrevious near-fatal asthmaPrevious admission to a PICU for asthmaAdmission for asthma in the last year
Excessive use of or overdependence on ß2 agonistsCurrent use or recent use of oral corticosteroids
Repeated attendances at emergency unit for asthma treatment, especially if in the last year
‘Brittle’ asthma (sudden onset of acute severe asthma attacks)
Poor adherence to medication
Psychosocial and/or family problems
Assessment
pulse rate
respiratory rate and degree of breathlessness (ability to complete sentences in one breath or to feed)
use of accessory muscles of respiration\amount of wheezing
degree of agitation and level of consciousness
PEFR
Initial and first-line management of acute asthma
Oxygen
Short-acting beta-2 (β2)-agonist bronchodilators
Steroid therapy
Ipratropium bromide
Additional therapy for acute asthma
Magnesium sulphate
Intravenous salbutamol infusion
Intravenous aminophylline
Child with asthma exacerbation
Clinical assessment,ABG’s,CXR,pulse
oximetry
Initial therapy in first hour of management
OxygenWhen spO2 <92 % via nasal cannula or face mask
B2-agonists:Nebuliser: salbutamol 0.5-0.6mg/kg+ saline. Repeat at 20 - 30-minute intervals
Steroid therapy:Hydrocortisone10 mg/kg IV statThen 5 mg/kg IV q 6 hrMP 2 mg/kg 8hour IV loading then0.5mgLkg IV every 6hrs Dexa 0.6 mg/kg IV
Iptatropium Bromide:Add 250 μg IB/dose to 2.5 - 5.0 mg of salbutamol with saline to make a total volume of 4 ml* in the same nebuliser and administer every 20 - 30 minutes initially then 4 - 6-h
Repeat assessment after 1hr
ModeratePEF < 60-80%Moderate symptoms
SevereHigh risk ptPEF<60%Severe symptoms
Treatment•Oxygen•B2-agonist nebulizatiion and IB every 60mins•Oral steroids•Continue 1-3 hrs until improvement
Treatment•Oxygen•B2-agonist and IB nebulization•Systemic steroids•A single dose of intravenous magnesium sulphate 25 - 75 mg/kg over 20 mins
Reassess after 1-2 hrs
Good responseResponse sustained 60mins after last treatmentNo distressSpO2 >90%PEFR>70%
Incomplete response Mild to
moderate Symptoms
PEFR <60%
SpO2 not improving
Poor responseHigh risk ptSevere symptomsPEFR <30%PCO2>45mHgPO2<60mm HgPlan for
discharge
Admit in ward
Admit to ICU
WARD CAREOxygenInhaled B2-agonists + IBSystemic corticosteroidsMonitoring PEFR,SpO2,pulse,K level
ICUOxygenInhaled B2agonists + IBSystemic corticosteroidsConsider iv *terbutaline infusion*IV loading dose of terbutaline(5 - 10 μg/kg iv in 10minz followed by continuous infusion (0.4-4ug/kg/min)Consider iv aminophylline infusionA 6 mg/kg loading dose of aminophylline should be given over 20 minutes under continuous ECG monitoring, followed by a continuous infusion at 0.5 - 1 mg/kg/h
Improved
Plan discharge
Improved
Poor response
Poor response
Reassess at intervals
Possible intubation &Mechanical ventilation
Criteria for DischargePEFR>60%Sustained on oral/inhaled medicationHome treatmentInhaled beta-agonistsOral steroidsCombination inhalersPatient education1. Take
medicine correctly
2. Review action plan
3. Close medical follow up
Criteria for ventilation: � Severe hypoxia � Depressed level of consciousness � Obvious life-threatening respiratory distress not responding to bronchodilatorImpending respiratory failure � Hemodynamic compromise, including bradycardia,pulsus paradoxus � Lactic acidosis associated with increased work of breathing � Apnea or near-apnea � Peak flows <40% of predicted
General guidelines for mechanical ventilation management:
1. Start with low tidal volume• Tidal volume 4-7 ml/kg • Low Ventilatory rate 10-14 breaths per minute• I:E ratio 1:4 to 1:6 • Tolerate hypercapnia• Goal pH>7.25• Peak pressures <30-35
2. Keep well sedated – consider ketamine
3. Prevent bronchoconstriction with suctioning by providing adequate sedation
4.Limit use of paralytics
NEED PRAYERS FOR MY FATHER’SHEALTH
THANK U