EMERGENCY MANAGEMENT OF

BRONCHIAL ASTHMA
DR. SAYED

DEFINITION
Asthma is a chronic inflammatory condition of bronchial airways. Three characteristics:

Airflow Limitation, usually reversible Airways Hyper responsiveness. Inflammation of the Bronchi.

Most common childhood chronic disease Affects ~4.8 million (CDC, 1995) 470,000 hospitalizations/yr >5000 deaths annually

DIAGNOSIS
Symptoms ( episodic / variable )

Wheeze Excessive Cough Chest Tightness Shortness of Breath, often worse at Night

Signs:

Sometimes None Wheeze diffuse, bilateral, expiratory (inspiratory) Tachypnea

Helpful Additional Informations.

Personal or Family H/O asthma or Atopy. H/O worsening after Aspirin, NSAID, Beta blocker use. Recognized triggersPollens, Dust, Animals, Exercise, Viral infections, Chemicals, Smoking, Irritants.

Objective Diagnostic Tests:

P.E.F. Charts : More than 20% Diurnal variation on P.E.F. Reversibility Test : FEV1 15% or >15% (200 ml ) after short acting Beta2 agonist or Steroid tablets. Exercise Test : FEV1 15% or >15 % decrease after 6 minutes of running exercise. Histamine or Methacholine Bronchial Provocation test Skin prick test Chest X ray, Blood & Sputum test Allergen Provocation test

Differential Diagnosis
C.O.P.D. Bronchiectasis Hyperventilation syndrome L.V.F. Foreign body Pulmonary Embolism Vocal cord dysfunction

Classification Of Asthma

According to Severity :
Mild Intermittent Asthma Mild Persistent Asthma Moderate Persistent Asthma Severe Persistent Asthma

Mild Intermittent Asthma

Symptoms

Lung Function Test

Symptoms < 2 times/wk Asymptomatic and normal PEF between exacerbations Exacerbations brief (few hrs - few days); intensity may vary Nighttime symptoms < 2 times/month

FEV1 or PEF > 80% predicted PEF variability < 20%

Mild Persistent Asthma

Symptoms

Lung Function Test

Symptoms > 2 times/wk but <1 time/day Exacerbations may affect activity Nighttime symptoms > 2 times/month

FEV1 or PEF > 80% predicted PEF variability 2030%

Moderate Persistent Asthma

Symptoms

Lung Function

Symptoms are Daily Pt has to use of inhaled short-acting beta2 agonist daily Exacerbations affect activity; > 2 times/wk; may last days Nighttime symptoms >1 time/wk

FEV1 or PEF > 60% - < 80% predicted PEF variability >30%

Severe Persistent Asthma

Symptoms

Lung Function Test

Continual Limited physical activity Frequent exacerbations Frequent nighttime symptoms

FEV1 or PEF < 60% of predicted PEF variability >30%

Asthma Management
Goals of Therapy:

Prevent symptoms Maintain (near) normal P.E.F. Maintain normal activity Prevent exacerbations & minimize ER visits/hospitalizations Optimal drug treatment, minimal problems Patient / Family satisfaction

Acute Severe Asthma

Unable to complete sentences in one breath. Respiratory rate 25 or >25/min. Heart rate 110 or >110/min. P.E.F. 33-50% best or predicted. Oxygen saturation <90%. Other Findings : Rhonchi, Pulsus Paradoxus, Cyanosis (late), PEF, ABG : Pa O2, Pa CO2

Life Threatening Asthma

A silent chest, cyanosis or feeble respiratory effort. Exhaustion, Confusion or Coma. Bradycardia or Hypotension. A high PaCO2 >6 KPa.(36 mm Hg) Sever hypoxaemia PaO2 <8 KPa.(60 mm Hg) O2 Saturation <85%. PEF <33% of predicted or best.

MANAGEMENT OF ACUTE SEVERE ASTHMA

OXYGEN. High flow oxygen (40-60%) by mask or cannula to all patients with acute severe asthma.

Beta 2 agonist bronchodilators. Repeated doses of Beta2 agonist (Salbutamol 5mg. Or Terbutaline 10 mg) should be given at 15-30 min. intervals or continuous nebulization of salbutamol at 5-10 mg./hour

Steroid therapy.

Inj. Hydrocortisone 200 mg. I/V (3-4 mg./Kg.) Inj. Hydrocortisone 100 mg. I/V 6 hourly.

If Life Threatening Features presents, add Ipratropium Bromide.

Nebulised Ipratropium Bromide (0.5mg. 4-6 hourly) should be added to Beta2 agonist.

Intravenous Aminophylline.
Inj. Aminophylline 250 mg. I/v Over 20 min. Then infusion of 0.5-0.7 mg. /Kg./hour.

Intravenous Magnesium Sulphate. A single dose of Magnesium Sulphate (1.2-2 gm.I/V infusion over 20 min.)

Intubation shouldnt be delayed if Acute Respiratory Failure is identified

REFERRAL TO ICU
Deteriorating PEF. Worsening Hypoxia. Hypercapnea. Fall in pH. Exhaustion, feeble respiration. Drowsiness, confusion. Coma or respiratory arrest.

MONITORING
Measure And record PEF after15-30 min. Record Oxygen saturation. Repeat ABGs. Within 2 hours and 4-6 hourly. Measure and record the heart rate. Measure S. Potassium Measure S. Theophylline concentration. CBC. Chest X-Rays. Sputum gram stain/culture. Antibiotics.

If Patients condition is Improving

* Give 02 40-60% + Prednisolone

30 -60 mg /24 hr Orally * Nebulized Salbutamol every 4 hr * Monitor P.E.F. and O2 saturation

During Discharge,
Patient must have * Been on discharge Medicine for 24 hr * Had Inhaler technique checked * PEF > 75% predicted or best * GP appointment within 24 hr * Respiratory clinic appointment within 4 weeks