Professional Documents
Culture Documents
Some pharmacology
Relievers
Short-acting 2-agonists
Salbutamol Terbutaline
Anticholinergics
Ipratropium bromide
Steroids Theophylline
(Select situations)
Oxygen
Hypoxia due to V / Q mismatch.
agonists may paradoxically worsen hypoxia
Inhaled 2-agonists
Drugs of choice.
Salbutamol / Terbutaline are similar. Severe acute episode nebuliser preferred
Rescue steroids
Early usage - reduces morbidity/ hospitalization Oral prednisolone 1-2 mg/kg for 3-7 days.
No tapering needed / No adverse effects
Anticholinergics
Ipratropium bromide Additive effect to 2 agonist in acute severe asthma Neb soln 0.5 ml <1yr, 1ml>1 yr (Compatible with 2 agonist solution.) Limit use to 24-48 hours to prevent atropine like effects (fever)
Aminophylline
Retains its role as reliever in acute severe attacks
improves diaphragmatic contractility mucociliary function inflammatory modulation
Dose:
Loading dose 5 mg/kg slow 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 2 agonists for mild intermittent airflow obstruction. Oral prednisolone for rescue therapy
Case..
Arpit decides to help his mother with Diwali cleaning. He starts coughing continuously and his mother rushes him to the clinic
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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 timehelps 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
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Wheezing*
None Terminal expiration with stethoscope Entire expiration with stethoscope During inspiration and expiration without stethoscope
Score
03
Mild
46 >6
Moderate Severe
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Home management
PS < 3 (mild grade) SA 2 agonist: 2 - 4 puffs through MDI + spacer + mask
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.
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E Room plan
PS 4-6(moderate)
O2 SA 2 agonist
Nebulised q 20 min x 3 or MDI + spacer + mask 2 puffs q 2 min increasing by 2 10 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
puffs till
Commence / Continue rescue steroid Continuous assessment SA 2 agonist neb hourly p.r.n. If good response(PS <3), initiate discharge plan
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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
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Ward plan
Continue oxygen,
Start IV fluids, IV/oral steroid SA 2 nebulization - hourly/ back-to-back
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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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hours
Discontinue ipratropium neb in 24-48 hours Reduce SA 2 agonist to q 2-4 hrly and then q 46hrly 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 are ready to go home?
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Discharge plan
Inhaled SA 2 agonist MDI + spacer + mask q 4-6 hour till symptoms Continue course of rescue steroid for 3-7 days (Tapering not necessary)
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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
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Asthma
Red flag signs
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 with
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To summarize
Diagnosis
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
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To summarize
Long term management
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
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To summarize
Acute management
Grading at a point in time decides management SA inhaled 2 agonists are used to manage acute exacerbations Frequent use of SA 2 agonists indicate poor control of asthma Taking care of the home environment reduces exacerbations of asthma Devices MDI should always be used with spacer
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