STATUS

ASTHMATICUS
DEPARTMENT OF EMERGENCY MEDICINE
LABASA DIVISIONAL HOSPITAL

PRESENTER: ABDUL MUSHIB IBRAHIM

MBBS
A&E INTERN

OVERVIEW
PART 1: STATUS ASTHMATICUS-ED PROTOCOL
PART 2: JOURNAL: Dupilumab in Persistent
Asthma with Elevated Eosinophil Levels
PART 3: TOP 12 ANTI-ASTHMATIC FOODS
PART 4: WEIRD FACT

PART 1
STATUS ASTHMATICUS-FIJI ED
PROTOCOL
BY
PROFESSOR: DR CRAIG ADAMS MD
18-MARCH-2013

FIRST LINE
corticosteroids - to be given stat at triage,
chose one of these five options:
A) oral prednisolone 1mg/kg daily (7 days)
B) IV methyl prednisolone 1mg/kg q6h (max
40mg q6h)
C) IV hydrocortisone 100mg q6h
D) IV dexamethasone 8mg q6h
E) IM dexa (x1 in ED & x1 prior to D/C)

FIRST LINE
Salbutamol
continuous nebulised 0.5% undiluted if patient
unable to ventilate
IV bolus 15 mcg/kg
IV infusion 5-10 mcg/kg/min initially for first
hour --> 1-2 mcg/kg/min
Notes: Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic
acidosis. Can occur with both IV and inhaled therapy.
Lactate commonly high.
Consider stopping/reducing salbutamol as a trial if you think this may be
the problem.

FIRST LINE
Ipratropium
nebulized 250 mcg q20min

FIRST LINE
N-saline
1-2 liters stat

SECOND LINE
Adrenaline
0.5-1 mg sc/im q20min
IV infusion 1mg in 100 ml --> run at 5-20
mcg/min (i.e. over 1-3 hours)

SECOND LINE
Ketamine
0.75 mg/kg IV bolus --> continuous infusion
of 0.15 mg/kg/h)

SECOND LINE
Magnesium Sulphate 50%
2.5g IV over 15-20 min then repeat
0.1ml/kg (50mg/kg) over 20 mins
then 0.06ml/kg/hr (30mg/kg/hour)

Aim to keep serum Mg between 1.5 and

2.5mmol/L

UNPROVEN BUT CONSIDER:

Aminophylline
i.v. loading dose: 10 mg/kg (maximum dose
500 mg) over 60 min.
NB:
-If currently taking oral theophylline, do not
give i.v. aminophylline
- take levels.

UNPROVEN BUT CONSIDER:

MAINTENANCE
1st wk life 2.5mg/kg IV over 1hr 12H
2nd wk life 3mg/kg 12H
3wk-12 mo ((0.12 x age in wk) + 3) mg/kg 8H
>12mo and <35kg, 55 mg/kg in 50ml 5%dex-hep at 1ml/hr (1.1mg/kg/hr) or
6mg/kg IV over 1hr 6H
>35kg and <17yr, or >17yr and smoker, 25 mg/ml at 0.028ml/kg/hr
(0.7mg/kg/hr) or 4mg/kg IV over 1hr 6H
>17yr non-smoker 25mg/ml at 0.02ml/kg/hr (0.5mg/kg/hr) or 3mg/kg IV
over 1hr 6H
elderly 25mg/ml at 0.014 ml/kg/hr (0.35mg/kg/hr) or 2mg/kg IV over 1hr
6H
Levels: 60-80umol/L (neonate) 60-110 (asthma) (x0.18=mcg/ml)

Alternative (also unproven) therapies

to prevent intubation:
Heliox
Glucagon
Nitroglycerin
Leukotriene Inhibitors
Clonidine - nebulized
Ca++ channel blockers - nebulized
Lidocaine - nebulized
ECC-note: consider external chest
compression/decompression for severe air
entrapment

INDICATION FOR INTUBATION

INDICATION FOR INTUBATION

1. Cardiac arrest
2. Respiratory arrest
3. Physical exhaustion
4. Altered mental state/restlessness & pulling mask off
5. Severe hypoxemia (pO2 <60) despite maximal oxygen
delivery through mask
6. Severe respiratory acidosis (pH <7.2) /hypercarbia
(pCO2 >70 mmHg) - not responding to treatment (or
worsening despite full treatment)
7. Respiratory rate >40
8. Silent chest
9. Unresolved lactic acidosis

INTUBATION-RSI
ketamine (1-1.5mg/kg) or
propofol (2mg/kg) over 2 min

plus
vecuronium (80-100 mcg/kg) or
succinylcholine (1.1 mg/kg) (avoid in
hyperkalemia)

INTUBATION
Ventilator Settings:
rate 6 b/min
tidal volume 6-10 ml/kg (ideal body weight)
peak inspiratory flow 60 L/min (constant flow)
or 80-90 L/min (decelerating flow)
I:E - 1:4 PEEP 4 cm H2O
fraction inspired oxygen (FiO2) 100% --> 60%

PART 2
THE NEW ENGLAND JOURNAL OF MEDICINE
Dupilumab in Persistent Asthma with Elevated
Eosinophil Levels
PUBLICATION DATE: 27 JUNE 2013
AUTHORS: Sally Wenzel, M.D., Linda Ford, M.D., David Pearlman, M.D., Sheldon Spector, M.D., Lawrence
Sher, M.D., Franck Skobieranda, M.D., Lin Wang, Ph.D., Stephane Kirkesseli, M.D., Ross Rocklin, M.D., Brian
Bock, D.O., Jennifer Hamilton, Ph.D., Jeffrey E. Ming, M.D., Ph.D., Allen Radin, M.D., Neil Stahl, Ph.D.,
George D. Yancopoulos, M.D., Ph.D., Neil Graham, M.D., and Gianluca Pirozzi, M.D., Ph.D.

AIM
We evaluated the efficacy and safety of
dupilumab -a fully human monoclonal
antibody to the alpha subunit of the
interleukin-4 receptor, in patients with
persistent, moderate-to-severe asthma and
elevated eosinophil levels.

METHOD
We enrolled patients with:
- persistent, moderate-to-severe asthma
- and a blood eosinophil count of at least 300
cells per microliter or a sputum eosinophil
level of at least 3%
- who used medium-dose to high-dose inhaled
glucocorticoids plus long-acting beta-agonists
(LABAs).
- We administered dupilumab (300 mg) or
placebo subcutaneously once weekly.

METHOD
Patients were instructed to discontinue LABAs at
week 4 and to taper and discontinue inhaled
glucocorticoids during weeks 6 through 9.
Patients received the study drug for 12 weeks or until
a protocol-defined asthma exacerbation occurred.
The primary end point was the occurrence of an
asthma exacerbation; secondary end points included
a range of measures of asthma control.
Effects on various type 2 helper T-cell (Th2)
associated biomarkers and safety and tolerability
were also evaluated.

RESULTS
6% patients had an asthma exacerbation with
dupilumab versus 44% with placebo ,
corresponding to an 87% reduction with
dupilumab.
Significant improvements were observed for
most measures of lung function and asthma
control.
Injection-site reactions, nasopharyngitis,
nausea, and headache occurred more
frequently with dupilumab than with placebo.

CONCLUSION
In patients with persistent, moderate-tosevere asthma and elevated eosinophil levels
who used inhaled glucocorticoids and LABAs,
dupilumab therapy, as compared with
placebo, was associated with fewer asthma
exacerbations when LABAs and inhaled
glucocorticoids were withdrawn, with
improved lung function and reduced levels of
associated inflammatory markers.

PART 3
TOP 12 ANTI-ASTHMATIC
FOODS

WEIRD FACT

QUIZ/WHIZ
SKIN OF WHICH ANIMAL IS THOUGHT TO
HAVE A BRONCHODILATOR EFFECT???
RECIPE???

REFERANCE
WWW.PACIFICDOCS.COM-CWM PROTOCOL.
THE NEW ENGLAND JOURNAL OF MEDICINE.
WWW.MAYOCLINIC.COM