LULUK ADIPRATIKTO

Asthma Management and Prevention Program: Five Components

1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations
2009

5. Special Considerations

Exacerbations of asthma (asthma attacks or acute asthma) are episodes of progressive increase in shortness of breath, cough,wheezing, or chest tightness, or some combination of these symptoms.

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (PEF or FEV1).

The aims of treatment are to relieve airflow obstruction and hypoxemia as quickly as possible,and to plan the prevention of future relapses.

ASSESEMENT OF SEVERITY
MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT

Mild Breatkless Walking

Moderate Talking Infant-softer Shorter cry

Severe At rest Infant stop feeding

Respiratory arrest imminent

Can lie down Talks in Alertness Respiratory rate Sentences Maybe agitated Increased

Prefer sitting Phrases Usually Agitated Increased

Hunched forward Words Usually Agitated Often>30/min Drowsy or confuse

Normal rate of breathing in awake children

Age <2months 2-12months 1-5 years 6-8years Normal rate <60/min <50/min <40/min <30/min

Accessory muscles
and suprasternal retractions Wheeze

Usually not

Usually

Usually

Paradoxical thoracoabdominal movement

Moderate,often only end expiratory

Loud

Usually loud

Absence of wheeze

Mild Pulse/min <100

Moderate 100-120 >120

Severe

Respiratory arrest imminent Bradycardia

Guide to limits of normal pulse rate in children: Infants Preschool School age 2-12 monthsNormal Rate 1-2 years 2-8 years < 160/min < 120/min < 110/min

Pulsus paradoxus

Absent
<10 mmHg

Maybe present
10-25 mmHg

Often present
>25 mmHg(adult) 20-40(child)

Absence suggests
respiratory musle fatique

PEF after initial bronchodilator % predicted or % personal best

Over 80%

Aprprox.60-80%

<60%predicted or personal best (<100L/min adult) or response lasts<2hrs

PaO2 and or

Normal Test not usually

>60 mmHg

<60 mmHg Possible cyanosis

necessary
PaCO2 <45 mmHg <45 mmHg >45 mmHg Possible respiratory failure Sat O2 >95% 91-95% <90%

Milder exacerbations, defined by a reduction in peak flow of less than 20%, nocturnal awakening,and increased use of short acting 2agonists can usually be treated in a community setting.

TREATMENT Bronchodilators. For mild to moderate exacerbations,repeated administration of rapidacting inhaled 2-agonists (2 to 4 puffs every 20 minutes for the first hour) Bronchodilator therapy delivered via
metered-dose inhaler (MDI), ideally with a spacer, nebulizer. No additional medication is necessary if the rapid-acting inhaled 2agonist produces a complete response (PEF returns to greater than 80% of predicted orpersonal best) and the response lasts for 3 to 4 hours.

Glucocorticosteroids. Oral glucocorticosteroids (0.5 to 1mg of prednisolone/kg or equivalent during a 24-hour period) should be used to treat exacerbations Inhaled glucocorticosteroids are effective as part of
therapy for asthma exacerbations. In one study, the combination of high-dose inhaled glucocorticosteroids and salbutamol in acute asthma provided greater bronchodilation than salbutamol alone(Evidence B), and conferred greater benefit than the addition of systemic glucocorticosteroids across all parameters, including hospitalizations, especially for patients with more severe attacks.

Severe exacerbations of asthma are life-threatening medical emergencies, treatment of which is often most safely undertaken in an emergency department

INITIAL ASSESSMENT
INITIAL TREATMENT REASSESS after 1 hour

MODERATE EPISODE

SEVERE EPISODE

REASSESS after 1-2 hour Good response

DISCHARGE

Incomplete response
ADMITE TO ACUTE CARE SETTING

Poor response
ICU

REASSESS after 1-2 hour

High risk of asthma With a history of near-fatal asthma requiring intubation and mechanical
ventilation Who have had a hospitalization or emergency care visit for asthma in the past year Who are currently using or have recently stopped using oral glucocorticosteroids Who are not currently using inhaled glucocorticosteroids Who are overdependent on rapid-acting inhaled 2-agonists, especially those who use more than one canister of salbutamol (or equivalent) monthly With a history of psychiatric disease or psychosocial problems, including the use of sedatives With a history of noncompliance with an asthma medication plan.

Initial Assessment
History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, PEF or FEV1, oxygen saturation, arterial blood gas if patient in extremis)

Initial Treatment Oxygen to achieve O2 saturation 90% (95% in children) Inhaled rapid-acting 2-agonist continuously for one hour. Systemic glucocorticosteroids if no immediate response, or if patient recently took oral glucocorticosteroid, or if episode is severe. Sedation is contraindicated in the treatment of an exacerbation.

REASSES
Criteria for Moderate Episode: PEF 60-80% predicted/personal best Physical exam: moderate symptoms, accessory muscle use Treatment: Oxygen Inhaled 2-agonist and inhaled anticholinergic every 60 min Oral glucocorticosteroids Continue treatment for 1-3 hours, provided there is improvement

Criteria for Severe Episode: History of risk factors for near fatal asthma PEF < 60% predicted/personal best Physical exam: severe symptoms at rest, chest retraction No improvement after initial treatment Treatment: Oxygen Inhaled 2-agonist and inhaled anticholinergic Systemic glucocorticosteroids Intravenous magnesium

Good Response within 1-2 Hours: Response sustained 60 min after last treatment
Physical exam normal: No distress PEF > 70% O2 saturation > 90% (95% children

Improved: Criteria for Discharge Home

PEF > 60% predicted/personal best

Sustained on oral/inhaled medication

Home Treatment:
Continue inhaled 2-agonist

Consider, in most cases, oral glucocorticosteroids Consider adding a combination inhaler Patient education: Take medicine correctly Review action plan Close medical follow-up

Incomplete Response within 1-2 Hours:

Risk factors for near fatal asthma Physical exam: mild to moderate signs PEF < 60% O2 saturation not improving

Admit to Acute Care Setting

Oxygen Inhaled 2-agonist + anticholinergic Systemic glucocorticosteroid Intravenous magnesium Monitor PEF, O2 saturation, pulse

Poor Response within 1-2 Hours:

Risk factors for near fatal asthma Physical exam: symptoms severe, drowsiness, confusion PEF < 30% PCO2 > 45 mm Hg P O2 < 60mm Hg

Admit to Intensive Care

Oxygen Inhaled 2-agonist + anticholinergic Intravenous glucocorticosteroids Consider intravenous 2-agonist Consider intravenous theophylline Possible intubation and mechanical ventilation