acute asthma
Asthma Foot -
Department: Internal Aciller
Asthma Foot
Symptoms:
Progressive breathlessness, coughing, wheezing, or the emergence of a feeling of pressure in the head. These are accompanied by pulmonary function test disorders such as PEF, FEV1 decline. The main treatment of asthma is oxygen supplementation, short-acting β2 agonists and systemic steroids.
Treatment Aim
It corrects airway obstruction as quickly as possible and prevents recurrence of attacks. Serious attacks should be treated, especially in patients at risk, under close observation and hospital conditions. Mild attacks with a PEF less than 20% can be treated at home.
Fatal Asthma Tiers
• Type 1 (slow start)
- Subacute (1 or several days)
- 80-85%
- Large mucus plugs
- Eosinophilic
- Slow-minimal response to bronchodilators
• Type 2 (acute asphyxic asthma)
- Acute (in hours)
- 15-20%
- Bronchospasm
- Neutrophilic
- Bronchodilator fast-good response
Severe Asthma Symptoms
• Unable to speak in the form of phrases
• Expected FEV1 <40% or expected or best PEF <40% (life-threatening asthma <25%
• O2 saturation <90-92%
• PaO2 <60 mmHg
• PaCO2> 45 mmHg
• Use of accessory respiratory muscles
• Pulsus paradoxus
• Silent lung on examination
• Hospital bed
• Cyanosis and sweating
• Consciousness blur or confusion
• Hypotension or bradycardia
Oxygen
• The pulse oximetry control should be performed with nasal cannula or mask (1-3 L / min) as SaO2> 90%.
• Although the use of high-flow oxygen in severe asthma exacerbations does not indicate the likelihood of COPD,
- where microatheters and intrapulmonary shunts can form,
- It may cause decrease in cardiac output and coronary blood flow,
- Considering that severe airway obstruction may increase CO2 retention,
Oxygen therapy should be given with a flow rate that maintains SaO2> 90% with oxymetry.
Fast acting b2-agonists
• They are the first drugs to be selected in the treatment of attacks.
• Salbutamol: 2.5-5 mg 3 times a day in 20 minutes followed by continuous inhalation or 10-15 mg / hour.
anticholinergics
• Treatment of ipratropium bromide addition increases bronchodilator response.
• Anticholinergics combined with short-acting β2 agonists have been shown to increase PEF and FEV1 levels and reduce hospitalizations in patients according to their individual use.
Systemic Steroids
• Systemic steroids significantly accelerate exacerbation recovery, therefore they should be given in all asthma attacks except mild attacks.
• Prednisone 40-80 mg.
• Orally administered steroids have been shown to be as effective as intravenous administration.
• Patients who need immediate steroid initiation;
- that is not responsive to the initially given? 2-agonist,
- At present, an attack has occurred while taking systemic steroids,
- Patients who require systemic steroids in previous attacks.
Inhaler Steroids
• High doses of inhaler (nebul) steroids can also be used.
• However, it is not recommended as the first option in terms of cost effectiveness.
Magnesium sulphate:
• Blocks calcium channels in smooth muscle, preventing muscle contraction and resolving spasm.
• Emergency service is not recommended for routine use for patients with atactia.
- If FEV1 is applied to the hospital, the expectation is 25-30%
- In adults who do not respond to initial treatment,
- It has been shown that after one hour of treatment, the FEV1 can reduce the admission rates in some patients who do not exceed 60% of the expected.
• i.v has been found to be more effective than i.v theophylline and i.v.beta.2 agonists in the treatment of magnesium exacerbation. 2 gr. magnesium is administered as an infusion over a period of 120 minutes in 250 ml of 0.9% saline solution.
Intravenous Theophylline:
• In adults, an additional benefit of being given in severe asthma exacerbations has not been demonstrated.
• Use for this reason;
- Near fatal asthma,
- Inhaler and intravenous β2 agonists,
- Inhaler ipratropium bromide
- IV steroids and
- IV magnesium is restricted to patients who do not respond.
• i.v theophylline is administered by infusion over 6 mg / kg for more than 30 minutes followed by infusion with 0.5 mg / kg / hour id.
Heliox:
• Heliox consists of 80/20 helium and oxygen.
• There is not enough data to support routine use,
it can be tried in asthma attacks without treatment.
• There is a need for more money to use in standard epilepsy treatment.
Adrenalin:
• Treatment can be used as a rescue treatment in asthma attack that does not respond.
• It is used in the form of nebula and i.v infusion.
• i.v should be used, especially if hypotension is also present.
• Reduce the α-agonist effect.
• β-agonist effect bronchodilates.
Leukotriene Antagonists
• In acute asthma attack in emergency department, i.v. 20 minutes after administration of montelukast. then there was an increase in FEV1.
• 60 minutes from oral zafirlukast. Then there was an increase in FEV1 and a decrease in dyspnea.Antibiotic
• Routine use is not beneficial.
• Should be used if there are signs of pneumonia or other bacterial infection.
Lung X-ray
• Lung grafting of ataxic patients
there is no priority in the evaluation. If pneumothorax or pneumonia is suspected.
• Chest film should be taken in patients who do not show any improvement in the 6-12 hour period after treatment.
Arterial Blood Gas
• Not required for every asthma attack.
• Treatment should be taken in unresponsive patients.
Noninvasive Mechanical Ventilation
• These are not enough yet, with studies showing that they are effective.
• Early noninvasive mechanical ventilation in asthma, a risk of developing respiratory failure, may be tried as an alternative to intubation.
• However, there is a need for wider series for routine use.
Intensive Care and Ventilator Support
Severe asthma attacks that are unresponsive or progressively disrupted in emergency services.
• Going to respiratory failure.
- Hypoxia (PaO2 <60 mmHg) that does not resolve despite oxygen support and / or
- Hypercapnia (PaCO2> 45 mmHg)
• Unconsciousness
• Cyanosis and silent lung
• Shortness of breath
• Heart or respiratory arrest.
Intubation
• Clinic
- Cardiac arrest
- Respiratory arrest or severe bradypnea
- Severe tachypnea (> 40 / min) and patient fatigue
- Deterioration in mental condition
- Silent lung
Intubation
• Arterial blood gas
- pH <7.2
- PaCO2> 55-70 mmHg or 5 mmHg / h increase in PaCO2
- Hypoxia (PaO2 <60 mmHg) that does not resolve despite oxygen support
- Ongoing lactic acidosis
Ventilator Settings
• Start with FiO2 1 and titrate SO2> 94%
• Tidal volume 5-6 ml / kg
• Ventilator speed is 6-8 breaths / minute
• Inspiration / expiration ratio> 1: 2
• Minimal PEEP ≤ 5 cm H 2 O
• Peak inspiratory pressure <40cmH2O
• Target plateau pressure <20 cmH2O
• Effective humidity control
Cursing of asthma attacks
• Most of the attacks resolve within two to three hours of treatment and are sent to the emergency servist homes.
• 3% of patients returning home return 24 hours, 7% returning within one week with repetitive attacks.
• 20-30% of patients do not respond well to emergency room treatment and need to be hospitalized.
• Complete recovery of attacks at the hospital is slow.
Discharge criteria
• Short-acting β2 agonists do not require shorter intervals than 3-4 hours.
• SaO2> 90%. (room air)
• The patient is in good condition.
• It does not wake up with breathlessness against night or sadness.
• Physical examination is normal or near normal.
• The PEF or FEV1 value is greater than 70%.
(after the short acting [beta] 2 agonist)
• The use of inhalers in proper condition is an indication that the patient may be discharged.Risk factors for asthma related death
• Previous serious attack. (asthma due to intubation or intensive care)
• 2 or more hospitalizations in the last year or more than three emergency services.
• Excessive short-acting β-agonist use.
• Difficulty in feeling airway obstruction or aggravated asthma severity.
• Low socioeconomic status.
• Patients without treatment.
• Psychiatric illness or serious psychosocial problems.
• Associated diseases (cardiovascular or pulmonary)
Child Abuse Treatment
• O2 (SO2> 95)
• Fast acting inhaler β2-agonists
• Use of ipratropium bromide in combination with b2-agonists in children increases hospital efficacy while reducing hospital admissions.
• Systemic steroids 0.5-2 mg / kg day.
• When the efficacy of fast acting β2-agonists is considered, theophylline does not have much in the acute attack.
• Although not recommended routinely in the treatment of intravenous magnesium sulphate exacerbations, it has been shown to help reduce hospitalization rates in children who do not respond to treatment. Pregnancy and Asthma • The most common breath during pregnancy
m systemic disease (4-7%) • The most severe attacks in pregnancy 24-36. It is observed between the weeks, the symptoms are decreasing in the last 4 weeks and 90% of the asthmatic patients do not have any problems during the birth • At least one urgent application in 11-18% of the cases of asthmatic patients and 62% of them are reported to be hospitalized.
Attack Therapy • Frequent viral infections or inadequate preventive treatment • Very fast and energetic treatment to prevent fetal hypoxia.
• Mother PO2 should be kept above 70mmHg, O2 over 95% • Nasal short acting beta2-agonist, oxygen and systemic steroid are used.
resources
Turkish Thoracic Society Guide to diagnosis and treatment of asthma
Analytic Review: Management of Life-Threatening Asthma in Adults
Mannam and Siegel J Intensive Care Med.2010; 25: 3-15
Review article: Management of acute severe and near-fatal asthma
Emergency Medicine Australasia (2009) 21, 259-268
The Journal of Emergency Medicine, Vol. 37, No. 2S, pp. S1-S5,2009
An Umbrella Review: Corticosteroid Therapy for Adults with Acute
Asthma The American Journal of Medicine (2009) 122, 977-991
Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments EmergMed J 2009 26: 783-785
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