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Asthma in Emergency room

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Presentation on theme: "Asthma in Emergency room"— Presentation transcript:

1 Asthma in Emergency room
ผศ.นพ.วัชรา บุญสวัสดิ์ พบ. Ph.D ภาควิชาอายุรศาสตร์ คณะแพทย์ศาสตร์ มหาวิทยาลัยขอนแก่น

2 Contents epidemiology pathophysiology of asthma management of asthma at ER prevention of asthma exacerbation

3 Asthma morbidity in the past year
Boonsawat et al.Survey of asthma control in Thailand 2001

4 Admission and ER visit due to asthma in the past year according to severity classification

5 Asthma admission in Thailand (excluding Bangkok)
Health Information Division, Bureau of Health Policy and Planing

6 ER visit at Srinagarind hospital (Teaching hospital)

7 ER visit at Nampong hospital (district hospital)

8 Mechanism of airway obstruction in severe asthma

9 Airway obstruction Uneven ventilation Hyperinflation Work of breathing
V/Q mismatching Wasted ventilation VO2 ,VCO2 Hypoxemia, hypercapnia Respiratory acidosis Metabolic acidosis

10 Management of asthma at ER
Step1. Diagnosis Step 2. Assess the severity Step 3. Treatment Step 4. Assess the response

11 Step1. Diagnosis Asthma ? Upper airway obstruction ? COPD exacerbate ?
Congestive heart failure ?

12 Step 2. Assess the severity

13 Assess the severity History
near fatal asthma requiring mechanical ventilation long duration of current attack deterioration despite oral steroids

14 Assess the severity Physical examination inability to lie supine
impaired sensorium inability to speak use of accessory muscle RR >30 PR >120

15 Assess the severity Lab PEFR < 100L/M. FEV1 < 700 cc ABG CXR

16 Fischl’s index Predicitive Index PR > 120 RR > 30
Pulsus paradox >= 18 PEFR < 120 Dyspnea accessory-muscle use Wheezing N Engl J Med 1981;305:783-9

17 Step 3. Treatment goal of treatment: correction of hypoxemia
rapid reversal of airflow obstruction with minimum side effect

18 Treatment Oxygen Bronchodilators Corticosteroids

19 Rapid –acting inhaled b2-agonists
Nebulization MDI with spacer

20 Classes of b2-agonists RESCUE MEDICATION M A I N T E N A N C E fast
Speed of onset RESCUE MEDICATION fast onset, short duration fast onset, long duration M A I N T E N A N C E fast inhaled terbutaline inhaled salbutamol inhaled formoterol slow onset, short duration slow onset, long duration oral terbutaline oral salbutamol oral formoterol slow inhaled salmeterol oral bambuterol Duration of action short long

21 Nebulized versus intravenous albuterol in hypercapnic acute asthma
47 patients admitted with severe asthma PEF<150 L/m and PaCO2 > 40 nebulize 5 mgx2 vs IV 0.5 mg salbutamol in 1hr 86% of nebulize gr had been treat successfully (vs 48 % in IV gr) increase PEF, decrease PaCO2 greater in neulize gr nebulize route has a greater efficacy and fewer side effect than intravenous route Salmeron S.Am J Respir Crit Care Med 1994;149:

22 Nebulization MDI with spacer

23 Ipratropium bromide

24 The effect of adding Ipratropium bromide to salbutamol in the treatment of acute asthma
Chang in mean FEV1 at 45 min 200 Total 55 (2-107) N=977 100 IB+S better S better TOTAL CA NZ US -100 SF Lanes. Chest 1988;114:

25 risk of hospitalization
CA NZ US TOTAL IB+S S IB+S S IB+S S IB+S S Patients hospitalized risk ratio 95%CI ( ) ( ) ( )

26 Effect of nebulized ipratropium on the hospitalization rates of children with asthma
Qureshi et al.NEJM1988;339:1030-5

27 albuterol MDI vs. albuterol and IB
First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albutterol in the emergency department 180 patients, FEV1<50% albuterol MDI vs. albuterol and IB subjects who received IB had an overall 20.5% greater improvement in PEFR reduce the risk of hospital admission 49% (39% vs 20%) RR=0.51(95%CI ) Five patients (95% CI 3-17) would need to be treated with IB to prevent a single admission Rodrigo et al. Am J Respir Crit Care Med 2000;161:1862-8

28 10 studies including 1483 adults with acute asthma
A Meta-analysis of the effect of Ipratropium bromide in adult with acute asthma 10 studies including 1483 adults with acute asthma improve lung function reduction in rate of hospital admission Rodrigo et al. Am J Med1999; 107:

29 reduce the risk of hospitalization by 30% (RR 0.72 95%CI 0.53-0.99)
Should inhaled anticholinergics should be added to b2 agonist for treating acute childhood and adolescent asthma? A systematic review reduce the risk of hospitalization by 30% (RR %CI ) Eleven children would need to be treated to avoid one admission improve lung function no increase side effect Plotnick LH.BMJ1998;317:

30 Addition of Ipratropium bromide to b2-agonist
improve lung function reduce hospitalization no additional side effects

31 การรักษาอื่นๆที่ยังไม่ใช่การรักษามาตรฐาน
Magnesium Helium Oxygen therapy (Heliox ) general anesthesia Montelukast

32 Step 4. Assess the response
Dyspnea PE PR, RR, Accessory muscle use, PEFR

33 PEFR at 30 min after treatment<40% predicted
Predicitive Index Poor Response PEFR at 30 min after treatment<40% predicted Change in PEFR at 30 min after treatment <60 L/Min Chest 1998; 114:

34 Acute Severe Asthma B2-agonist (Neb or MDI) q min + Corticosteroid Improve B2-agonist q 1-2h Not improve add anticholinergic Admit PEFR > 70 % Discharge

35 PEF<50% PEF>50% NIH.NAEPP 1997 Acute Severe Asthma
B2-agonist q 20 min + Corticosteroid B2-agonist +IB q 20 min + Corticosteroid Not improve add anticholinergic Improve B2-agonist q 1-2h Admit PEFR > 70 % Discharge NIH.NAEPP 1997

36 Prevent future relapses

37 Airway Hyperresponsiveness
Symptoms Airway inflammation Stimuli Remodelling Airway Hyperresponsiveness

38 50 % reduction in asthma ER relapses
Facilitated referral to asthma spectialist reduces relapses in asthma emergency room visits 50 % reduction in asthma ER relapses greater use of inhaled corticosteroids J Allergy Clin Immunol 1991;87:1160-8

39 Results of a program to reduce admissions for adult asthma
104 asthmatic required multiple hospitalization Intensive outpatient treatment inhaled corticosteroid peak flow monitor management plan Threefold reduction in readmission Mayo PH.Ann Internal Med 1990;112:

40 conclusions asthma exacerbation is common in ER
bronchospasm mucosal edema inflammation is the cause of obstruction coticosteroid,b2 agonist, anticholinergic is first line drugs asthma in ER indicate poor asthma control

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