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Asthma A Chronic disease of the airways that may cause: WheezingWheezing BreathlessnessBreathlessness Chest tightnessChest tightness Nighttime or early.

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Presentation on theme: "Asthma A Chronic disease of the airways that may cause: WheezingWheezing BreathlessnessBreathlessness Chest tightnessChest tightness Nighttime or early."— Presentation transcript:

1 Asthma A Chronic disease of the airways that may cause: WheezingWheezing BreathlessnessBreathlessness Chest tightnessChest tightness Nighttime or early morning coughingNighttime or early morning coughing

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3 The bronchospasm characteristic of the acute asthmatic attack is typically reversible. (برونکواسپاسم که با درمان بهبود یابد کاراکتریک حمله آسم حاد است) It improves spontaneously or within minutes to hours of treatment

4 Asthma can exist by itself or coexist with: chronic bronchitis, orchronic bronchitis, or emphysema, oremphysema, or bronchiectasisbronchiectasis

5 Symptoms/Chief Complaint Progressive dyspneaProgressive dyspnea CoughCough Chest tightnessChest tightness Wheezing/coughingWheezing/coughing

6 The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contractionThe rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction

7 Focus of Therapy Pharmacologic manipulation of airway smooth musclePharmacologic manipulation of airway smooth muscle Do not overlook physiologic impairment caused by mucous production and mucosal edemaDo not overlook physiologic impairment caused by mucous production and mucosal edema Bronchospasm can be reversed in minutesBronchospasm can be reversed in minutes Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks -Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks - may lead to atelectasis, infectious bronchitis, pneumonitismay lead to atelectasis, infectious bronchitis, pneumonitis

8 Asthma Triggers Immunologic reactionImmunologic reaction Viral respiratory/sinus infectionsViral respiratory/sinus infections change in temperature/humiditychange in temperature/humidity Drugs/Chemicals -Drugs/Chemicals - aspirin, NSAIDSaspirin, NSAIDS ExerciseExercise GE RefluxGE Reflux Laughing/coughingLaughing/coughing Environmental factors -Environmental factors - strong odors, pollutants, dust, fumesstrong odors, pollutants, dust, fumes

9 Patient Exam WheezingWheezing may be audible w/o stethoscope ویز در آسم معمولا بازدمی است (بازدم طولانی تر است) شدت ویز با شدت آسم ارتباطی ندارد Use of accessory muscles of inspirationUse of accessory muscles of inspiration (رتراکسیون بین دنده ای و...) diaphragmatic fatiguediaphragmatic fatigue Paradoxical respirationsParadoxical respirations (شکم و قفسه سینه عکس هم حرکت میکنند) خستگی عضلات تنفسی و احتمال آپنه تنفسی Reflect impending ventilatory failure Altered mental status -Altered mental status - lethargy, exhaustion, agitation, confusion

10 Patient Exam Hyperrsonance to percussionHyperrsonance to percussion decreased intensity of breath soundsdecreased intensity of breath sounds prolongation of expiratory phase w or w/o wheezingprolongation of expiratory phase w or w/o wheezing The intensity of the wheeze may not correlate with the severity of airflow obstructionThe intensity of the wheeze may not correlate with the severity of airflow obstruction “quiet chest” - very severe airflow obstruction“quiet chest” - very severe airflow obstruction

11 Risk factors for death from asthma: Past history of sudden severe exacerbations Prior intubation for asthma Prior admission for asthma to an intensive care unit Two or more hospitalizations for asthma in the past year Three or more emergency care visits for asthma in the past year Hospitalization or emergency care visit for asthma within the past month Use of more than two canisters per month of inhaled short-acting 2-agonist Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids Difficulty perceiving airflow obstruction or its severity Comorbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease Serious psychiatric illness or psychosocial problems Low socioeconomic status in urban residents Illicit drug use

12 Asthma Treatment Nebulized B-adrenergic drugsNebulized B-adrenergic drugs CorticosteroidsCorticosteroids Nebulized anticholinergicsNebulized anticholinergics Magnesium sulfateMagnesium sulfate OxygenOxygen Long acting beta-agonistsLong acting beta-agonists Inhaled steroidsInhaled steroids

13 Managing Asthma: Indications of a severe attack: Breathless at rest (تنگی نفس در استراحت) hunched forward (روی تخت خم شود) talking in words rather than sentences (استفاده از کلمات بریده) Agitated (Peak flow rate) PFR< 60% of normal in Spirometry

14 Treatment Goals of Severe Asthma Improve airway function rapidlyImprove airway function rapidly Avoid hypoxemiaAvoid hypoxemia Prevent respiratory failure and deathPrevent respiratory failure and death

15 Classifying Severity of Asthma Exacerbations Symptoms Mild Moderate Severe Breathlessness walking talking at rest Position Can lie down Prefers sitting upright Talks in Sentences Phrases Words Alertness May be agitated Usually agitated Usually agitated

16 Classifying Severity of Asthma Exacerbations Mild Moderate Severe Signs Mild Moderate Severe نکته: اختلاف فشارخون بین دم و بازدم بیمار = Pulsus Paradoxus

17 Classifying Severity of Asthma Exacerbations Functional assessment Mild Moderate Severe نکته: در اورژانس پالس اکسیمتری موجود است که میتوانیم بر اساس آن آسم را طبقه بندی کنیم

18 Respiratory Arrest Imminent Drowsy or confusedDrowsy or confused Paradoxical thoracoabdominal movementParadoxical thoracoabdominal movement Absent WheezeAbsent Wheeze BradycardiaBradycardia Absence Pulsus paradoxus suggests respiratory muscle fatigueAbsence Pulsus paradoxus suggests respiratory muscle fatigue

19 Asthma Mimickers Asthma Mimickers تشخیص افتراقی های آسم)) Congestive heart failure ("cardiac asthma") Upper airway obstruction Aspiration of foreign body or gastric acid Bronchogenic carcinoma with endobronchial obstruction Metastatic carcinoma with lymphangitic metastasis Sarcoidosis with endobronchial obstruction Vocal cord dysfunction Multiple pulmonary emboli (rare)

20 treatment of acute asthma Goal in the ED reverse airflow obstruction rapidly by repetitive or continuous administration of inhaled 2-agonistsreverse airflow obstruction rapidly by repetitive or continuous administration of inhaled 2-agonists ensure adequate oxygenationensure adequate oxygenation relieve inflammationrelieve inflammation

21 Initial Assessment History physical examination (auscultation use of accessory muscles, heart rate, respiratory rate) PEFR or FEV oxygen saturation other tests as indicated

22 Diagnosis Bedside spirometryBedside spirometry rapid, objective assessment,guide to the effectiveness of therapy. rapid, objective assessment,guide to the effectiveness of therapy. The forced expiratory volume in 1 s (FEV1)The forced expiratory volume in 1 s (FEV1) peak expiratory flow rate (PEFR) peak expiratory flow rate (PEFR) Sequential measurementsSequential measurements management decisionsmanagement decisions

23 Pulse oximetry assessing oxygenation and monitoring oxygen saturation during treatment.assessing oxygenation and monitoring oxygen saturation during treatment. ABG is not indicated in most patients with mild to moderate asthma exacerbationABG is not indicated in most patients with mild to moderate asthma exacerbation (در همه بیماران آسمی ABG نیاز نیست مگر اینکه بخواهیم سطح PCO2را بدانیم)

24 ABG assess for hypoventilation with carbon dioxide retention and respiratory acidosis clinical evidence of severe attacksclinical evidence of severe attacks PEFR or FEV1 of less than 25 percent predictedPEFR or FEV1 of less than 25 percent predicted With acute attacks, ventilation is stimulated, resulting in a decrease in partial pressure of carbon dioxide (PaCO2)With acute attacks, ventilation is stimulated, resulting in a decrease in partial pressure of carbon dioxide (PaCO2) normal or slightly elevated PaCO2 (e.g., 42 mm Hg) indicates extreme airway obstruction and fatigue and may herald the onset of acute ventilatory failurenormal or slightly elevated PaCO2 (e.g., 42 mm Hg) indicates extreme airway obstruction and fatigue and may herald the onset of acute ventilatory failure

25 Radiography clinical indication of a complicationclinical indication of a complication pneumothorax, pneumomediastinum, pneumonia, or other medical concernpneumothorax, pneumomediastinum, pneumonia, or other medical concern one-third of asthma exacerbations requiring admission, will demonstrate an abnormality on chest radiographone-third of asthma exacerbations requiring admission, will demonstrate an abnormality on chest radiograph CXR) کمک کننده نیست مگر برای پیداکردن تریگر و تشخیص افتراقی ها)

26 CBC اندیکاسیون ندارد modest leukocytosis secondary to administration of:modest leukocytosis secondary to administration of: B -agonist therapy or corticosteroid treatment In patients taking theophylline before ED presentation, a serum theophylline levelIn patients taking theophylline before ED presentation, a serum theophylline level بیماری که تئوفیلین میگرفته سطح تئوفیلین چک شود

27 ECG Routine electrocardiogram is unnecessary which resolve with treatment:Routine electrocardiogram is unnecessary which resolve with treatment: 1. 1.right ventricular strain, or 2. 2.abnormal P waves, or 3. 3.nonspecific ST- and T-wave abnormalities Older patients, especially those with coexisting heart disease, should have cardiac monitoring during treatment (EKG در بیمارانی که بیماری زمینه ای قلبی دارند میگیریم زیرا به طور روتین تغییرات غیر اختصاصی دیده میشوند که بادرمان آسم رفع میگردند)

28 Impending or Actual Respiratory Arrest Intubation and mechanical ventilation with 100% 02 Nebulized B2 agonist and anticholinergic Intravenous steroid Admit to ICU

29 درمان بر اساس FEV1 یا PEFR FEV1 or PEFR >50% اکسیژن تا رساندن 90%≤So2 استنشاق ß2-agonist تا 3 بار در ساعت اول استرویید خوراکی (اگر درمانهای بالا فورا جواب نداد یا اخیرا داروی استرویید خوراکی مصرف میکرده است) نکته: چون نبولایزر بتا 2 آگونیست (سالبوتامول) نداریم, از اسپری سالبوتامول 8 پاف هر 20 دقیقه میدهیم تا 3 بار و سپس ارزیابی مجدد FEV1 or PEFR <50% (Severe Exacerbation) اکسیژن تا رساندن 90%≤So2 استنشاق دوز زیاد ß2-agonist و آنتی کولینرژیک با نبولایزر هر 20دقیقه یا مداوم برای مدت یک ساعت. استرویید خوراکی

30 Repeat Assessment Symptoms. physical examination. PEFR. 02 saturation. other test as needed

31 Severe Exacerbation

32 Moderate Exacerbation

33 Incomplete Response

34 Good Response

35 Discharge Home

36 Poor Response

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38

39 medications are used in the treatment of acute asthma adrenergic agonistsadrenergic agonists anticholinergicsanticholinergics glucocorticoidsglucocorticoids Magnesium, heliox (mixture of helium and oxygen), and ketamine may be considered when the aforementioned medications fail to relieve bronchospasm.Magnesium, heliox (mixture of helium and oxygen), and ketamine may be considered when the aforementioned medications fail to relieve bronchospasm. Mast cell-stabilizing agents, methylxanthines, and leukotriene modifiers are currently reserved for maintenance therapy onlyMast cell-stabilizing agents, methylxanthines, and leukotriene modifiers are currently reserved for maintenance therapy only

40 Adrenergic Agents Adrenergic receptorsAdrenergic receptors Stimulation of B 1-receptors increases rate and force of cardiac contraction and decreases small intestine motility and toneStimulation of B 1-receptors increases rate and force of cardiac contraction and decreases small intestine motility and tone B2-adrenergic stimulation promotes bronchodilation, vasodilation, uterine relaxation, and skeletal muscle tremorB2-adrenergic stimulation promotes bronchodilation, vasodilation, uterine relaxation, and skeletal muscle tremor

41 Adrenergic Agents stimulation of the enzyme adenyl cyclase, which converts intracellular adenosine triphosphate into cyclic adenosine monophosphatestimulation of the enzyme adenyl cyclase, which converts intracellular adenosine triphosphate into cyclic adenosine monophosphate enhances the binding of intracellular calcium to cell membranes, reducing the myoplasmic calcium concentration, and results in relaxation of bronchial smooth muscleenhances the binding of intracellular calcium to cell membranes, reducing the myoplasmic calcium concentration, and results in relaxation of bronchial smooth muscle inhibit mediator release and promote mucociliary clearance.inhibit mediator release and promote mucociliary clearance.

42 side effect of B-adrenergic drugs: skeletal muscle tremor (most common) nervousness, anxiety, insomnia, headache, hyperglycemia, palpitations, tachycardia, and hypertension potential cardiotoxicity(combination with theophylline not significant problems) Arrhythmias and evidence of myocardial ischemia(rare)

43 Inhaled short-acting B-2 agonists Albuterol Nebulizer solution (5 mg/mL) Nebulizer solution (5 mg/mL) 2.5–5.0 mg every 20 min for 3 doses2.5–5.0 mg every 20 min for 3 doses then 2.5–10 mg every 1–4 h as needed or 10–15 mg per h continuouslythen 2.5–10 mg every 1–4 h as needed or 10–15 mg per h continuously Only selective B-2 agonists are recommendedOnly selective B-2 agonists are recommended for optimal delivery, dilute aerosols to minimum of 4 mL at gas flow of 6–8 L per min for optimal delivery, dilute aerosols to minimum of 4 mL at gas flow of 6–8 L per min

44 Albuterol (MDI) Meter Dose Inhalation (90μ/puff) (MDI) Meter Dose Inhalation (90μ/puff) 4–8 puffs every 20 min up to 4 h4–8 puffs every 20 min up to 4 h then every 1–4 h as needed then every 1–4 h as needed As effective as nebulized therapy if patient is able to coordinate inhalation maneuver; use spacer/holding chamberAs effective as nebulized therapy if patient is able to coordinate inhalation maneuver; use spacer/holding chamber

45 Inhaled short-acting B-2 agonists Bitolterol Bitolterol Nebulizer solution (2 mg/mL) Nebulizer solution (2 mg/mL) MDI (370 macg/puff) MDI (370 macg/puff) PirbuterolPirbuterol MDI (200 g/puff)MDI (200 g/puff)

46 Inhaled short-acting B-2 agonists Systemic (injected), B-2 agonistsSystemic (injected), B-2 agonists Epinephrine (1:1000 or 1 mg/mL)Epinephrine (1:1000 or 1 mg/mL) 0.3–0.5 mg SC every 20 min for 3 doses0.3–0.5 mg SC every 20 min for 3 doses Terbutaline (1 mg/mL)Terbutaline (1 mg/mL) 0.25 mg SC every 20 min for 3 doses0.25 mg SC every 20 min for 3 doses No proven advantage of systemic therapy over aerosol

47 Anticholinergics potent bronchodilators in patients with asthma and other forms of obstructive lung diseasepotent bronchodilators in patients with asthma and other forms of obstructive lung disease anticholinergics affect large, central airways,anticholinergics affect large, central airways, whereas B-adrenergic drugs dilate smaller airwayswhereas B-adrenergic drugs dilate smaller airways competitively antagonize acetylcholine at the postganglionic junction between the parasympathetic nerve terminal and effector cellcompetitively antagonize acetylcholine at the postganglionic junction between the parasympathetic nerve terminal and effector cell blocks the bronchoconstriction induced by vagal cholinergic- mediated innervation to the larger central airwaysblocks the bronchoconstriction induced by vagal cholinergic- mediated innervation to the larger central airways concentrations of cyclic guanosine monophosphate in airway smooth muscle are reduced,further promotin bronchodilationconcentrations of cyclic guanosine monophosphate in airway smooth muscle are reduced,further promotin bronchodilation

48 Anticholinergics Ipratropium bromide Ipratropium bromide Nebulizer solution (0.2 mg/mL) Nebulizer solution (0.2 mg/mL) 0.5 mg every 30 min for 3 doses0.5 mg every 30 min for 3 doses then every 2–4 h as neededthen every 2–4 h as needed Should not be used as first-line therapy;Should not be used as first-line therapy; should be added to 2 agonist therapy;should be added to 2 agonist therapy; may mix in same nebulizer with albuterolmay mix in same nebulizer with albuterol MDI (18 g/puff)MDI (18 g/puff) 4–8 puffs every 6–8 h4–8 puffs every 6–8 h

49 side effects dry mouth dry mouth ThirstThirst difficulty swallowingdifficulty swallowing Less commonlyLess commonly tachycardia, restlessness, irritability, confusion, difficulty in micturition, ileus, blurring of vision, or an increase in intraocular pressuretachycardia, restlessness, irritability, confusion, difficulty in micturition, ileus, blurring of vision, or an increase in intraocular pressure

50 Corticosteroids highly effective drugs in asthma exacerbationhighly effective drugs in asthma exacerbation one of the cornerstones of treatmentone of the cornerstones of treatment mechanism of action is unknownmechanism of action is unknown (مکانیسم فعالیت نامشخص است) Restoring B-adrenergic responsiveness reducing inflammation The onset of anti-inflammatory effect is delayed at least 4 to 8 h after intravenous or oral administration. 4) تا 8 ساعت بعد از مصرف خوراکی یا وریدی, اثرات آن شروع میشود)

51 Corticosteroids administered within 1 h of arrival in the EDadministered within 1 h of arrival in the ED reduces the need for hospitalization prednisone 40 to 60 mg, oral methylprednisolone 60 to 125 mg IV High-dose corticosteroid therapy offers no advantageHigh-dose corticosteroid therapy offers no advantage Additional doses should be given every 4 to 6 h until significant subjective and objective improvements are achieved Additional doses should be given every 4 to 6 h until significant subjective and objective improvements are achieved discharging all patients with mild persistent or more severe asthma on maintenance inhaled corticosteroids in addition to a burst of oral corticosteroiddischarging all patients with mild persistent or more severe asthma on maintenance inhaled corticosteroids in addition to a burst of oral corticosteroid

52 Corticosteroids Corticosteroids PrednisonePrednisone MethylprednisoloneMethylprednisolone PrednisolonePrednisolone 120–180 mg per d in 3 or 4 divided doses for 48 h,120–180 mg per d in 3 or 4 divided doses for 48 h, then 60–80 mg per d until FEV1, or PEFR reaches 70% of predicted or personal best then 60–80 mg per d until FEV1, or PEFR reaches 70% of predicted or personal best For outpatient "burst," use 40–60 mg per d, for 3–10 d in adultsFor outpatient "burst," use 40–60 mg per d, for 3–10 d in adults

53 Theophylline no longer considered a first-line treatmentno longer considered a first-line treatment in combination with inhaled B 2-adrenergic drugs,in combination with inhaled B 2-adrenergic drugs, increase the toxicity, but not the efficacy, of treatmentincrease the toxicity, but not the efficacy, of treatment more sustained bronchodilator effect, improving respiratory muscle endurancemore sustained bronchodilator effect, improving respiratory muscle endurance improving resistance to fatigueimproving resistance to fatigue anti-inflammatoryanti-inflammatory side effects nervousness, nausea, vomiting, anorexia, and headachenervousness, nausea, vomiting, anorexia, and headache At plasma levels greater than 30 g/mL, there is a risk of seizures and cardiac arrhythmias. At plasma levels greater than 30 g/mL, there is a risk of seizures and cardiac arrhythmias.

54 magnesium sulfate acute, very severe asthmaacute, very severe asthma (i.e., FEV1 <25 percent predicted) (i.e., FEV1 <25 percent predicted) The dose is 1 to 2 g IV over 30 min.The dose is 1 to 2 g IV over 30 min.

55 Heliox, Ketamine, and HalothaneHeliox, Ketamine, and Halothane Mast Cell ModifiersMast Cell Modifiers Leukotriene ModifiersLeukotriene Modifiers

56 Mechanical Ventilation progressive hypercarbia and acidosisprogressive hypercarbia and acidosis ExhaustedExhausted confused,confused, does not relieve the airflow obstruction eliminates the work of breathing and enables the patient to rest while the airflow obstruction is resolveddoes not relieve the airflow obstruction eliminates the work of breathing and enables the patient to rest while the airflow obstruction is resolved Direct oral intubationDirect oral intubation


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