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Acute severe asthma.

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Presentation on theme: "Acute severe asthma."— Presentation transcript:

1 Acute severe asthma

2 Acute severe asthma : who is at most risk ?
Previous life-threatening attacks Severe disease (3 or >3 drugs for control; emergency steroid in past ; ever admitted in last 1 year) Psychiatric morbidity Non-compliance Requiring 2 or > 2 Bronchodilator inhalers monthly

3 Near fatal episodes Misuse of drugs/alcohol Psychiatric illness Denial
Non compliance Learning difficulties Previous admission to ICU for asthma Brittle asthma Social isolation, income and employment difficulties Previous self discharge from hospital Br Med J 2005;

4 What is acute severe asthma ?
ANYONE OF: PEF 33-50% best or predicted RR 25/min Heart rate  110/min Inability to complete sentences in one breath

5 What is life threatening asthma ?
ANYONE OF: PEF < 33% best or predicted Sat O2 < 92% PaO2< 55 mm Hg Normal PaCO2 Silent chest Cyanosis Feeble respiratory effort Heart rate  110/min Inability to complete sentences in one breath

6 Contd……. Bradycardia Dysrhythmia Hypotension Exhaustion Confusion Coma

7 What is near fatal asthma?
Increased PaCO2 Requiring mechanical ventilation

8 What is brittle asthma? Type 1… > 40% diurnal variability in PEF for > 50% of the time over a period > 150 days despite intense therapy Type 2 … sudden severe attacks on a background of apparently well controlled asthma

9 Criteria for hospital admission
Near fatal attack  ADMIT IN ICU Life threatening attack  ADMIT IN ICU Severe attack persisting after initial treatment Previous near fatal or brittle attack Concerns about compliance Living alone Psychological problems Physical disability / learning difficulty Pregnancy Presentation at night

10 Hospital Treatment – Immediate action
CBC (to r/o infection) Chest X-ray (to r/o pneumothorax) Oxygen (40-60%) β2 agonist –nebulised or MDI + spacer Inhaled Ipratropium can be added if required Systemic steroid (Prednisolone / Hydrocortisone) Inhaled steroids to be continued or started as soon as posible Avoid sedation

11 Nebulised salbutamol 5 mg or mg/kg salbutamol hourly (to a maximum of 10 mg per hour have been used in trials so far) Nebulised Ipratropium bromide mcg 6 hourly

12 Acute severe asthma…continues
Oxygen continues Nebulised ß2-agonist (5 mg salbutamol every 20 minutes or continuously at 5-10mg/hr) Nebulised ipratropium bromide (500 mcg 4-6 hrly ) Combination of above two

13 Acute severe Asthma Treatment (Contd.) Obtain IV access
Start steroids (4 mg/kg hydrocortisone loading dose, then 100 mg 6 hrly) Antibiotics ( not routinely ) Adequate hydration Still deteriorating - Start Aminophylline infusion ( mg/kg/hr)

14 Acute severe Asthma Treatment (Contd.) Adrenaline (0.1 mg sc)
Cautious CPAP (ideally BiPAP) Mechanical ventilation RR Low TV ( ml / kg) I:E ratio 1:3 or longer Maintain PaO2 > 60 mmHg Allow PaCO2 to rise, provided pH > 7.2 Adequate sedation and paralysis

15 Management of acute severe Asthma in children > 2 years
High O2 concentrations β2 agonist –nebulised or MDI + spacer Systemic steroids ( Oral / IV ) IV Bronchodilators ( Salbutamol 15μg/kg bolus or continuous infusion of 1-2μg/kg/min upto 5μg/kg/min in PICU)

16 Treatment (general practice)
Oxygen (Check Room air O2 saturation if available) Nebulised salbutamol 5 mg Prednisolone (30-60 mg) or IV Hydrocortisone 200 mg Nebulised Ipratropium Bromide (500 mcg) SC Terbutaline / IV Aminophylline (5mg/kg bolus over 20 mins.) Arrange for ambulance

17 Acute Asthma Emergency Department Management
Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators , O2 if needed Good Response Incomplete/Poor Response Respiratory Failure Add Systemic Glucocorticosteroids Observe for at least 1 hour Good Response Poor Response If Stable, Discharge to Home Discharge Admit to Hospital Admit to ICU

18 Instructions / points on discharge
Been on discharge medication for 24 hours Inhaler technique checked PEFR diurnal variability < 25% Oral + inhaled steroids / bronchodilators ? PEFR meter Follow-up appointment < 48 hrs with GP

19 ‘Treat acute severe asthma at least 4 days before it occurs’
Thomas Petty


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