1 In the Name of God Asthma in Pregnancy Obstetrics and Gynecology Department Hormozgan University of Medical Sciences Presentation by Mitra Ahmad Soltani 2006

2 Guideline on the Management of Asthma Guideline on the Management of Asthma A national clinical guideline Thorax 2003; 58 (Suppl I): i1-i92 Williams Obstetrics Asthma in pregnancy The British Thoracic Society Scottish Intercollegiate Guidelines Network

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4 Assessment of PEF Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92

5 Definition of asthma Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 “A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.”

6 Diagnosis of asthma in adults Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Consider the diagnosis of asthma in patients with some or all of these features Symptoms (episodic/variable) wheeze wheeze shortness of breath shortness of breath chest tightness chest tightness cough cough

7 Diagnosis of asthma in adults Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Symptoms (episodic/variable) wheeze shortness of breath chest tightness coughSigns none (common) none (common) wheeze – diffuse, bilateral, expiratory (  inspiratory) wheeze – diffuse, bilateral, expiratory (  inspiratory) tachypnea tachypnea Consider the diagnosis of asthma in patients with some or all of these features

8 Diagnosis of asthma in adults Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Helpful additional information personal/family history of asthma or atopy personal/family history of asthma or atopy history of worsening after aspirin/NSAID,  blocker use history of worsening after aspirin/NSAID,  blocker use recognised triggers – pollens, dust, animals, exercise, viral infections, chemicals, irritants recognised triggers – pollens, dust, animals, exercise, viral infections, chemicals, irritants pattern and severity of symptoms and exacerbations pattern and severity of symptoms and exacerbations Symptoms (episodic/variable) wheeze shortness of breath chest tightness cough Signs none (common) wheeze – diffuse, bilateral, expiratory (  inspiratory) tachypnea Consider the diagnosis of asthma in patients with some or all of these features

9 Diagnosis of asthma in adults Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Objective measurements >20% diurnal variation on  3 days in a week for 2 weeks on PEF diary >20% diurnal variation on  3 days in a week for 2 weeks on PEF diary or FEV 1  15% (and 200ml) increase after short acting ß 2 agonist or steroid tablets or FEV 1  15% (and 200ml) increase after short acting ß 2 agonist or steroid tablets or FEV 1  15% decrease after 6 minutes of running exercise or FEV 1  15% decrease after 6 minutes of running exercise histamine or methacholine challenge in difficult cases histamine or methacholine challenge in difficult cases Symptoms (episodic/variable) wheeze shortness of breath chest tightness cough Signs none (common) wheeze – diffuse, bilateral, expiratory (  inspiratory) tachypnea Helpful additional information personal/family history of asthma or atopy history of worsening after aspirin/NSAID,  blocker use recognised triggers – pollens, dust, animals, exercise, viral infections, chemicals, irritants pattern and severity of symptoms and exacerbations Consider the diagnosis of asthma in patients with some or all of these features

10 Differential diagnosis of asthma in adults Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Some of symptoms of asthma are shared with diseases of other systems Numerous relatively common lung diseases Need to differentiate from infections and restrictive lung disorders, and between local and generalised obstruction Differential diagnoses include: COPD COPD cardiac disease cardiac disease laryngeal, tracheal or lung tumour laryngeal, tracheal or lung tumour bronchiectasis bronchiectasis foreign body foreign body interstitial lung disease interstitial lung disease pulmonary emboli pulmonary emboli aspiration aspiration vocal cord dysfunction vocal cord dysfunction hyperventilation hyperventilation

11 Indications for referral of adults with suspected asthma Diagnosis unclear or in doubt Unexpected clinical findings e.g. crackles, clubbing, cyanosis, heart failure Spirometry or PEF measurements do not fit the clinical picture Suspected occupational asthma Persistent shortness of breath (not episodic, or without associated wheeze) Unilateral or fixed wheeze Stridor Persistent chest pain or atypical features Weight loss Persistent cough and/or sputum production Non-resolving pneumonia Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

12 Diagnosis of asthma in adults: practice points Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Record presence of wheeze in patient’s notes  Try to confirm diagnosis with objective tests before long-term therapy is started  Question diagnosis if little response to treatment  Perform chest X-rays in patients with atypical symptoms

13 Overview: Diagnosis and natural history Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 Diagnose before treating Try to confirm diagnosis with objective tests before long-term therapy is started Differentiate from other respiratory and non-respiratory conditions Question the diagnosis if little response to treatment

14 Non-pharmacological management The British Thoracic Society Scottish Intercollegiate Guidelines Network Non-pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

15 Rationale for non-pharmacological management Non-pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Although little evidence, possible that avoiding certain factors might: facilitate management of asthma reduce requirement for pharmacotherapy modify fundamental causes of asthma. Factors that induce the disease not necessarily same as those that incite a pre-existing problem so distinction between: primary prophylaxis – interventions before any evidence of disease secondary prophylaxis – interventions after onset of disease to reduce its impact

16 Potential strategies for primary prophylaxis Non-pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92A Breast-feeding should be encouraged as protects against early life wheezing B Parents and parents-to-be who smoke should be advised to stop and given appropriate support as there is increased wheezing in infants exposed to smoke

17 Potential strategies for secondary prophylaxis Non-pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 In committed families with evidence of house dust mite allergy and who wish to try mite avoidance, the following are recommended: complete barrier bed covering systems complete barrier bed covering systems removal of carpets removal of carpets removal of soft toys from bed removal of soft toys from bed high temperature washing of bed linen high temperature washing of bed linen acaricides to soft furnishings acaricides to soft furnishings dehumidification dehumidification

18 Non-pharmacological management of asthma Non-pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Use of ionisers cannot be encouraged as no evidence of benefit and suggestion of adverse effect  In difficult childhood asthma, may be a role for family therapy as adjunct to pharmacotherapy C Weight reduction recommended in obese patients with asthma  Treat gastro-oesophageal reflux if present but generally no impact on asthma control No consistent evidence or recommendations about complementary or alternative treatment for asthma (e.g acupuncture, Buteyko or other breathing exercises, hypnosis, homeopathy or manipulation therapy)

19 Pharmacological management The British Thoracic Society Scottish Intercollegiate Guidelines Network Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 All doses of inhaled steroids in this section refer to beclomethasone (BDP) given via metered dose inhaler. Adjustment may be necessary for fluticasone and/or other devices

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21 Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Stepwise management of asthma in adults Step 1: Mild intermittent asthma Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy

22 Asthma control Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Asthma control means: minimal symptoms during day and night minimal symptoms during day and night minimal need for reliever medication minimal need for reliever medication no exacerbations no exacerbations no limitation of physical activity no limitation of physical activity normal lung function (FEV 1 and/or PEF >80% predicted or best) normal lung function (FEV 1 and/or PEF >80% predicted or best)

23 Asthma control Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Asthma control means: minimal symptoms during day and night minimal need for reliever medication no exacerbations no limitation of physical activity normal lung function (FEV 1 and/or PEF >80% predicted or best) Aim for early control, with stepping up or down as required

24 Asthma control Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Asthma control means: minimal symptoms during day and night minimal need for reliever medication no exacerbations no limitation of physical activity ) normal lung function (FEV 1 and/or PEF >80% predicted or best) Aim for early control, with stepping up or down as required Before initiating a new drug therapy: check compliance with existing therapies check compliance with existing therapies check inhaler technique check inhaler technique eliminate trigger factors eliminate trigger factors

25 Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required Stepwise management of asthma in adults Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

26 Stepwise management of asthma in adults Step 2: Regular preventer therapy Add inhaled steroid mcg/day * 400mcg is an appropriate starting dose for many patients Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma

27 Stepwise management of asthma in adults Step 3: Add-on therapy 1. Add inhaled long-acting ß 2 agonist (LABA) 2. Assess control of asthma: good response to LABA – continue LABA good response to LABA – continue LABA benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 800mcg/day * (if not already on this dose) benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 800mcg/day * (if not already on this dose) no response to LABA – stop LABA and increase inhaled steroid to 800mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline) no response to LABA – stop LABA and increase inhaled steroid to 800mcg/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline) Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

28 Stepwise management of asthma in adults Step 4: Persistent poor control Consider trials of: increasing inhaled steroid up to 2000mcg/day * increasing inhaled steroid up to 2000mcg/day * addition of fourth drug (e.g. leukotriene receptor antagonist, SR theophylline, ß 2 agonist tablet) addition of fourth drug (e.g. leukotriene receptor antagonist, SR theophylline, ß 2 agonist tablet) Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

29 Stepwise management of asthma in adults Step 5: Continuous or frequent use of oral steroids Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 2000mcg/day * Consider other treatments to minimise the use of steroid tablets Refer patient for specialist care Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent Step 4: Persistent poor control

30 Overview: Pharmacological management Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92 Add inhaled long-acting  2 agonists rather than increasing the dose of inhaled steroids (above 800mcg/day in adults and 400mcg/day in children) Step down therapy to lowest level consistent with maintained control

31 Inhaler devices The British Thoracic Society Scottish Intercollegiate Guidelines Network Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92

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34 Peak flow meter

35 Spacer

36 Dry powder inhaler

37B Prescribe inhalers only after patients have been trained and have demonstrated satisfactory technique  Reassess inhaler technique as part of structured clinical review Reassess inhaler technique as part of structured clinical review The choice of device may be determined by choice of drug The choice of device may be determined by choice of drug If patient unable to use a device satisfactorily, find alternative If patient unable to use a device satisfactorily, find alternative Titrate medication needs against clinical response to ensure optimum efficacy Titrate medication needs against clinical response to ensure optimum efficacy Device selection Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92

38AA Use pMDI and large volume spacer for adults and children aged 2-12 years with mild and moderate exacerbations of asthma  pMDI + spacer preferred delivery method for children aged 0-5 years A In children aged 5-12 years with chronic asthma, pMDI + spacer is as effective as any other hand held inhaler A In adults, pMDI ± spacer is as effective as any other hand held inhaler, but patients may prefer dry powder inhalers  Base choice of reliever inhaler for stable asthma on patient preference/ability to use, as many patients will not carry a spacer A Salbutamol non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosing Delivery of ß 2 agonists Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92Adults Children 5-12 years Children <5 years

39 pMDI + spacer preferred delivery method for children aged 0-5 years A For children aged 5-12 years, pMDI + spacer is as effective as any dry powder inhaler A In adults, a pMDI ± spacer is as effective as any dry powder inhaler  HFA-BDP pMDI can be substituted for CFC-BDP pMDI at 1:2 dosing, but should incorporate period of close monitoring A Fluticasone non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosing Delivery of inhaled steroids Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92Adults Children 5-12 years Children <5 years

40 Use and care of spacers Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92 Ensure spacer compatible with pMDI used Ensure spacer compatible with pMDI used Administer drug by repeated single actuations of pMDI into spacer, each followed by inhalation Administer drug by repeated single actuations of pMDI into spacer, each followed by inhalation Minimise delay between pMDI actuation and inhalation Minimise delay between pMDI actuation and inhalation Tidal breathing is as effective as single breaths Tidal breathing is as effective as single breaths Spacers should be cleaned monthly by washing in detergent and air drying, with mouthpiece wiped clean of detergent before use Spacers should be cleaned monthly by washing in detergent and air drying, with mouthpiece wiped clean of detergent before use Drug delivery may vary significantly due to static charge Drug delivery may vary significantly due to static charge Replace after 6-12 months Replace after 6-12 months

41 Overview: Inhaler devices Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92 pMDI + spacer is preferred delivery method in children aged 0-5 years pMDI + spacer is as effective as other delivery methods for other age groups Choice of inhaler should be based on patient preference and ability to use

42 Asthma in pregnancy The British Thoracic Society Scottish Intercollegiate Guidelines Network Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92

43 5 to 9 percent of pregnant women suffer from asthma PGF2 alfa is contraindicated in asthmatic women/ LT inhibitors are contraindicated in pregnancy Asthma is a risk factor for preeclampsia, preterm labor, LBW babies, and perinatal mortality

44 Changes in respiratory system in pregnancy Reduced FRC PCO2 more than 35 is considered as abnormal (non pregnant state is 40 mmHg) No change in PEF or FEV1 Stress dose of hydrocortisone (100 mg IV TDS) for those who receive systemic steroids Fentanyl as narcotic NVD is preferred- Epidural is a better choice than general anesthesia

45D Offer pre-pregnancy counselling about continuing asthma medications during pregnancy to ensure good asthma control C Monitor pregnant women with asthma closely to ensure therapy is appropriate for symptoms  Advise women who smoke about dangers and give appropriate support to stop smoking Asthma in pregnancy Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92

46C Give drug therapy for acute asthma as for the non-pregnant patient D Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospital D Deliver oxygen immediately to maintain saturation above 95%  Continuous fetal monitoring is recommended for severe acute asthma  For women with poorly controlled asthma during pregnancy there should be close liaison between the respiratory physician and obstetrician Management of acute asthma in pregnancy Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92

47C Use  2 agonists, inhaled steroids and oral/IV theophyllines as normal during pregnancy D Check blood levels of theophylline in acute severe asthma and in those critically dependent on therapeutic theophylline levels C Use steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy D Do not commence leukotriene antagonists during pregnancy C Encourage women with asthma to breast feed. Use asthma medications as normal during lactation Drug therapy for asthma during pregnancy and lactation Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92

48 Advise women that acute asthma is rare in labour  Advise women to continue their usual asthma medications in labour  In the absence of acute severe asthma, reserve caesarean section for the usual obstetric indications C If anaesthesia is required, regional blockade is preferable to general anaesthesia in women with asthma  Women receiving steroid tablets at a dose exceeding prednisolone 7.5mg per day for more than 2 weeks prior to delivery should receive parenteral hydrocortisone 100mg 6-8 hourly during labour D Use prostaglanding F2  with extreme caution in women with asthma because of the risk of inducing bronchoconstriction Management of asthma during labour Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92

49 Overview: Asthma in pregnancy Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92 Continue treatment as usual Monitor pregnant women with asthma closely to ensure therapy is appropriate for symptoms Acute severe asthma in pregnancy should be treated as usual, but in a hospital setting If anaesthesia is required, regional blockade is preferred

50 Management of acute asthma The British Thoracic Society Scottish Intercollegiate Guidelines Network Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92

51 Patients at risk of developing near fatal or fatal asthma Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Severe asthma Adverse behavioural or psychosocial features and Recognised by combination of:

52 Patients at risk of developing near fatal or fatal asthma Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 and Adverse behavioural or psychosocial features Severe asthma recognised by one or more of: previous near fatal asthma (previous ventilation or respiratory acidosis) previous near fatal asthma (previous ventilation or respiratory acidosis) previous asthma admission previous asthma admission requiring  3 classes of asthma medication requiring  3 classes of asthma medication heavy use of ß 2 agonist heavy use of ß 2 agonist repeated attendances at A&E for asthma care repeated attendances at A&E for asthma care brittle asthma brittle asthma Recognised by combination of:

53 Patients at risk of developing near fatal or fatal asthma Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Severe asthma Adverse behavioural or psychosocial features recognised by one or more of: non-compliance with treatment or monitoring non-compliance with treatment or monitoring failure to attend appointments failure to attend appointments self-discharge from hospital self-discharge from hospital psychosis, depression, other psychiatric illness or deliberate self-harm psychosis, depression, other psychiatric illness or deliberate self-harm current or recent major tranquilliser use current or recent major tranquilliser use denial denial alcohol or drug abuse alcohol or drug abuse obesity obesity learning difficulties learning difficulties employment problems employment problems income problems income problems social isolation social isolation childhood abuse childhood abuse severe domestic, marital or legal stress severe domestic, marital or legal stress and Recognised by combination of:

54 Lessons learnt from studies of asthma deaths Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92B Health care professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death  Keep patients who have had near fatal asthma or brittle asthma under specialist supervision indefinitely  Respiratory specialist should follow up patients admitted with severe asthma for at least a year after admission Many deaths from asthma are preventable – 88-92% of attacks requiring hospitalisation develop over  6 hours Factors include: inadequate objective monitoring failure to refer earlier for specialist advice inadequate treatment with steroids

55 Initial assessment – the role of symptoms, signs and measurements Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Clinical features Clinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack

56 Initial assessment – the role of symptoms, signs and measurements Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Clinical featuresClinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack PEF or FEV 1 Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and cheaper than FEV 1. PEF as % previous best value or % predicted most useful

57 Initial assessment – the role of symptoms, signs and measurements Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Clinical featuresClinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack PEF or FEV 1 Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and cheaper than FEV 1. PEF as % previous best value or % predicted most useful Pulse oximetry Necessary to determine adequacy of oxygen therapy and need for arterial blood gas measurement. Aim of oxygen therapy is to maintain SpO 2  92%

58 Initial assessment – the role of symptoms, signs and measurements Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Clinical featuresClinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack PEF or FEV 1 Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and cheaper than FEV 1. PEF as % previous best value or % predicted most useful Pulse oximetryNecessary to determine adequacy of oxygen therapy and need for arterial blood gas measurement. Aim of oxygen therapy is to maintain SpO 2  92% Blood gases (ABG) Necessary for patients with SpO 2 <92% or other features of life threatening asthma

59 Initial assessment – the role of symptoms, signs and measurements Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Clinical featuresClinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack PEF or FEV 1 Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and cheaper than FEV 1. PEF as % previous best value or % predicted most useful Pulse oximetryNecessary to determine adequacy of oxygen therapy and need for arterial blood gas measurement. Aim of oxygen therapy is to maintain SpO 2  92% Blood gases (ABG) Necessary for patients with SpO 2 <92% or other features of life threatening asthma Chest X-ray Not routinely recommended in patients in the absence of: suspected pneumomediastinum or pneumothorax suspected pneumomediastinum or pneumothorax suspected consolidation suspected consolidation life threatening asthma life threatening asthma failure to respond to treatment satisfactorily failure to respond to treatment satisfactorily requirement for ventilation requirement for ventilation

60 Initial assessment – the role of symptoms, signs and measurements Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Clinical featuresClinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack PEF or FEV 1 Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and cheaper than FEV 1. PEF as % previous best value or % predicted most useful Pulse oximetryNecessary to determine adequacy of oxygen therapy and need for arterial blood gas measurement. Aim of oxygen therapy is to maintain SpO 2  92% Blood gases (ABG) Necessary for patients with SpO 2 <92% or other features of life threatening asthma Chest X-rayNot routinely recommended in patients in the absence of: suspected pneumomediastinum or pneumothorax suspected consolidation life threatening asthma failure to respond to treatment satisfactorily requirement for ventilation Systolic paradox Abandoned as an indicator of the severity of an attack

61 Management of acute severe asthma in adults : potential discharge Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 In all patients who received nebulised ß 2 agonists prior to presentation, consider an extended observation period prior to discharge In all patients who received nebulised ß 2 agonists prior to presentation, consider an extended observation period prior to discharge If PEF <50% on presentation, prescribe prednisolone 40-50mg/day for 5 days If PEF <50% on presentation, prescribe prednisolone 40-50mg/day for 5 days In all patients ensure treatment supply of inhaled steroid and ß 2 agonist and check inhaler technique In all patients ensure treatment supply of inhaled steroid and ß 2 agonist and check inhaler technique Arrange GP follow up for 2 days post presentation Arrange GP follow up for 2 days post presentation Refer to asthma liaison nurse/chest clinic Refer to asthma liaison nurse/chest clinic

62 Assessment and management of acute asthma in adults in general practice Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Moderate asthma Acute severe asthma Life threatening asthma INITIAL ASSESSMENT PEF >50% best or predicted PEF 33-50% best or predicted PEF <33% best or predicted

63 Assessment and management of acute asthma in adults in general practice Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Moderate asthma Acute severe asthma Life threatening asthma INITIAL ASSESSMENT PEF >50% best or predictedPEF 33-50% best or predictedPEF <33% best or predicted FURTHER ASSESSMENT Speech normal Speech normal Respiration <25 breaths/min Respiration <25 breaths/min Pulse <110 beats/min Pulse <110 beats/min Cannot complete sentences Cannot complete sentences Respiration  25 breaths/min Respiration  25 breaths/min Pulse  110 beats/min Pulse  110 beats/min SpO 2 <92% SpO 2 <92% Silent chest, cyanosis, or poor respiratory effort Silent chest, cyanosis, or poor respiratory effort Bradycardia, dysrhythmia or hypotension Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma Exhaustion, confusion or coma Caution: Patients with severe or life threatening attacks may not be distressed and may not have all the abnormalities listed. The presence of any should alert the doctor.

64 Assessment and management of acute asthma in adults in general practice Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Moderate asthma Acute severe asthma Life threatening asthma INITIAL ASSESSMENT PEF >50% best or predictedPEF 33-50% best or predictedPEF <33% best or predicted FURTHER ASSESSMENT Speech normal Respiration <25 breaths/min Pulse <110 beats/min Cannot complete sentences Respiration  25 breaths/min Pulse  110 beats/min SpO 2 <92% Silent chest, cyanosis, or poor respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma MANAGEMENT Treat at home or in surgery and ASSESS RESPONSE TO TREATMENT Consider admission Arrange immediate ADMISSION

65 Treatment of acute asthma in adults in general practice Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Moderate asthma exacerbation Acute severe asthma Life threatening asthma High dose bronchodilator: High dose bronchodilator: - ideally via oxgen driven nebuliser (salbutamol 5mg or terbutaline 10mg) - ideally via oxgen driven nebuliser (salbutamol 5mg or terbutaline 10mg) - Or via spacer/air driven nebuliser (1 puff times) - Or via spacer/air driven nebuliser (1 puff times) If PEF >50-75% predicted/best: give prednisolone 40-50mg give prednisolone 40-50mg continue or step up usual treatment continue or step up usual treatment Oxygen 40-60% if available Oxygen 40-60% if available High dose ß 2 bronchodilator as for moderate asthma High dose ß 2 bronchodilator as for moderate asthma Prednisolone 40-50mg or intravenous hydrocortisone 100mg Prednisolone 40-50mg or intravenous hydrocortisone 100mg If no response: ADMIT Oxygen 40-60% Oxygen 40-60% Prednisolone 40-50mg or intravenous hydrocortisone 100mg immediately Prednisolone 40-50mg or intravenous hydrocortisone 100mg immediately High dose ß 2 bronchodilator as for moderate asthma exacerbation and ipratropium 0.5mg High dose ß 2 bronchodilator as for moderate asthma exacerbation and ipratropium 0.5mg

66 Management of acute severe asthma in adults : PEF >75% predicted Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92Time Measure PEF and arterial saturations PEF >75% best or predicted: mild 5 min Give usual bronchodilator min Clinically stable AND PEF >75% 60 min 120 min POTENTIAL DISCHARGE

67Time Measure PEF and arterial saturations PEF 33-75% best/predicted: moderate/severe features of severe asthma PEF <50% best of predicted PEF <50% best of predicted Respiration  25/min Respiration  25/min Pulse  110 breaths/min Pulse  110 breaths/min Cannot complete sentence in one breath Cannot complete sentence in one breath 5 min Give salbutamol 5mg by oxygen-driven nebuliser min Clinically stable AND PEF >75% Clinically stable AND PEF <75% No life threatening features AND PEF 50-75% Life threatening features OR PEF <50% Management of acute severe asthma in adults : PEF 33-75% predicted Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 IMMEDIATE MANAGEMENT High concentration oxygen (>60% if possible) High concentration oxygen (>60% if possible) Give salbutamol 5mg plus ipratropium 0.5mg via oxygen-driven nebuliser Give salbutamol 5mg plus ipratropium 0.5mg via oxygen-driven nebuliser AND prednisolone 40-50mg orally or IV hydrocortisone 100mg AND prednisolone 40-50mg orally or IV hydrocortisone 100mg

68Time Measure PEF and arterial saturations PEF 33-75% best/predicted: moderate/severe min Clinically stable AND PEF >75% Clinically stable AND PEF <75% No life threatening features AND PEF 50-75% Life threatening features OR PEF <50% Repeat salbutamol 5mg nebuliser Give prednisolone 40-50mg orally 60 min Patient recovering AND PEF >75% No signs of severe asthma AND PEF 50-70% Signs of severe asthma OR PEF <50% Management of acute severe asthma in adults : PEF 33-75% predicted Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 IMMEDIATE MANAGEMENT Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen- driven nebuliser after 15 minutes Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen- driven nebuliser after 15 minutes Consider continuous salbutamol nebuliser 5-10mg/hr Consider continuous salbutamol nebuliser 5-10mg/hr Consider IV magnesium sulphate 1.2-2g over 20 minutes Consider IV magnesium sulphate 1.2-2g over 20 minutes Correct fluid/electrolytes, especially K + disturbances Correct fluid/electrolytes, especially K + disturbances Chest X-ray Chest X-ray

69 Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen- driven nebuliser after 15 minutes Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen- driven nebuliser after 15 minutes Consider continuous salbutamol nebuliser 5-10mg/hr Consider continuous salbutamol nebuliser 5-10mg/hr Consider IV magnesium sulphate 1.2-2g over 20 minutes Consider IV magnesium sulphate 1.2-2g over 20 minutes Correct fluid/electrolytes, especially K + disturbances Correct fluid/electrolytes, especially K + disturbances Chest X-ray Chest X-rayADMIT Patient should be accompanied by a nurse or doctor at all times min Clinically stable AND PEF >75% 60 min Patient recovering AND PEF >75% No signs of severe asthma AND PEF 50-70% Signs of severe asthma OR PEF <50% OBSERVE monitor SpO 2, heart rate and respiratory rate Patient stable AND PEF >50% Signs of severe asthma OR PEF <50% 120 min POTENTIAL DISCHARGE Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92 Management of acute severe asthma in adults : PEF 33-75% predicted Time Measure PEF and arterial saturations PEF 33-75% best/predicted: moderate/severe

70 Management of acute severe asthma in adults : PEF <33% predicted Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92Time Measure PEF and arterial saturations PEF <33% best or predicted OR any life threatening features: SpO2 <92% SpO2 <92% Bradycardia, arrhythmia, hypotension Bradycardia, arrhythmia, hypotension Silent chest, cyanosis, poor respiratory effort Silent chest, cyanosis, poor respiratory effort Exhaustion, confusion, coma Exhaustion, confusion, coma 5 min min Obtain senior/ICU help now if any life-threatening features are present IMMEDIATE MANAGEMENT High concentration oxygen (>60% if possible) High concentration oxygen (>60% if possible) Give salbutamol 5mg plus ipratropium 0.5mg via oxygen-driven nebuliser Give salbutamol 5mg plus ipratropium 0.5mg via oxygen-driven nebuliser AND prednisolone 40-50mg orally or IV hydrocortisone 100mg AND prednisolone 40-50mg orally or IV hydrocortisone 100mg Measure arterial blood gases Markers of severity: Normal or raised PaCO 2 (PaCO 2 >4.6 kPa; 35mm Hg) Normal or raised PaCO 2 (PaCO 2 >4.6 kPa; 35mm Hg) Severe hypoxia (PaO 2 <8 kPa; 60mm Hg) Severe hypoxia (PaO 2 <8 kPa; 60mm Hg) Low pH (or high H + ) Low pH (or high H + ) 60 min Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen-driven nebuliser after 15 minutes Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen-driven nebuliser after 15 minutes Consider continuous salbutamol nebuliser 5-10mg/hr Consider continuous salbutamol nebuliser 5-10mg/hr Consider IV magnesium sulphate 1.2-2g over 20 minutes Consider IV magnesium sulphate 1.2-2g over 20 minutes Correct fluid/ electrolytes, especially K + disturbances Correct fluid/ electrolytes, especially K + disturbances Chest X-ray Chest X-ray 120 min ADMIT – Patient should be accompanied by a nurse or doctor at all times

71 Patient education and concordance The British Thoracic Society Scottish Intercollegiate Guidelines Network Patient education and self-management. Concordance and compliance. Thorax 2003; 58 (Suppl I): i1-i92