1. Management of exacerbations of asthma – Recent update
DR. JALAL MOHSIN UDDIN
DTCD, FCPS (Pulmonology)

2. What do you mean by exacerbation?
Exacerbations represent an acute or sub-acute worsening in symptoms and lung function from the patient’s usual status, sometimes it may be the initial presentation of asthma.
It is defined as loss of control of any class or variant of asthma, which may cause mild to life threatening attack.

3. Risk factors for acute exacerbation :
Non compliance to preventive drugs
Infection, most commonly viral URTI
H/O exposure to allergens
Use of more than two canisters of inhaled short acting ß2 agonist per month.
Emotional instability
Current use of systemic corticosteroids or recent withdrawal from this drug.

4. Factors that increase the risk of asthma-related death
A history of near-fatal asthma requiring intubation and mechanical ventilation
Hospitalization or emergency care visit for asthma in the past year.
Currently using or having or recently stopped using oral corticosteroids.
Not currently using inhaled corticosteroid.
Over-use of SABAs, especially use of more than one canister of salbutamol within one month, etc.

5. Management of acute exacerbation of asthma at various levels
Self-management of exacerbations with a written asthma action plan.
Management of asthma exacerbations in primary care.
Management of asthma exacerbation in the emergency department.
Management after hospitalization which also include ICU management.

6. Self-management of exacerbations with a written asthma action plan.
A) For all patient ( mild to severe exacerbation)
1. Increase usual reliever:
(a)Increase frequency of Short acting ß2 agonist (SABA) , For MDI add spacer. (˟˟Rule of 5).
(b) Low dose ICS/formoterol - Increase frequency of reliever use (maximum formoterol total 72 mcg/day).

7. (2)Increase usual controller :
(a) For maintenance and reliever ICS/formoterol : continue maintenance ICS/formoterol and increase reliever ICS/formoterol as needed .
(b) For maintenance ICS : At least double ICS; consider increasing ICS to high dose (maximum 2000 mcg/day).
(c) For maintenance ICS/salmeterol : Step up to higher dose formulation of ICS/salmeterol, or consider adding a separate ICS inhaler.

8. (B) Severe exacerbation
Add oral corticosteroid (OCS) and contact doctor.
OCS(prednisone or prednisolone) is given in following condition :
(1) Deteriorate rapidly or PEF or FEV1 <60% personal best or predicted.
(2) Patient not responding to treatment over 48 hours.
(3) Have a history of sudden severe exacerbations.
Dose :Adult : prednisolone 1mg/kg/day (maximum 50 mg) usually for 5-7 days. Children : 1-2mg/kg/day (maximum 40 mg) usually 3-5 days.

9. ˟˟Rule of 5
1) Ensure the patient is sitting comfortably up right, be calm and reassuring.
2) Give 5 puffs of reliever inhaler.
If spacer is available , shake inhaler and insert mouth piece into spacer.
Place the spacer mouthpiece into patient’s mouth. Give one puff.
Ask the person to breath in and out normally for about five breaths.
Repeat in quick succession until 5 puffs have been given.

10. Use of spacer

11. If spacer is not available , shake inhaler and place mouthpiece in patient’s mouth.
Give 1 puff as the patient inhale slowly and steadily.
Ask the patients to hold the breath for 5 seconds. Then ask the patients to take 5 normal breathe. Repeat until 5 puffs have been given.
3) Wait for 5 minutes
4) If there is no improvement, give another 5 puffs.
5) Repeat the process for 5 times if little or no improvement transfer the patient to hospital, Keep giving puffs every 5 minutes till hospital care begins.

12. Management of asthma exacerbation in primary care
Primary care can be given in doctors chamber or primary health care centre like Upozilla health complex.
A brief history and relevant physical examination should be done with prompt initiation of therapy, and findings should be documented in the notes. If the patient shows signs of severe or life-threatening exacerbation, treatment with SABA, controlled oxygen and systemic corticosteroids should be initiated while arranging for the patient’s urgent transfer to an acute care facility.

13. Flow chart of management of asthma exacerbation in primary care

14. Life – Threatening : Drowsy, confused , silent chest.
Assess the patient Is it asthma ?
Risk factors for asthma related death
Severity of exacerbation
Life – Threatening : Drowsy, confused , silent chest.
Mild/Moderate Talks in phrases, prefers sitting to lying, not agitated, RR ↑, Pulse bpm, O2 saturation-90—95%, PEF>50% predicted or best
Severe : Talks in wards, sits hunched forwards, agitated, RR>30/min, Accessory muscles in use, Pulse>120bpm, O2 saturation <90%, PEF ≤ 50%
URGENT
Transfer to acute care facility . While waiting: give SABA, O2, systemic corticosteroid
Start treatment : SABA puffs by MDI+Spacer, repeat every 20 min for 1 hr. Prednisolone , *Controlled Oxygen : target saturation 93 – 95%.
WORSENING
Continue treatment with SABA as needed Asses response at 1 hr or earlier
Asses for discharge
IMPROVING

15. * Controlled oxygen therapy (if available) : Oxygen therapy should be titrated against pulse oximetry (if available) to maintain oxygen saturation at 93-95%(94-98% for children 6-11yrs). Controlled or titrated oxygen therapy gives better clinical outcomes than high-flow 100% oxygen therapy.

16. Management of asthma exacerbations in the emergency department
Severe exacerbation of asthma are the life-threatening medical emergencies, which are most safely managed in an acute care setting e.g. emergency department.
Besides history taking and physical examination, objective assessments are also needed as the physical examination alone may not indicate the severity of the exacerbation.

17. 1) Measurement of lung function : This is strongly recommended
1) Measurement of lung function : This is strongly recommended. If possible, and without unduly delaying treatment. PEF or FEV1 should be recorded before treatment is initiated. Lung function should be monitored at on hour and at intervals until a clear response to treatment has occurred or a plateau is reached.

18. 2)Oxygen saturation should be done preferably by pulse oximetry
2)Oxygen saturation should be done preferably by pulse oximetry . This is especially useful in children if they are unable to perform PEF. Saturation levels <92% is a predictor of the need for hospitalization. Saturation levels <90% in children or adults signal the need for aggressive therapy. Saturation should be assessed before oxygen is commenced, or 5 minutes after oxygen is removed.
3) Arterial blood gas measurements should be considered for patients with a PEF or FEV1 <50% predicted or for those who do not respond to initial treatment or are deteriorating.

19. 4)Chest X-ray is not routinely recommended, it should be considered if a complicating or alternative cardiopulmonary process is suspected(especially in older patients), or for patients who are not responding to treatment where a pneumothorax may be difficult to diagnose clinically. Positive CXR findings in children may be found if there is fever, no family history of asthma and presence of localized findings in chest examination or in case of suspected foreign body inhalation.
Pneumothorax
Foreign body

20. Flow chart of management of asthma exacerbations in acute care facility, eg; emergency department

21. INITIAL ASSESMENT Are any of the following present ?
A: air way B : Breathing C : circulation Drowsiness, confusion , Silent chest
YES NO
Further management by clinical status according to worst feature
Consult ICU, start SABA and O2 and prepare patient for intubation
Mild or Moderate
Short-acting ß2 agonists , ●consider ipratropium bromide, ● controlled O2 to maintain saturation 93—95% (child 94—98%) , ● Oral corticosteroids.
Severe
● SABA + Iprarropium bromide , ● controlled O2 , ● Oral or IV corticosteroids , ● consider IV magnesium , ● consider high dose ICS
If continuing deterioration, treat as severe and re-asses for ICU
Assess clinical progresss frequently measure lung function in all patients one hour after initial treatment
FEV or PEF 60-8o% and symptoms improved , Moderate consider for discharge
FEV1 or PEF <60%, severe ,continue treatment and reassess frequently

22. Drugs used in acute care settings
1) Oxygen : Desirable oxygen saturation is 93-95% (94-98% for children 6-11 yrs), oxygen should be administered by nasal cannulae or mask. In severe exacerbations, contrlled low flow oxygen therapy using pulse oximetry is preferable. Saturation at 93-95% is associated with better physiological outcomes than with high flow 100% oxygen therapy.
2) Inhaled SABA : Inhaled SABA therapy should be administered frequently . The most cost effective and efficient delivery is by MDI with spacer. A reasonable approach to inhaled SABA in exacerbation would be initially use continuous therapy, followed by intermittent on-demand therapy for hospitalized patients.

23. 3)Epinephrine (for anaphylaxis) : Intramascular epinephrine (adrenaline) is indicated in addition to standard therapy for acute exacerbation associated with anaphylaxis and angioedema. It is not routinely indicated for other asthma exacerbations.

24. 4) Systemic corticosteroids : Systemic corticosteroids speed resolution of exacerbation and prevent relapse , and should be utilized in all but the mildest exacerbations in adults, adolescents and children 6-11yrs. Where possible, systemic corticosteroid s should be administered to patient within 1 hr of presentation. Use of systemic corticosteroids is particularly important in the emergency department if:
Initial SABA treatment fails to achieve
lasting improvement in symptoms
The exacerbation developed while the
patient was taking OCS
The patient has a history of previous
exacerbation requiring OCS

25. Oral coticosteroids is as effective as intravenous
Oral coticosteroids is as effective as intravenous. Oral route is preferred because it is quicker, less invasive and less expensive. For children a liquid formulation is preferred to tables. OCS require at least 4 hrs to produce a clinical improvement. Intravenous corticosteroids can be administered when patient are too dyspneic to swallow; if the patient is vomiting; or when patients require non-invasive ventilation or intubation.

26. Dosage : daily doses of OCS equivalent to 50 mg prednisolone as a single morning dose, or 200 mg hydrocortisone in divided doses, are adequate for most patients. For children , an OCS dose of 1-2 mg/kg up to a maximum of 40 mg/day is adequate. 5 and 7 day courses in adults have been found to be as effective as 10 and 14 day courses respectively, and a 3-5 day course in children is usually considered sufficient. Oral dexamethasone for 2 days can also be used.

27. 6. Inhaled corticosteroids:
Within the emergency department : high-dose ICS given within the first hour after presentation reduces the need for hospitalization in patients not receiving systemic corticosteroids. ICS containing medications significantly reduce the risk of asthma related death or hospitalization.
7. Ipratropium bromide : In moderate to severe exacerbation , treatment in the emergency department with both SABA and ipratropium , a short-acting anticholinergic, is associated with fewer hospitalizations and greater improvement in PEF and FEVI compared with SABA alone.

28. 8. Aminophylline and theophylline : Intrvenous aminophylline and theophylline should not be used in the management of asthma exacerbation, in view of their poor efficacy and safety profile , and the greater effectiveness and relative safety of SABA. The use of intravenous aminophylline is associated with severe and potentially fatal side-effects, particularly in patients already treated with sustained – release theophylline.

29. 9.Magnesium : Intravenous magnesium sulfate is not recommended for routine use in asthma excerbations; however, when administered as a single 2 g infusion over 20 minutes, it reduces hospital admission in some patients, including adults with FEV1<25-30% predicted at presentation; adults and children who fail to respond to initial treatment and have persistent hypoxemia; and children whose FEV1 fails to reach 60% predicted after 1 hr of care. Nebulized salbutamol is most often administered in normal saline; however, it can also be administered in isotonic magnesium sulfate .

30. 10. Leukotriene receptor antagonists : There is limited evidence to support a role for LTRAs in acute asthma. Small studies have demonstrated improvement in lung function.
11.ICS/LABA combinations : The role of these medications in the emergency department or hospital is unclear. One study showed that high dose budesonide/formoterol in patients in the emergency department, all of whom received prednisolone, had similar efficacy and safety profile to SABA.

31. 12. Antibiotics : Evidence does not support a role of antibiotics in asthma exacerbations unless there is strong evidence of lung infection (eg. Fever or purulent sputum or radiological evidence of pneumonia or features of sinusitis). Aggressive treatment with corticosteroids should be implimented before antibiotics are considered.
13. Sedatives should be strictly avoided during exacerbations of asthma because of the respiratory depressant effect of anxiolytic and hypnotic drugs. An association between the use of these drugs and avoidable asthma deaths has been reported.

32. Management after hospitalization also include ICU management.
Clinical status (including the ability to lie flat) and lung function 1hr after commencement of treatment are more reliable predictors of the need for hospitalization than the patient’s status on arrival.

33. Following criteria are important for hospitalization of patient:
1. If pre-treatment FEV1 or PEF is <25% predicted or personal best, or post-treatment FEV1 or PEF is <40% predicted or personal best, hospitalization is recommended.
2. Use more than eight ß2-agonist puffs in the previous 24 hrs.
3.Severity of the exacerbation (eg. Need for resuscitation or rapid medical intervention on arrival, respiratory rate>22 breaths/min, oxygen saturation <95%, final PEF < 50% predicted).
4. Past history of severe exacerbations(eg. Intubations, asthma admissions).
5.Previous unscheduled office and emergency department visits requiring use of OCS.

34. When will you transfer the patient to ICU ?
Severe dyspnoea that does not respond to initial treatment.
Use of accessory muscle and sign of fatigue.
Altered mental conciousness.
SpO2 <90% despite adequate supplementary O2 .
A raising pCO2
ABG pH < 7.25.

35. When you can take support of Non invasive positive pressure ventilation ?
Respiratory distress with use of accessory muscles of respiration.
Abdominal paradox
Respiratory rate >30/min.
ABG shows pH-7.25 to 7.35 or PaCO2--55 to 92 or PaO2/FiO2 <200 .
PaCO2- 50 to 54, but SpO2 < 88% despite O2 supplement .
Patient refuse intubation.

36. Indications of intubations and invasive mechanical ventilation
Severe dyspnea with use of accessory muscle of respiration and paradoxical abdominal movement.
Respiratory rate>35/min.
Life threatening hypoxemia (PaO2<40 mm Hg)
Severe acidosis (pH<7.25)& hypercapnia PaCO2>60 mm of Hg.
Respiratory arrest .
Somnolence and impaired mental status.
Hypotension and shock.
NIPPV failure.

37. Asses for discharge if following targets are achieved :
1) Symptoms improved, not needing SABA
2)PEF improving, and >60-80% of personal best or predicted
3)Oxygen saturation >94% in room air
4)Resources at home adequate.

38. Management plan at discharge :
Reliever : continue as needed
Controller : start or step up
Check inhaler technique , adherence.
Prednisolone : continue , usually for 5-7 days(3-5 days for children)
Follow up : within 2-7 days

39. Follow up :
Reliever : reduce to as-needed.
Controller : continue higher dose for short term (1-2 weeks) or long term (3 months), depending on background to exacerbation.
Risk factors : check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherence.

40. Take home message :
Severe acute asthma ,sometimes may be the initial presentation of asthma.
Every patient should have written asthma action plan for self-management of exacerbations .
Controlled or titrated oxygen therapy gives better clinical outcomes than high-flow 100% oxygen therapy.
Measurement of lung function is strongly recommended. If possible, and without unduly delaying treatment.

41. Take home message :
Oral coticosteroids is as effective as intravenous. 5 and 7 day courses in adults have been found to be as effective as 10 and 14 day courses respectively.
Clinical status (including the ability to lie flat) and lung function 1hr after commencement of treatment are more reliable predictors of the need for hospitalization than the patient’s status on arrival.

42. Thank You All