1. Asthma Exacerbations Gil C. Grimes, MD 2008-4-17 Family Medicine

2. Objectives Discuss triggers Describe generalized approach to asthma exacerbation Understand initial medical approach Understand the role of steroids Understand the role of supplemental medications

3. Asthma Triggers Allergens Dust, dander, molds, grass pollens, tree pollen Synergy with respiratory viruses 26 % of those admitted had respiratory virus 66% sensitized to mite or animal dander BMJ 2002:30;324:763

4. Asthma Triggers Air pollutants Ozone, sulfur dioxide, cigarette smoke Cohort study asthmatic children showed association between exacerbation and nitrogen dioxide (lancet 2003 7;36:1939) Ozone exposure increase rescue med use in moderate pediatric asthmatics (JAMA 2003 290;14:1859)

5. Asthma Triggers Respiratory infections #1 cause in young children Seasonal viral infection can increase IgE and eosinophils (Arch Int Med 1998 158;22:2453) Rhinovirus increases LRT complications in asthmatics (Lancet 2002 Mar9;359:831) RSV bronchiolitis in child <12 months risk factor for later asthma 11 of 47 at 3 years with RSV 1 of 93 at 3 years without RSV Pediatrics 1995 April;95(4):500 Consider atypical bacteria (10% of admitted peds)

6. Asthma Triggers Miscellaneous GERD Perfume Sulfites Exercise Emotion (laughing or crying) Foods (shellfish, chocolate, nuts)

7. The case 38 year old female with asthma who has been wheezing since being at a party earlier that evening. Thought she was having an allergic reaction and gave herself Epinephrine which helped for a while. She has been treating with her MDI for the last two hours without improvement (16 or more puffs). PMH: Asthma, allergies prior tobacco Meds: Azmacort, Singulair, Zyrtec, Albuterol O: 134/58 P104, AF, R28 Sat 90% (RA)

8. Approach to the patient What do you do first? What is you first medication? How long will you do this prior to changing? How will you monitor for change?

9. Initial approach Precipitating Factors Chest pain Sputum production Fever Just like prior attacks? Have you taken steroids? What has worked in the past? Have you ever been intubated? What are your medications?

10. Evaluation Physical Severe Tachycardia Tachypnea Accessory muscle use Retractions Flaring in infants Ability feed in infants Inability to recline PEFR <50% of best

11. Evaluation Physical Life Threatening Cyanosis Silent chest Fatigue Inability to speak Decreased level of consciousness PEFR <33% of best

12. Vitals Pulse oximetry Radiograph Pneumothorax Pneumomediastinum Pneumonia Poor response to therapy

13. Laboratory Testing ABG Not terribly predictive Stage I respiratory alkalosis decreased PCO2 Stage II alkalosis and hypoxia Stage III fatigue CO2 rises (repeat if PCO2 >30) Stage IV respiratory failure elevated PCO2 correlates with PEFR <200L/min

14. Mortality risks Higher in adults Status most common cause of death asthmatics Decreased FEV1, advanced age, h/o tobacco use Eosinophilia increases mortality 7.4x Increased FEV1>50% after bronchodilator increases mortality risk 7x

15. Clinical Calculators Pediatric Calculator Asthma Score (0-10 points) Respiratory rate 40-60 (1 pts) >60 (2 pts) Wheezing via stethoscope expiratory (1pt) inspiratory & expiratory (2pts) Retractions subcostal (1pts) subcostal & intercostal (2pts) Observed dyspnea mild (1pts) marked (2pts) I-E ratio equal (1pts) I<E (2pts) Higher score correlates with length of stay

16. Therapy Generally accepted and effective Oxygen supplementation (titrate) Beta-2 agonists Atrovent Magnesium Sulfate (?) Hydration

17. Oxygen First line therapy 2-3 Liters via nasal cannula Target 92% pulse ox NRB vs. Nasal cannula 100% increased PaCO2 100% decreased PEFR Chest 2003 Oct;124(4):1312

18. Aerosol Medications Metered Dose Inhalers Meta-analysis of MDI vs. Neb in pediatrics Nebs increased admission rate Difference greatest with severe cases Key is proper use of MDI J Pediatric 2004 Aug 145(2):172

19. Beta 2 Agonist Demonstrated Benefit If nebulized dose used, oxygen powered not air powered (BMJ 2001 323:98) Continuous Nebs more effective than once hourly Every 15 minutes or continuous No difference in side effects Reduced admissions Most improvement among severest group Cochrane review Issue 2, 2004

20. Beta 2 agonist IV Route? Cochrane review Issue 2 2004 15 studies indicates no evidence to support this approach Does not address SQ epinephrine or terbutaline Inhalation route is preferred route

21. Anticholinergics Moderate to severe exacerbations in children Multiple doses of Anicholinergics effective 25% reduction in admissions NNT 12 Single dose not effective Cochrane review Issue 2 2004 No benefit to continuing once admitted Arch Pediatric Adolescent Med 2001;155:1329

22. Steroids Low dose steroids appear as effective as high dose 80 mg/day of methyprednisalone 400 mg/day hydrocortisone Parenteral no better than oral Reduces readmission rates, relapse rate, and rescue inhaler use for 21 days Best if given within one hour of arrival in ED Cochrane review Issue 2, 2004

23. Magnesium Intravenous route Adults beneficial with severe exacerbation (FEV1<25% predicted) 1.2-2 gm IV over20-30 minutes NNT 8 Ann Emerg Med 2000;36:181-90 Cochrane review Issue 2, 2004 Pediatrics Small RCT (30 patients) Used 40 mg/kg IV vs. saline NNT to prevent one admission 2 Arch Pediatric Adolescent Med 2000;154:979

24. Magnesium Nebulized route Small RCT 58 adults 2.5 ml mag sulfate with 2.5 mg Albuterol via neb 3 doses q 30 minutes NNT 5 for admission Lancet 2003 Sept 27;362:1079

25. Unclear or Useless Tx Antibiotics No identified role Cochrane issue 2, 2004 Heliox No identified role Cochrane issue 2, 2004 Aminophylline Results in more side effects no reduction in patient oriented outcomes Cochrane issue 2, 2004

26. Decision Tree in ER Good response to therapy Absence of symptoms Absence of signs PEFR > 300 L/min Watch for 4 hours for wearing off of beta Admit if response is poor Continued wheezing Continued dyspnea PEFR <200 L/min Pneumothorax, pneumomediastinum Consider Intubation/BiPAP Obtunded Sitting up/leaning forward with diaphoresis Patient exhaustion