Acute Asthma Exacerbation

Peak Flow Meter values will go ____ if a patient is feeling is not feeling well

Lower

If patient is unable to use proper technique with a valve holding chamber what option is the alternative

Nebulizer treatment

What signs and symptoms after an exacerbation are considered a good response to initial treatment

No wheezing or dyspnea

Typical Clinical Course Based on Moderate Severity

Office or ED management - relief from frequent inhaled SABA and oral corticosteroids if symptoms last 1 to 2 days

48 y.o.f arrives in ER with upper respiratory infection (URI) x 4 days with progressively worsening dyspnea and perioral cyanosis. History asthma without previous intubation with 3 ED visits in 9 months, GERD, depression, and renal stones 9 years ago. Meds: Albuterol MDI 2 puff PRN, Advair Diskus 250/50 1 inhalation BID, Lansoprazole 30 mg PO BID, and Lexapro 20 mg QD. Exam positive for chest tightness, labored breathing, and wheezing. BP 155/92. P 112. T 37.8 C. R 24. O2 sat 88%. Wt 68kg. Ht 5'6". Patient alert taking several breaths between sentences. PEF current 140 L/min, personal best 400 L/min. CXR no acute process or masses. Recommend initial therapy.

PEF = 35% --> Severe 1. Oxygen 2. Inhaled SABA - Albuterold MDI with valve holding chamber 8 puffs every 20 minutes for 1 hour plus ipratropium 8 puffs 3. Prednisolone 60 mg PO BID 4. Reassess in 1 hour

Exacerbation means _____ across the board

patient usual statues requires a change in their medication

Asthma Exacerbation respond ____ to usual bronchodilator therapy (SABA)

poorly

After an exacerbation with poor response to initial treatment what is the first step that should be taken

repeat SABA therapy immediately and add oral steroid burst

How long does a patient continue corticosteroid treatmetn

until PEF is greater than 70%

What signs and symptoms after an exacerbation are considered an incomplete response to initial treatment

Persistent wheezing or dyspnea

Asthma Exacerbation Allergen Triggers

Pollens, dust mites, animal dander, fungal spores, and cockroaches

High Dose Albuterol Neb

5 mg every 20 minutes for 3 doses then 2.5 to 10 mg every 1 to 4 hours as needed OR 10 to 15 mg/hr continuously

Mild-to-Moderate and Severe Oxygen to achieve SaO2 greater than

90%

Oral Steroid:Systemic Steroid conversion

1:1

What PEF value after an exacerbation are considered a Mild-to-Moderate response to initial treatment for ED visits

More than 40%

Impending or Actual Respiratory Arrest ER asthma exacerbation treatment

Nebulized SABA and ipratropium, intravenous corticosteroids, and consider adjunct therapy. Patient should be admitted to Hospital Intensive Care Unit (ICU)

In the ER would you collect an PEF or and FEV1?

PEF. FEV1 is more technical and more effort

Base action plan for acute asthma exacerbation on

Peak Flow Value

Typical Clinical Course Based on Life-threatening Severity

Possible ICU admission - minimal or no relief from frequent inhaled SABA requiring IV corticosteroids. Adjunctive therapies are helpful

Oral Steroid medications

Prednisone, Methylprednisone, and Prednisolone

Risk factors for Death from Asthma Exacerbation

Previous severe exacerbation requiring intubation or ICU admission for asthma, hospitalization or emergency care visit for asthma in the past year, currently using or having recently stopped (month) using oral corticosteroid, using more than 1 canister of inhaled short acting beta agonist (SABA) per month, history of psychiatric disease or psychosocial problems, poor adherence with asthma medications and/or written asthma action plan, poor perceiver of symptoms, and not currently using inhaled corticosteroids

After an exacerbation with poor response to initial treatment when should patient contact physician for follow up

call clinician immediately AND go to the ER, if drowsiness is occurring consider calling 9-1-1

Asthma Exacerbation Environmental Triggers

cold air, tobacco, and wood smoke

How long should home treatment for acute asthma exacerbation last?

continue more intensive treatment for several days

Hypoxemia

decreased level of oxygen in the blood

exacerbation should be referred to as

flare up

At Home Acute Asthma Exacerbation Treatment what should be done first

Assess severity! Patients at high risk for fatal attack require immediate medical attention after initial treatment

Steroid dosing

40 to 80 mg/day in 1 or 2 divided doses

What PEF values after an exacerbation are considered an incomplete response to initial treatment for at home treatment

50-70%

Initial Home Treatment for Acute Asthma Exacerbation

6 puffs of inhaled SABA (2 to 6 puff but use upper range) by MDI with valve holding chamber then repeat in 20 minutes

Max Inpatient pediatric corticosteroid dosing

60 mg

Max Outpatient corticosteroid dosing

60 mg

High Dose Albuterol MDI

8 puffs every 20 minutes up to 4 hours then every 1 to 4 hours as needed

What OTC product are not recommended for home management treatment for asthma exacerbation

Antihistamines and Cough/Cold products

Asthma Exacerbation Emotional Triggers

Anxiety, stress, and laughter

After an exacerbation with good response to initial treatment when should patient contact physician for follow up

Contact clinician for follow up at patients convenience should continue to use SABA every 3 to 4 hours for the next few days till appointment

After an exacerbation with incomplete response to initial treatment when should patient contact physician for follow up

Contact clinician urgently - that day - for follow up

35 y.o.m. diagnosed with moderate persistent asthma tell you that he is calling from home currently experiencing increased coughing. After initial treatment patient still experiencing persistent dyspnea. Current peak flow 350 L/min while normal is 550 L/min. What is the treatment plan for his exacerbation?

Continue inhaled SABA every 20 minutes. Add Prednisone 60 mg PO. Contact clinician immediately

Treatment Goals for Asthma Exacerbation

Correction of significant hypoxemia, rapid reversal of airflow obstruction, reduction of the likelihood of relapse of the exacerbation or future recurrence of severe airflow obstruction, and development of a written asthma action plan in case of further exacerbation

Typical Clinical Course Based on Mild Severity

Home management - prompt relief with inhaled SABA and possible short course of oral corticosteroids

Dose response curve is shifted to the ______. What does this mean for the dosing?

Right - increased concentration of bronchospatics mediators resulting in higher and more frequent doses needed during acute exacerbation

Ipratropium pharmacological class

SAMA -Anticholinergic bronchodilator

Respiratory rate would be [increase/decreased] during an asthma exacerbation

increased

What PEF value after an exacerbation are considered a Severe response to initial treatment for ED visits

less than 40%

What PEF value after an exacerbation are considered a poor response to initial treatment for at home treatment

less than 50%

Toxicities of Short-term Systemic Glucocorticoids

Insomnia, glucose intolerance, mood alteration, increased appetite and GI distress HPA axis suppression if more than 4 steroid burst per year

Adjunct therapy medication and dosing

Magnesium sulfate 2 g IV over 20 minutes

Pursed-lips and controlled breathing is recommended in home treatment of asthma exacerbation for what reason

May help maintain calm but does not improve lung function

Not recommended therapy in ED and Hospital Asthma Exacerbations

Methylxanthines (Adenosine), Antibiotics (unless BACTERIAL infection), aggressive hydration, mucolytics, sedation, and chest physical therapy

Outpatient corticosteroid dosing

1 - 2 mg/kg/day as 1 to 2 divided doses for 3 to 10 days

Mild-to-Moderate and Severe asthma exacerbation should be reevaluated after ____

1 hour

Impending or Actual Respiratory Arrest Oxygen to achieve SaO2

100% by intubation and mechanical ventialation

In ER what information do you need to collect for asthma exacerbation

Brief history including cause of exacerbation, physical assessment focused on pulmonary function, viral signs, heart rate, respiratory rate, PEF, and oxygen saturation

Typical Clinical Course Based on Severe Severity

ED visit and hospital admission - partial relief from frequent inhaled SABA and oral corticosteroids if symptoms last more than 3 days. Adjunctive therapies are helpful

Initial Mild-to-Moderate ER asthma exacerbation treatment

Inhaled SABA by MDI with valve holding chamber or Neb up to 3 doses in first hour

35 y.o.m. diagnosed with moderate persistent asthma tell you that he is calling from home currently experiencing increased coughing. What initial treatment is recommended for his asthma exacerbation?

Albuterol MDI 6 puffs with valve holding chamber

General Clinical Presentation of Acute Asthma Exacerbation

Anxious, acute distress, dyspnea, wheezing, cough, chest tightness/burning, oftentimes only able to say a few words with each breath, pale or cyanotic skin, or supraclavicular and intercostal retractions

Asthma Exacerbation Medication triggers

Aspirin, NSAIDS, beta blockers, sulfites, and benzalkonium chloride

48 y.o.f arrives in ER with upper respiratory infection (URI) x 4 days with progressively worsening dyspnea and perioral cyanosis. History asthma without previous intubation with 3 ED visits in 9 months, GERD, depression, and renal stones 9 years ago. Meds: Albuterol MDI 2 puff PRN, Advair Diskus 250/50 1 inhalation BID, Lansoprazole 30 mg PO BID, and Lexapro 20 mg QD. Exam positive for chest tightness, labored breathing, and wheezing. BP 155/92. P 112. T 37.8 C. R 24. O2 sat 88%. Wt 68kg. Ht 5'6". Patient alert taking several breaths between sentences. PEF current 140 L/min, personal best 400 L/min. CXR no acute process or masses. Does this patient have any risk factors for death from an asthma exacerbation?

Depression, Past hospitalization from asthma exacerbation in past year,

Monitoring for ED and Hospital Asthma Exacerbation

FEV1 or PEF, oxygen saturation, signs and symptoms (presence of drowsiness predicts impending respiratory failure)

T/F Breathing warm moist air is recommended for home treatment for asthma exacerbation

False

T/F Inhaled Ipratropium is first line therapy

False

T/F Dry Powder Inhalers are recommended for Acute Asthma Exacerbation

False - DPI are not recommended

T/F Ipratropium has been shown to provide further benefit once the patient is hospitalized

False - has not been shown to provide further benefit, should be discontinued however minimal side effects so not priority

T/F IV corticosteroid works faster than oral corticosteroid

False - oral is faster and easier to use

T/F Adjunct therapy is recommended for routine use for asthma exacerbation

False - sever life-threatening exacerbation or severe after 1 hour of conventional treatment

After initial treatment for an asthma exacerbation when should an oral steroid burst be considered

Good Response - if patient is on the edge of good response

Initial Severe ER asthma exacerbation treatment

High-dose inhaled SABA PLUS Ipratropium by MDI with valve holding chamber every 20 minutes or Neb continuously for 1 hour PLUS oral systemic corticosteroid

After initial treatment for an asthma exacerbation when should an oral steroid burst be added

Incomplete or Poor Response - patient needs additional help controlling symptoms

What is an asthma exacerbation

Progressively worsening asthma symptoms including shortness of breath, cough, wheezing, and chest tightness

Albuterol brand names

Proventil, Ventolin, ProAir, and AccuNeb

When are Adjunctive therapes helpful

Severe and Life-threatening condition. ED visits and hospital admission with possible ICU admission

What signs and symptoms after an exacerbation are considered a poor response to initial treatment

Symptoms of wheezing or dyspnea do not improve or worsen

Inhaled Short Acting Beta Agonist Side Effects for Asthma Exacerbation

Tachycardia, Hyperglycemia, Hypokalemia, Tremors, Restlessness, and Anxiety

T/F Drinking large volumes of liquid is not recommended home treatment for asthma exacerbation

True

T/F Inhaled Ipratropium can be mixed with Albuterol for nebulization solution or MDI

True

T/F Inhaled Ipratropium cannot be used as monotherapy

True

T/F Outpatient corticosteroid dosing does not required tapering

True

Asthma Exacerbation Respiratory infection triggers

Usually viral - most common

48 y.o.f arrives in ER with upper respiratory infection (URI) x 4 days with progressively worsening dyspnea and perioral cyanosis. History asthma without previous intubation with 3 ED visits in 9 months, GERD, depression, and renal stones 9 years ago. Meds: Albuterol MDI 2 puff PRN, Advair Diskus 250/50 1 inhalation BID, Lansoprazole 30 mg PO BID, and Lexapro 20 mg QD. Exam positive for chest tightness, labored breathing, and wheezing. BP 155/92. P 112. T 37.8 C. R 24. O2 sat 88%. Wt 68kg. Ht 5'6". Patient alert taking several breaths between sentences. PEF current 140 L/min, personal best 400 L/min. CXR no acute process or masses. What is the most likely precipitant for this exacerbation

Viral Infection

Additive therapy in Mild-to-Moderate ER asthma exacerbation treatment if no immediate response

add oral systemic corticosteroid

Upon discharge from hospital medication should include

adjust medications to outpatient regiment, patient education and include: SABA, complete course of oral corticosteroids and long term control therapy

Cyanosis

blue skin due to poor circulation of oxygen - look at finger/toes and lips

What PEF values after an exacerbation are considered a good response to initial treatment for at home treatment

greater than or equal to 80%

At Home Acute Asthma Exacerbation Treatment should always include

having medication available at home

Signs and symptoms suggestive of more serious exacerbation should result in initial treatment with clinician consultation

marked breathlessness, inability to speak more than short phrases, use of accessory muscles, and drowsiness