Management of Acute Asthma and COPD Exacerbations

systemic corticosteroids reduce

mucus production, reduce bronchial hyper responsiveness, reduce airway edema and exudation

Acute Severe COPD- increased

muscle fatigue

systemic corticosteroids increases

receptor density 4 hours after administration

Corticosteroids shorten

recovery time

Acute Asthma Presentation may progress over

several days to hours Some patients progress rapidly over 1-2 hours

Ipratropium is indicated in

severe asthma exacerbation not completely responsive to beta 2 agonists

Uncontrolled asthma progresses to

severe bronchospasm that results in profound airway narrowing Inflammation Airway edema Excessive mucus accumulation

Corticosteroids longer courses are not more efficacious than

short courses Patients with frequent exacerbations may require higher doses and longer courses of therapy with tapering

Acute Severe COPD- Increased inflammatory mediators in the

sputum i. Neutrophils, eosinophils

Ipratropium reverses cholinergic-mediated bronchoconstriction induced by

triggers: histamine prostaglandins exercise allergens

Antibiotics usual duration

5-10 days

Goal O2 saturation

88-92% may need home o2 at rest or with acitivity

Goal SPO2

>90% (EPR-3) or 93-95% (GINA)

Ipratropium produces a further improvement in

lung function of 10-15% over Beta 2 agonists alone

Acute Severe COPD- COPD is characterized by recurrent exacerbations

Change in patient's baseline symptoms Cough, dyspnea, sputum production

Acute respiratory failure is an acute drop in

PaO2 of 10-15mmHg

Factors Favoring Hospitalization

Presence of high risk comorbidity i. pneumonia, arrhythmia, CHF, diabetes, renal or hepatic failure Suboptimal response to outpatient management Marked worsening of dyspnea Inability to eat or sleep due to symptoms Worsening hypoxemia or hypercapnia Mental status changes Lack of home support for care Uncertain diagnosis

Acute Severe Asthma is poorly responsive to

bronchodilators

Systemic corticosteroids indication

can prevent/reverse down-regulation and desensitization of β2 receptors in the lung

Acute respiratory failure Acute increase in PaCO2 with

decreased pH to ≤7.3

Acute Severe Asthma Treatment is characterized by

early initiation and intensification of treatment

Albuterol Administration

every 20 minutes or continuously shows higher efficacy Continuous administration via nebulizer shows decreased hospitalization and greater FEV1/PEF improvements compared to hourly at the same total dose

Discharge Criteria

-Able to use long acting bronchodilators with or without inhaled corticosteroids -Short acting β2-agonist no more than q 4 hours -Patient able to walk across room if ambulatory -Patient able to eat/sleep without frequent dyspnea -Clinically stable for 12-24 hours -Stable ABGs for 12-24 hours -Understands home medication i. Assess need for home O2- necessary if O2 sat 88% or less at rest or during ambulation -Follow up arranged within 4-6 weeks

Acute Severe Asthma Treatment - Goals of Therapy

-Correction of significant hypoxemia -Rapid reversal of airflow obstruction -Reduction of the likelihood of relapse of the exacerbation -Reduction of the likelihood of future recurrence of severe airflow obstruction -Development of a written asthma action plan in case of a further exacerbation

Indications for Mechanical Ventilation- Invasive

-NIV failure -Respiratory arrest -Inability to remove secretions -Bradycardia with AMS -Hemodynamic instability -Ventricular arrhythmias -Life-threatening hypoxemia

Goals of COPD Exacerbation Treatment

-Prevent hospitalization or reduce duration of stay -Prevent acute respiratory failure and death -Resolution of exacerbation symptoms -Return to baseline clinical status and quality of life

Acute asthma mild to moderate presentation

-Talks in phrases -Prefers sitting to lying -Not agitated -Respiratory rate increased -Accessory muscles not used -Pulse 100-120 bpm -O2 sat 90-95% -PEF > 50% predicted or best

systemic corticosteroids - treatment duration

5-7 day course in adults, 3-5 days in children

Short Acting Bronchodilators

Bronchodilation as well as decreased mucous production Nebulizer may be more convenient for patient, but overall efficacy is equal to MDI Usually use albuterol plus ipratropium combination therapy See asthma section for dosing guidelines

Albuterol- Nebulizer vs. MDI in severe acute asthma

Controversy regarding most efficacious route

Oxygen description

Hypoxemia from ventilation-perfusion mismatch should be immediately correctible via low flow O2

Acute asthma -Life threatening

Drowsy, confused Silent chest- not enough air movement to produce wheezing

Indications for Mechanical Ventilation- Noninvasive

Respiratory acidosis- arterial pH ≤7.35 / PaCO2 ≥ 45mmHg Severe dyspnea with increased work of breathing i. Use of accessory muscles ii. Paradoxical motion of the abdomen iii. Retraction of intracostal spaces

Acute Severe Asthma Attacks may correspond with triggering event:

Respiratory infection Allergens or environmental factors Exercise Medications

Acute Respiratory Failure manifestations

Restlessness Confusion Tachycardia Diaphoresis Cyanosis Hypotension Irregular breathing

Uncomplicated exacerbations- recommended therapy

macrolide (azithromycin, clarithromycin) second or third generation cephalosporin doxycline therapies not recommended: TMP/SMX, amoxicillin, first generation cephalosporins, and erythromycin

Ipratropium has poor absorption across mucosae and blood brain barrier

Low incidence of side effects Slower onset than β2 agonists (30-60min)

COPD Exacerbations

An acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.

Management of Exacerbations

Assess severity of symptoms, blood gases, chest radiograph Administer supplemental oxygen Bronchodilators i. Increase dose and frequency of short-acting agents ii. Combine short-acting β-2 agonists and anticholinergics iii. Use spacers or nebulizers Add oral or intravenous corticosteroids Consider antibiotics if signs of bacterial infection Consider noninvasive mechanical ventilation

Treatment of Acute Asthma Options

Inhaled short acting β2 agonists Systemic corticosteroids Inhaled ipratropium Oxygen

Albuterol

Beta 2 agonist Most effective bronchodilators for asthma Fast onset (5-10 min)

Acute Asthma Signs

Expiratory and inspiratory wheezing Dry hacking cough Tachypnea Tachycardia Pale skin PEF & FEV1 <40% of normal predicted value, Decreased PaO2 and O2 saturation (<90% is severe)

Acute Severe Asthma Treatment- close monitoring of objective measures of oxygenation and lung function

FEV1 30 minutes following B2 agonist O2 saturation

ipratropium reduce hospitalization rate in patients with

FEV1 <30%

Corticosteroid improve

FEV1 and PAO2

Complicated exacerbations with risk of P aeruginosa

Fluoroquinolone with enhanced pneumococcal and p aeruginosa (levofloxacin)

Antibiotics- Pseudomonas in

GOLD 3 and GOLD 4 patients

Antibiotics

Hemophilus influenzae, Streptococcus pneumoniae, and Morexella catarrhalis are most common bacterial pathogens

Mag Sulfate indication

Indicated for ED administration after bronchodilators used for 1 hour without appropriate response

Acute Severe COPD Severity

Mild One cardinal symptom plus one of the following URTI within 5 days, fever, increased wheezing, increased cough, tachycardia or tachypnea >20% above baseline Moderate- two cardinal symptoms Severe- three cardinal symptoms

Management of COPD Exacerbations

Monitor fluid balance and nutrition Consider venous thromboembolism prophylaxis Identify and treat associated conditions i. Heart failure ii. Arrhythmias Closely monitor condition of patient

Helium- Inert gas given in combination with oxygen to:

Reduce resistance to gas flow Increase ventilation i. Low density decreases the pressure gradient needed to achieve a given level of airflow ii. Converts turbulent flow to laminar flow

systemic corticosteroids - multiple daily administration warranted in severe patients initially

Severe airway inflammation decreases binding affinity of corticosteroid receptors in the lung May transition to once daily dosing after patient stabilizes

Indications for ICU Admission

Severe dyspnea that responds inadequately to initial emergency therapy Mental status changes Persistent or worsening hypoxemia despite supplemental oxygen and noninvasive ventilation i. PaO2 <40mmHg ii. Worsening respiratory acidosis pH <7.25 Need for mechanical ventilation Hemodynamic instability i. Need for vasopressors

Acute asthma severe presentation

Talks in words Sits hunched forward Agitated Respiratory rate > 30/min Accessory muscles being used Pulse rate >120bpm O2 sat < 90% (on room air) PEF 50% or lower than predicted/best

May use PO or IV initially

The GOLD guidelines recommend 40mg PO prednisone for 5 days There is insufficient evidence to provide firm conclusions on the optimal duration of corticosteroids

COPD exacerbation

Un-hospital mortality as high as 6-8% for hospitalized patients Many patients do not return to baseline clinical status for several weeks As many as half readmitted within 6 months Mortality after hospitalization i. 1 year: 22-43% ii. 2 years: 36-49%

Antibiotics indication

Worsening dyspnea Increase in sputum volume Increase in sputum purulence May use if 2/3 as long as sputum purulence is one of them OR Mechanical ventilation

Acute Severe COPD Cardinal symptoms

Worsening dyspnea Increase in sputum volume Increase in sputum purulence

Acute Severe COPD- worsening lung hyperinflation

Worsening dyspnea and poor gas exchange Chronic airflow limitation may not change remarkably

Oxygen- Some severely resistant patients may proceed to

acute respiratory distress syndrome and require invasive ventilation (covered in IS-XI)

Complicated exacerbations- recommended therapy

amoxicillin/clavulanate, fluoroquinolone with enhanced pneumococcal activity (levofloxacin, gemifloxacin, moxifloxacin)

Some antibiotics such as azithromycin also have

anti-inflammatory effect

Acute Severe Asthma usually results from

failure of a therapeutic regimen for persistent asthma

Mag Sulfate AEs

hypotension, facial flushing, sweating, nausea, loss of deep tendon reflexes, and respiratory depression

Acute Severe COPD has profound

hypoxemia, hypercapnia Respiratory acidosis Respiratory failure

Magnesium sulfate description

moderately potent bronchodilator