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
