Acute asthma exacerbation management in the ed l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 41

Acute Asthma Exacerbation: Management in the ED PowerPoint PPT Presentation


  • 104 Views
  • Uploaded on
  • Presentation posted in: General

Acute Asthma Exacerbation: Management in the ED. Patrick PLAISANCE, M.D., PhD. Associate Professor Department of Anesthesia, MGH, MUHC. NIH Definition. Chronic inflammatory changes in the bronchial submucosa Increased responsiveness of the airways Reversible expiratory airway obstruction.

Download Presentation

Acute Asthma Exacerbation: Management in the ED

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Acute asthma exacerbation management in the ed l.jpg

Acute Asthma Exacerbation: Management in the ED

Patrick PLAISANCE, M.D., PhD.

Associate Professor

Department of Anesthesia, MGH, MUHC.


Nih definition l.jpg

NIH Definition

  • Chronic inflammatory changes in the bronchial submucosa

  • Increased responsiveness of the airways

  • Reversible expiratory airway obstruction


Slide4 l.jpg

Ventilatory and Hemodynamic Consequences

  • Ventilatory :

    •  dynamic resistances

    •  residualvolume

    • Atelectases

    • V/P mismatching

    • Airways dynamic collapse

  • Hemodynamic :

    • Paradoxical pulse > 18 mmHg


Triggering factors l.jpg

Triggering Factors

  • Infection:

    • Bacterial sinusitis

    • Tracheo-bronchial infection

    • Viral infection of the airways

  • Medications:

    • Beta blockers (collyrium), aspirine, NSAI, antibiotics

  • Others:

    • Gastro-oesophageal reflux

    • Psycho-sociological factors

    • Stress

    • Exercise

    • Stop of chronic treatment


Bad prognosis factors l.jpg

Bad Prognosis Factors

  • Previous severe exacerbations

  • Hospitalization within the last year

  • Psycho-sociological factors

  • Previous intubations

  • Stop of corticosteroid treatment

  • Low patient’s compliance


Slide7 l.jpg

Importance of

an Early Treatment


Slide8 l.jpg

Inhalation versus IV Infusion

in Mild Exacerbations


Slide9 l.jpg

Inhalation versus IV Infusion

in Severe Exacerbations


Slide10 l.jpg

Efficacy of the Inhaled Route

- nebulizer

- gas flow

- driving gas


Advantages of the inhaled route l.jpg

Advantages of the Inhaled Route

  • Direct respiratory tropism

  • Short onset of action

  • Low doses

  • Less side-effects

  • Simultaneous O2 delivery

  • Humidification of the airways


Intermittent versus continuous nebulization l.jpg

Intermittent versus Continuous Nebulization

  • Small benefit from continuous nebulization

    • Gibbs et al. Acad Emerg Med, 2000

  • Beneficial effect on severe exacerbations

  • No increased side-effects

    • Moler et al. Am J Respir Crit Care Med, 1995

  • Reduction of staff time

    • Fink et al. Respir Care 2000


Guidelines on nebulizer therapy british thoracic society thorax 1997 l.jpg

Guidelines on Nebulizer Therapy(British Thoracic Society, Thorax 1997)

  • Driving gas (SpO2 > 90%):

    • Air + simultaneous O2 (nasal prong)

    • O2

  • Fill volume of 4 mL (if residual volume > 1 mL)

  • Flow rate 6-8 L/min

  • Nebulization time < 10 min


Meter dose inhalers with holding chambers l.jpg

Meter-Dose Inhalerswith Holding Chambers

  • As effective as nebulizers (Cates et al. Cochrane Database Syst Rev, 2000)

    • Similar hospital admission rate

    • Similar improvement in PEFR and FEV1

    • Children:

      •  HR more important

      •  duration of the treatment in the ED

  • Progressive administration of the medication

  • Interesting for children < 3 years


2 mechanism of action l.jpg

2+ Mechanism of Action

  •  muco-ciliary clearence

  •  vascular permeability

  • Inhibition of transmitter release from mast cells


2 agonists l.jpg

2 Agonists

  • Selective (Terbutaline, Salbutamol)

    • First line therapy

    • Short onset of action (2-5 min)

    • Long duration of action (3-6 h)

    • Different routes of administration

  • Non selective (epinephrine)

    • Vasoconstricting agent

    • Short duration of action

    • Side effects


Anticholinergics mechanism of action l.jpg

AnticholinergicsMechanism of Action

  • Ach competitive inhibitors

  • muscarinic receptors antagonists

  • Bronchodilators

  • Inhibitors of the bronchoconstriction induced by irritant agents


Anticholinergics 2 agonists children l.jpg

Anticholinergics + 2 AgonistsChildren

  • Schuh S et al. Pediatr 1995:

    • N = 120

    • 5-17 y.o.

    •  FEV1,  PEFR,  hospitalization stay:

      • Salbutamol < salbutamol + 1 ipratropium < Salbutamol + 3 ipratropium

      • More interesting in severe exacerbations


Anticholinergics 2 meta analyses children l.jpg

Anticholinergics + 2 +Meta-analyses Children

  • Plotnick LH et al. Cochrane Database Syst Rev 2000

    • N = 836 children

    • Spirometric improvement

    •  Hospital admission rates


Anticholinergics 2 agonists meta analyses adults l.jpg

Anticholinergics + 2 AgonistsMeta-analyses Adults

  • Rodrigo et al. Am J Med 1999

    • n = 1483

    • Randomized studies, double-blind, controlled

    • Results:

      • Pulmonary function improvement

      •  Hospital admission

  • Stoodley et al. Ann Emerg Med 1999

    • N = 1377

    • Slight clinical improvement

    • No side-effects


Anticholinergics and 2 in adults l.jpg

Anticholinergics and 2+ in Adults

Groups  PEFR (L/min)  PEFR (L/min) PEFR (L/min) Hospital

T12h T36h T60h stay (d)

_______________________________________________________

S + IB 12h 68 62 56 5,4*

S + IB 36h 81 73 47 4,1

S + IB 60h100 69 42 4

* p < 0,01

Brophy C et al. Thorax 1998


Corticosteroids l.jpg

Corticosteroids

  •  hospital admission if administered within the 1st hour

  • Equal benefit of orally and IV administration

    • Rowe et al. Cochrane Database Syst Rev, 2000

  • Dose ranging from 30-400 mg methylprednisolone :

    • Manser et al. Cochrane Database Syst Rev, 2000

  • Inhaled vs systemic corticosteroids: (Edmonds et al. Cochrane Database Syst Rev. 2003)

    •  PEFR and FEV1 as compared with placebo

    • as effective as systemic corticosteroids ?

    • Combination better than systemic route alone ?


Methylxanthines l.jpg

Methylxanthines

  • No benefit from adding methylxanthines to 2+

  • More adverse effects

    • Parameswaran et al. Cochrane Database Syst Rev 2000


Mgso 4 l.jpg

MgSO4

  • Inhalation:

    • Improvement in clinical score (Fischl),  PEFR,  PP

    • Nannini LJJr. Am J Med 2000

    • Mangat HS Eur Respir J 1998

      •  PEFR

  • IV:

    • Boonyavorakul C. Respiratology 2000

      • Hospital admission = NS; score = NS

    • Rowe BH. Ann Emerg Med 2000

      •  admission rate in severe asthma exacerbations


Helium properties l.jpg

Helium Properties

  • Inert gas, colourless, odourless

  • Density lower than air and O2

  • No diffusion through cellular membranes

  • No chemical and physiological action

  • Action due to its physical properties

    No bronchodilator and anti-inflammatory action


Barach et al ann int med 1935 l.jpg

Barach et al. Ann Int Med 1935

  • The use of Helium in the Treatment of Asthma and Obstructive Lesions in the Larynx and Trachea


Studies l.jpg

Studies

  • Small trials or case reports with poor methodology

  • Evaluation criteria varying from one study to another

  • Different treatment duration


Importance of flow rate l.jpg

Importance of Flow Rate

. Continuous nebulization

. P1 = 3,5 bars

Gas flow Q = 8 L/min Q = 12.7 L/min Q = 8 L/min

He/O2 He/ O2 O2

_____________________________________________________________

P2 (bars) 0.641.411.45

MMAD (mm)5.363.183.60

Nebulized mass

after 10 ’ (g)2.253.352,.85

Nebulized mass

after 15 ’ (g)3.354.083.69

Nebulized mass

after 20 ’ (g)3.834.464.06


Slide29 l.jpg

PEFR

L/min

*

*

*

*p < 0,01


Slide31 l.jpg

ASUR2001

Within the last 3 months

38 %

4 087 asthma exacerbations

30 %

30%

23 %

25%

20%

15%

8 %

10%

5%

0%

no

(n = 1237)

General Practitioner

(n =1555)

Pneumologist

(n = 962)

Both

(n =333)

Patients having a peak flow at home : 16 % (n = 652)

Salmeron et al. Asthma severity and adequacy of management in accident and emergency departments in France : a prospective study.

The Lancet ; 2001 ; 358 : 629 – 35.


Slide32 l.jpg

ASUR2001

Severity Upon Arrival

Fatal asthma

(PEFR < 30%)

26 %

(n = 975)

49 %

(n = 1834)

Severe exacerbation

(30 %  PEFR  50 %)

Mild to moderate exacerbation

(PEFR > 50%)

25 %

(n = 963)

The severity of exacerbation is independent of :

  • age

  • gender

  • recent corticosteroid treatment per os

  • hospitalization within the last year

Salmeron S, et al. Asthma severity and adequacy of management in accident and emergency departments in France : a prospective study.

The Lancet ; 2001 ; 358 : 629 – 35.


Slide33 l.jpg

ASUR2001

Treatment in the ED

  • inhaled 2 agonists : 92 % (n = 3492)

  • inhaled anticholinergics : 49 % (n = 1841)

  • systemic corticosteroids : 60 % (n = 2251)

95 %

(n = 924)

93 %

(n = 1708)

89 %

(n = 860)

90 %

80 %

68 %

(n = 666)

70 %

61 %

(n = 1117)

51 %

(n = 494)

60 %

50 %

(n = 913)

49 %

(n = 468)

45 %

(n = 434)

50 %

Fatal asthma

40 %

Severe exacerbation

30 %

20 %

Mild to moderate exacerbation

10 %

0

Inhaled

2 agonists

Inhaled

anticholinergiques

Systemic

corticosteroids

Salmeron S, et al. Asthma severity and adequacy of management in accident and emergency departments in France : a prospective study.

The Lancet ; 2001 ; 358 : 629 – 35.


Pre determined management plan l.jpg

Pre-Determined Management Plan

  • McFadden et al. Am J Med 1995

    • Length of stay in the ER

    • Admission rates

    • Re-admission

    • Cost savings


Initial monitoring l.jpg

Initial Monitoring

  • Pulse oxymetry

  • PEFR (best of three)

  • Pulse, BP

  • RR

  • Clinical judgement:

    • Cyanosis

    • Use of accessory muscles

    • Stridor

    • diaphoresis

  • Blood gasses


Initial treatment in children l.jpg

Initial Treatment in Children

Inhaled Treatment Associated Treatment

every 20’ within the 1st hour

. O2 6-8 L/min (SpO2 95%) . Salbutamol or Terbutaline

. Salbutamol 0.5%: 0.03 mL/kg or 7-10 g/kg SC

Terbutaline 5 mg + IB 0.25 mg . HSHC 5 mg/kg or methyl-

. Or 0.2-0.3 puffs/kg with MDI prednisolone 2 mg/kg IVD

+ HC


Initial treatment in adults l.jpg

Initial Treatment in Adults

Inhaled Treatment Associated Treatment

every 20 min within the 1st hour

. O2 6-8 L/min (SpO2 90%) . Salbutamol or Terbutaline

. Salbutamol 2.5 mg (or 7.5 mg (0.5 mg) or epinephrine continuously) + IB 0.5 mg 0.25 mg SC

. or 2-3 puffs with MDI + HC . HSHC 200-400 mg or

. or epinephrine 2 mg + 3 mL NS methyl-prednisolone 1 mg/kg IV


Inhospital treatment l.jpg

Inhospital Treatment

Initial treatment

Improvement (PEFR: 50-70%)

No improvement (PEFR < 50%)

2+: 1/h for 1-3 h

2+ + IB: 3/h pdt 1-3 h

2 IV

Good response

response>1h

Examination nl

PEFR > 70%

Incomplete Response

. Moderate signs

. PEFR: 50-70%

No improvement

. Severe signs

. PEFR < 30%

. PaCO2 > 45 mmHg

. PaO2 < 60 mmHg

Discharge

ICU

PEFR > 70%

Examination nl

12h with no tt

Admission

No improvement

within 6-12h


Antibiotics l.jpg

Antibiotics

  • Graham et al. Cochrane Database Syst Rev. 2001

    • No benefit when comparing antibiotics to placebo

  • Indications: GOLD-guideline (Pauwels et al. Respir Care 2001)

    • Worsening dyspnea and cough

    • Increased sputum volume and purulence

    • Infiltrates on the chest X-ray


Slide40 l.jpg

NIV

  • VS-PEP (Shivaran U et al. Resp 1987)

    •  residual volume

    •  respiratory work

    • Risks:

      • Overdistension of zones with low resistance

      • Pulmonary hyperinflation


Conclusion l.jpg

Conclusion

  • Importance of an early treatment

  • Importance of nebulization

  • Combination 2 agonists/Ipratropium Bromide

  • Combination of different routes

  • PEFR monitoring

  • Interest of MgSO4 and Helium ?


  • Login