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ACUTE ASTHMA IN CHILDREN AKUTE ASMA IN KINDERS

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  1. ACUTE ASTHMA IN CHILDRENAKUTE ASMA IN KINDERS Prof Sharon Kling Dept Paediatrics & Child Health Stellenbosch University

  2. What is acute asthma?Wat is akute asma? • Worsening of chronic asthma • Worsening shortness of breath, cough, wheezing • Which does not respond to usual reliever (bronchodilator) therapy • Verergering van chroniese asma • Verergerende kort-asemheid, hoes, fluit • Wat nie op gewone verligter (brongodilator) terapie respondeer nie

  3. Triggers of acute asthmaSnellers van akute asma • Viral respiratory tract infections - rhinovirus – the common cold • Environmental exposures • Environmental tobacco smoke • Allergens • Virale respiratoriese infeksies – verkoue - rinovirus • Omgewingsfaktore • Sigaretrook • Allergene

  4. Presentation / Presentasie • Cough / hoes • Wheezing / fluit • Increased work of breathing / Verhoogde werk van asemhaling • Anxiety / angs • Restlessness / rusteloosheid • Hypoxia / hipoksie

  5. Asthma mortality by country: Centers for Disease Control 2000 > 1.01 0.51 – 1.0 0 – 0.5 No standardized data available

  6. Definition / Definisie • Progressive respiratory failure due to acute asthmaProgressiewe respiratoriese versaking as gevolg van akute asma • Unresponsive to usual therapyWat nie op gewone terapie respondeer nie

  7. Pathophysiology of asthmaPatofisiologie van asma • Asthma is primarily an inflammatory disease / ‘n inflamma-toriese siekte Smooth muscle spasmGladdespierspasma Airway oedemaLugwegedeem Mucous pluggingMukusproppe

  8. Pathophysiology of acute asthma Patofisiologie van akute asma • Airway obstruction  air trapped in the lung with resultant hyperinflationLugweg obstruksie  lug word in long vas gevang met hiperinflasie • Ventilation / perfusion mismatch  hypoxaemia Ventilasie / perfusie wanbalans  hipoksemie • Increased work of breathing under hypoxic conditions  acidosisVerhoogde werk van asemhaling met hipoksie  asidose

  9. Acute Asthma: AssessmentAkute Asma: Evaluasie • History / Geskiedenis • Vital signs /Vitale tekens • Objective measurementsObjektiewe metings • Response to therapyRespons op behandeling

  10. Objective Evaluation Objektiewe Evaluasie • Respiratory rate / asemhalingsspoed • Retraction / retraksie • Ability to speak / vermoëomtepraat • Ability to feed / vermoëomtevoed • Peak flow / piekvloei • O2 saturation / O2saturasie

  11. Danger Signs in Acute AsthmaGevaartekens in Akute Asma • Rising pulse rate • Pulsusparadoxus • Agitation, restlessness or ↓ consciousnessSilent chest on auscultation • Chest pain • Cyanosis • Peak flow < 50% pred • Rising PaCO2 • Stygendepolsspoed • Pulsusparadoksus • Agitasie, rusteloos-heid, of ↓bewussyn • Stilborskas • Borskaspyn • Sianose • Piekvloei <50% voorsp • Stygende PaCO2

  12. Approach to acute asthmaBendering tot akute asma • Initiate therapy / begin terapie • Assessment / evaluering • Assess response to therapyEvalueer response op behandeling • Plan further therapy / managementBeplan verdere terapie / hantering

  13. Initiate Therapy:Begin Terapie: • OxygenSuurstof • Inhaled Beta-2 agonist Inhalasie Beta-2 agonis (salbutamol, fenoterol) • Oral steroids (prednisone)Orale steroïede (prednisoon)

  14. O2 4 L/min • ß2 agonist x2 20 min apart ACUTE ASTHMA ATTACK • ß2 agonist • MDI-spacer with face mask < 3 yrs; mouth piece > 3 yrs • 2-5 puffs; 1 puff every 10 secs • Nebulised 1ml in 3 ml normal saline

  15. O2 4 L/min • ß2 agonis x2 20 min uitmekaar AKUTE ASMA AANVAL • ß2 agonis • MDI-spacer met gesigmasker < 3 jaar; mondstuk > 3 jaar • 2-5 puffs; 1 puff elke 10 seks • Genebuliseer 1ml in 3 ml normal saline

  16. O2 4 L/min • ß-2 agonist x2 20 min apart ACUTE ASTHMA ATTACK EVALUATE RESPONSE NON- RESPONDER RESPONDER Peak flow > 80% pred/best < 80% pred/best Resp rate < 40 > 40 Retraction Absent Present Speech Normal Decreased Feeding Normal Decreased

  17. O2 4 L/min • ß-2 agonis x2 20 min uitmekaar AKUTE ASMA AANVAL EVALUEER RESPONS NIE- RESPONDEERDER RESPONDEERDER Piekvloei > 80% voorsp/beste < 80% voorsp/beste AH spoed < 40 > 40 Retraksie Afwesig Teenwoordig Spraak Normaal Verminder Voeding Normaal Verminder

  18. RESPONDER NON- RESPONDER • EVALUATE • Current therapy • Precipitating factors • Follow-up • INTENSIFY THERAPY • O2 • ß-2 agonist • Ipratropium bromide • Oral steroids (prednisone) • Hydration NON- RESPONDER EVALUATE AT DISCHARGE FOLLOW-UP WARD OR ICU

  19. RESPONDEERDER NIE-RESPONDEERDER • EVALUEER • Huidige terapie • Presipiterende faktore • Opvolg • INTENSIFISEER TERAPIE • O2 • ß2 agonis • Ipratropium bromied • Orale steroïede (prednisoon) • Hidrasie NIE-RESPONDEERDER EVALUEER MET ONTSLAG OPVOLG SAAL of ISE

  20. Acute asthma: first line therapyAkute asma: aanvanklike terapie • Oxygen / suurstof • Inhaled ß-2 agonists (short-acting)Inhalasie ß-2 agoniste (kortwerkend) • Corticosteroids (oral or IV)Kortikosteroïede (oraal of BA) • Fluid: do not overhydrate (50 ml/kg/24h)Vog: moet nie oorhidreer nie (50ml/kg/24uur)

  21. OxygenSuurstof

  22. Oxygen • Deliver high flow oxygen Hoëvloeisuurstof • Preferably via nasal catheterVerkieslikdmvnasalekateter

  23. Inhaled ß-2 agonistsInhalasie ß-2 agoniste

  24. Inhaled ß-2 agonistsInhalasie ß-2 agoniste • Examples / voorbeelde: • Salbutamol (Ventolin®, Venteze®, Asthavent®) • Formoterol (Berotec®)

  25. Method of AdministrationMetode van toediening • Nebuliser / nebuliseerder • MDI / spacer • more rapid onset / vinniger aankoms • fewer side-effects / minder newe-effekte • shorter time in hospital / korter hospitaal verblyf • Home-made spacers as effective as conventional spacerTuisgemaakte “spacers” net so effektief

  26. Nebuliser & MDI+spacer

  27. CorticosteroidsKortikosteroïede

  28. Corticosteroids: routeKortikosteroïede: roete • Oral preferable • As effective as IV • Less invasive • Less expensive • Dose: 1-2 mg/kg/day prednisone • Oraalverkieslik • Effektiefsoos BA • Minder indringend • Goedkoper • Dosering: 1-2 mg/kg/dag prednisoon

  29. Second Line TherapyTweedeLinieTerapie

  30. Anticholinergics / Anticholinergiesemiddels (Ipratropium bromide / bromied) • Magnesium sulphateMagnesium sulfaat • Adrenaline: subcutaneousAdrenalien: subkutaan

  31. AnticholinergicsAnticholinergieseMiddels • ß-2 agonist + ipratropium bromide (IB) given 4-6 hourlyß-2 agonis + ipratropiumbromied (IB) 4-6 uurliks • Examples / Voorbeelde IB: Atrovent®, Ipvent®

  32. Magnesium sulphate /sulfaat • For use in severe acute asthma • Causes relaxation of bronchial smooth muscle • Dose 40 mg/kg over 10 minutes • Gebruik in ergeakuteasma • Veroorsaakont-spanning van brongialegladdespier • Dosering 40 mg/kg oor 10 minute

  33. Adrenaline / Adrenalien • Only if no nebuliser or MDI available ORSlegs as geennebuliseerder of MDI beskikbaarnieOF • If patient moribund and unable to benefit from inhaled therapyAs pasiënt so siek is datinhalasieterapieniewerknie

  34. DO NOT USE MOET NIE GEBRUIK NIE • Sedatives • Physiotherapy • Routine antibiotics • Mucolytics • Antihistamines • Sedeermiddels • Fisioterapie • Roetineantibiotika • Mukolitika • Antihistamiene

  35. Danger Signs in Acute AsthmaGevaartekens in Akute Asma • Rising pulse rate • Pulsusparadoxus • Agitation, restlessness or ↓ consciousnessSilent chest on auscultation • Chest pain • Cyanosis • Peak flow < 50% pred • Rising PaCO2 • Stygendepolsspoed • Pulsusparadoksus • Agitasie, rusteloos-heid, of ↓bewussyn • Stilborskas • Borskaspyn • Sianose • Piekvloei <50% voorsp • Stygende PaCO2

  36. Indications for ICU admissionIndikasiesvir ISE toelating • Poor response to maximal therapy in ward • Hypoxaemia (PaO2 < 8kPa) despite O2 • PaCO2 > 4.5kPa • PEFR < 30% expected or best • Clinical signs of severe asthma • Swakrespons op maksimaleterapie in saal • Hipoksemie (PaO2 < 8kPa) tsv O2 • PaCO2 > 4.5kPa • PEFR < 30% voorspel of beste • Kliniesetekens van ergeasma

  37. Treatment in ICUBehandeling in ISE • Continuous inhalation of ß-2 agonist / anticholinergic combination • IV Aminophylline (theophylline) • IV ß-2 agonists (salbutamol) • Ventilation • Aanhoudendeinhalasieß-2 agonis / anticholinerge • BA aminofillien (teofillien) • BA ß-2 agoniste (salbutamol) • Ventilasie

  38. Aminophylline / Aminofillien • Narrow therapeutic indexSmalterapeutieseindeks • Side effects / newe-effekte • Cardiac arrhythmias / arritmeë • Hypotension / hipotensie • Convulsions / konvulsies • Use only in ICUGebruikslegs in ISE

  39. Summary / Opsomming

  40. Useful websites • National Asthma Education Programme (NAEP) www.asthma.co.za • Allergy Society of SA (ALLSA) www.allergysa.org • SA Thoracic Society (SATS) www.pulmonology.co.za