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NEAR FATAL ASTHMA. DANIEL A. NADER, D.O., F.C.C.P., F.A.C.P. NEAR FATAL ASTHMA. 5,000 DEATHS PER YEAR LIFE THREATENING ATTACKS MORE COMMON AFRICAN-AMERICANS, WOMEN, INNER-CITY PATIENTS AT GREATEST RISK LARGELY PREVENTABLE, MAY OCURR IN ANY ASTHMATIC. PREDISPOSING RISK FACTORS.

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near fatal asthma

NEAR FATAL ASTHMA

DANIEL A. NADER, D.O., F.C.C.P., F.A.C.P.

near fatal asthma1
NEAR FATAL ASTHMA
  • 5,000 DEATHS PER YEAR
  • LIFE THREATENING ATTACKS MORE COMMON
  • AFRICAN-AMERICANS, WOMEN, INNER-CITY PATIENTS AT GREATEST RISK
  • LARGELY PREVENTABLE, MAY OCURR IN ANY ASTHMATIC
predisposing risk factors
PREDISPOSING RISK FACTORS
  • PRIOR SEVERE ATTACKS (ESPICIALLY THOSE REQUIRING ASSISTED VENTILATION)
  • NONADHERANCE TO THERAPY
  • AGE > 40 YEARS
  • TOBACCO SMOKING
risk factors
RISK FACTORS
  • INADEQUATE USE OF INHALED STEROIDS
  • HOSPITALIZATION DESPITE CHRONIC ORAL STEROID USE
  • PSYCHIATRIC ILLNESS
  • RECREATIONAL DRUG AND ALCOHOL ABUSE
  • DIMINSHED ABILITY TO SENSE AND RESPOND TO AIRWAY OBSTRUCTION
risk factors1
RISK FACTORS
  • FREQUENT USE OF BETA AGONIST DRUGS
  • INDEPENDENT RISK FACTOR
  • FREQUENT USE IDENTIFIES POORLY CONTROLLED DISEASE
pathophysiology
PATHOPHYSIOLOGY
  • MUCOUS PLUGGING
  • VASCULAR DILATATION
  • AIRWAY EDEMA
  • DESQUAMATION OF AIRWAY EPITHELIAL CELLS
  • BRONCHIAL SMOOTH MUSCLE HYPERTROPHY
  • INFLAMMATORY CELLULAR INFILTATE
pathophysiology1
PATHOPHYSIOLOGY
  • DEATH FROM ASPHYXIA
  • MUCOUS PLUGGING, BRONCHOCONSTRICTION, AIRWAY EDEMA
  • HYPERINFLATION, AIR TRAPPING
  • HYPOXIA: V/Q MISMATCH
  • HYPERCARBIA: RESPIRATORY MUSCLE FATIGUE
clinical presentation
CLINICAL PRESENTATION
  • VIRAL URI’S
  • HEAVY ALLERGEN EXPOSURE
  • NONADHEARANCE TO THERAPY
  • AIR POLLUTION
  • WEATHER CHANGE
  • EMOTIONAL STRESS
  • DRUGS: ASPIRIN, BETA BLOCKERS
clinical presentation1
CLINICAL PRESENTATION
  • 90% PRESNET AFTER SEVERAL DAYS OF WORSENING SYMPTOMS
  • 10% RAPID DETERIORATION IN MINUTES OR HOURS
clinical presentation2
CLINICAL PRESENTATION
  • DYSPNEIC, ANXIOUS, DIAPHORETIC
  • SITTING UPRIGHT
  • TACHYCARDIC, TACHYPNEIC
  • WHEEZING TO ABSENT BREATH SOUNDS
  • USE OF ACCESSORY MUSCLES
laboratory
LABORATORY
  • ELEVATED WBC
  • INCREASED EOSINOPHILES
  • INCREASED LACTIC ACID
  • ABG VARIABLE
chest radiograph
CHEST RADIOGRAPH
  • HYPERINFLATION
  • EXCLUDE INFILTRATES, PULMONARY VASCULAR CONGESTION
  • PNEUMOTHORAX, PNEUMOMEDIASTINUM
peak flows
PEAK FLOWS
  • USUALLY < 30 TO 50% OF PATIENT’S PERSONAL BEST
  • USE CARE IN PERFORMING PEAK FLOW AS IT MAY WORSEN BRONCHOSPASM
  • FAILURE TO IMPROVE PF AFTER 30 MINUTES OF TREATMENT USUALLY REQUIRES HOSPITALIZATION
differential diagnosis
DIFFERENTIAL DIAGNOSIS
  • CHF
  • PE
  • COPD
  • VOCAL CORD DYSFUNCTION
  • HYPERVENTIALTION
  • ACUTE BRONCHITIS/PNEUMONIA
  • UPPER AIRWAY OBSTRUCTION
icu admission
ICU ADMISSION
  • RESPIRATORY ARREST
  • DEPRESSED MENTAL STATUS
  • ARRHYTHMIA
  • INTENSITY OF TREATMENT
  • INCREASED FRQUENCY OF NEBULIZED BETA AGONIST SIGNIFIES A PATIENT AT RISK FOR DETERIORATION
management
MANAGEMENT
  • BRONCHODILATORS
  • OXYGEN
  • CORTICOSTEROIDS
  • ADJUNCT THERAPY
  • MECHANICAL VENTIALTION
bronchodilators
BRONCHODILATORS
  • ALBUTEROL 2.5MG NEBULIZED EVERY 20 MINUTES
  • AIRWAY NARROWING ADVERSLY AFFECTS THE DOSE-RESPONSE CURVE AND DURATION OF ACTION
  • CONTINOUS NEBULIZTION IS AS EFFECTIVE AS BOLUS NEBULIZATION
bronchodialtors
BRONCHODIALTORS
  • IPRATROPIUM 0.5 MG COMBINED WITH ALBUTEROL PROVIDES IMPROVED BRONCHODILATION
  • THEOPHYLLINE HELPFUL WHEN PATIENT NOT RESPONDING TO BETA AGONIST AND STEROIDS
theophylline
THEOPHYLLINE
  • 5 MG/KG LOADING DOSE FOLLOWED BY CONTINOUS INFUSION AT 0.4 TO 0.7 MG/KG/HOUR
  • ANTI-INFLAMMATORY
  • IMPROVES MUCOCILIARY CLEARANCE
  • DIAPHRAGMATIC MUSCLE FUNCTION
  • ACCESSORY MUSCLE FUNCTION
  • RIGHT VENTRICULAR PERFORMANCE
corticosteroids
CORTICOSTEROIDS
  • ORAL AS EFFECTIVE AS INJECTABLE
  • METHYLPREDNISOLONE 40 TO 125 MG EVERY 6 HOURS
  • LOW DOSE AS EFFECTIVE AS HIGH DOSE
  • PREDNISONE 40 TO 50 MG DAILY UNTIL CLINICAL RESPONSE, THEN TAPER
adjunct therapy
ADJUNCT THERAPY
  • HELIOX: 80:20, 70:30, LESS DENSE GAS MAY ASSIST VENTILATION. AIRFLOW ACROSS NARROWED AIRWAYS IS LAMINAR AND LESS TURBULENT
  • MAY BUY SOME TIME
adjunct therapy1
ADJUNCT THERAPY
  • MAGNESIUM 2 GRAMS OVER 20 MINUTES
  • MAY INTERFERE WITH CALCIUM MEDIATED SMOOTH MUSCLE CONTRACTION
  • TOXIC LEVELS MAY PRECIPITATE HYPOTENSION AND LOSS OF DEEP TENDON REFLEXES
adjunct therapy2
ADJUNCT THERAPY
  • LEUKOTRIENE RECEPTOR ANTAGONISTS MAY BE HELPFUL
  • FURTHER STUDIES NEEDED BEFORE THEY CAN BE RECOMMENDED IN NEAR FATAL ASTHMA
adjunct therapy3
ADJUNCT THERAPY
  • OXYGEN
  • POTASSIUM
  • PROTON PUMP INHIBITORS OR H2 BLOCKERS
  • DVT PROPHALAXIS
other mangement
OTHER MANGEMENT
  • ANTIBIOTICS, MOST COMMON IFECTION WHICH PRECIPITATES ASTHMA IS VIRAL
  • INTRAVENOUS FLUIDS, REPLACEMENT ONLY
  • MUCOLYTICS
  • ANTIHISTAMINES
mechanical ventilation
MECHANICAL VENTILATION
  • CONSIDER NON-INVASIVE VENTIALTION (NIPPV)
  • DISADVANTAGES: LACK OF AIRWAY CONTROL, SKIN PRESSURE ULCERATION, VOMINTIN/ASPIRATION
  • ADVANTAGES: COMFORT, DECREASE NEED FOR SEDATION, LOWER RISK FOR VAP
intubation indications
INTUBATION INDICATIONS
  • PROGRESSIVE RESPIRATORY FAILURE
  • ALTERED MENTAL STATUS
  • HEMODYNAMIC INSTABILITY, REGARDLESS OF ABG
dynamic hyperinflation
DYNAMIC HYPERINFLATION
  • INSUFFICINET EXPIRATORY TIME
  • END EXHALATION VOLUME RISES
  • HEMODYNAMIC COMPROMISE AND BAROTRAUMA
mechanical ventilation1
MECHANICAL VENTILATION
  • ENSURE OXYGENATION
  • AVOID DYNAMIC HYPERINFLATION
  • PHYSICAL EXAM AND CXR DO NOT CORRELATE WELL WITH DHI
  • PLATEAU PRESSURES, PEAK AIRWAY PRESSURES, INTRINSIC (AUTO) PEEP
mechanical ventialtion
MECHANICAL VENTIALTION
  • PLATEAU PRESSURE: AT END INSPIRATORY HOLD (30-35 CM H20)
  • PEAK FLOW RATE: CORRELATES POORLY WITH RISK OF DHI
  • AUTO-PEEP: PRESSURE MEASURED AT END EXPIRATORY HOLD. REFLECTS DEGREE OF DHI POORLY, UNDERESTIMATES DHI
mechanical ventilation2
MECHANICAL VENTILATION
  • MINIMIZE DHI BY ENSURING SUFFICIENT EXPIRATORY TIME
  • 1. INCREASE INSPIRATORY FLOW RATE
  • 2. DECREASE RESPIRATORY RATE
  • 3. DECREASE TIDAL VOLUME
mechanical ventilation3
MECHANICAL VENTILATION
  • HYPERCAPNIA MAY BE A CONSEQUENCE OF PROTECTIVE VENTIALTION
  • PERMISSIVE HYPERCAPNIA
  • HYPERCAPNIA SIDE EFFECTS: CEREBRAL EDEMA,DECREASED MYOCARDIAL CONTRACTILITY, SYSTEMIC VASODILATATION, PULMONARY VASOCONSTRICTION
mechanical ventialtion1
MECHANICAL VENTIALTION
  • REQUIRES HEAVEY SEDATION
  • NARCOTIC PLUS BENZODIAZEPINE
  • PROPOFOL
  • NEUROMUSCULAR BLOCKADE
complications
COMPLICATIONS
  • NOSOCOMIAL PNEUMONIA
  • STRESS GASTRITIS
  • DVT
  • PE
  • MALNUTRITION
  • SEPSIS/MULTISYSTEM ORGAN FAILURE
outcomes
OUTCOMES
  • USING PRESENTED VENTILATION TECHNIQUES: 0 TO 4% MORTALITY
  • 21% MORTALITY WITH MV REALTED TO: TENSION PNEUMONTHORAX, CARDIAC ARREST, NOSOCOMIAL INFECTION, MULTISYSTEM ORGAN FAILURE
  • EXCESSIVELY AGGRESSIVE POSITIVE PRESSURE VENTIALTON
follow up
FOLLOW-UP
  • MORTALITY POST MV HOSPITALIZATION:
  • YEAR 1: 10.1%
  • YEAR 3: 14.4%
  • YEAR 6: 22.6%
follow up1
FOLLOW-UP
  • CLOSE PHYSICIAN COMMUNICATION
  • PATIENT EDUCATION
  • THERAPUETIC PLAN CENTERED AROUND INHALED CORTICOSTEROIDS