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CLINICAL PATHWAY FOR ADULT ASTHMA. Clinical Diagnosis of Asthma. Variability: Episodic breathlessness, wheezing, cough, chest tightness Precipitation by allergens or non-specific irritants” e.g. smoke, fumes, strong smells or exercise Nocturnal worsening of symptoms

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    2. Clinical Diagnosis of Asthma • Variability: • Episodic breathlessness, wheezing, cough, chest tightness • Precipitation by allergens or non-specific irritants” e.g. smoke, fumes, strong smells or exercise • Nocturnal worsening of symptoms • Positive family history of asthma & atopic disease • Response to appropriate asthma therapy

    3. Physical Examination Findings in Asthma • Most usual abnormal PE finding: • Wheezing on auscultation – confirms presence of airflow limitation • PE: • May be normal – because asthma symptoms are variable • Wheezing detected only on forced exhalation • Wheezing may be absent in severe cases due to severely reduced airflow and ventilation but usually with other signs

    4. Objective measurements in Asthma diagnosis • Rationale: • Demonstration of reversibility of airflow limitation enhances diagnostic confidence • Patients esp. those with long-standing asthma, frequently have poor recognition of symptoms and poor perception of severity • Physicians may inaccurately assess dyspnea and wheezing

    5. Lung Function Measurement in Asthma • Provides an assessment of severity of airflow limitation, its reversibility and variability • Provides confirmation of the diagnosis • Provides complementary information about different aspects of asthma control

    6. Spirometry in Asthma • Diagnosis of asthma: • Degree of reversibility of FEV1 should be >12% and >200ml from pre-bronchodilator value • Spirometry: • Reproducible but effort-dependent • Pre- & post test lacks sensitivity esp. those on treatment, so repeated testing at different visits is advised • Proper instructions on maneuver must be given

    7. PEF measurement in Asthma • Important in both diagnosis and monitoring • Peak flow meters are relatively inexpensive, portable, plastic and ideal for use in home settings for day-to-day objective measurement of airflow limitation • Can underestimate degree of airflow limitation particularly in severe cases

    8. PEF measurement in Asthma • Can be helpful to confirm the diagnosis of asthma: • 60 L/min (or 20% or more pre-BD PEF) improvement after inhalation of a bronchodilator • A diurnal variation of >20% (with twice daily readings >10%)

    9. PEF measurement in Asthma • Can help to improve asthma control esp. in those with poor perception of symptoms: • Self-monitoring using a PEF chart • Can help to identify environmental/occupational causes of asthma symptoms: • PEF daily or several times a day over periods of suspected exposure to risk factors (at home, workplace, during exercise or other activities)

    10. Controller Medications • Inhaled glucocorticosteroids • Long-acting inhaled β2-agonists • Systemic glucocorticosteroids • Leukotriene modifiers • Theophylline • Cromones • Long-acting oral β2-agonists • Anti-IgE

    11. Reliever Medications • Rapid-acting inhaled β2-agonists • Systemic glucocorticosteroids • Anticholinergics • Theophylline • Short-acting oral β2-agonists

    12. Asthma Exacerbations • Episodes of progressive worsening of shortness of breath, cough, wheezing or chest tightness or some combination of these symptoms • Characterized by significant decreases in PEF or FEV1 which are more reliable indicators of severity of airflow obstruction than degree of symptoms • May range from mild to life-threatening

    13. Severity of Asthma Exacerbations

    14. Features of Patients at high-risk for asthma-related death • Current use of or recent withdrawal from systemic corticosteroids • Emergency care visit for asthma in the past year • History of near-fatal asthma requiring intubation or mechanical intubation • Not currently using inhaled steroids • Overdependence on rapid acting inhaled β2-agonists, esp. those with more than one canister monthly • Psychiatric disease or psychosocial problems, incl. the use of sedatives • Noncompliance with asthma medication plan

    15. Management of Asthma Exacerbations • Treatment of exacerbations depends on: • The patient • Experience of health care professional • Therapies that are the most effective for the particular patient • Availability of medications • Emergency facilities

    16. Treatment of Exacerbations • The aims of treatment are to: • Relieve airway obstruction as quickly as possible • Relieve hypoxemia • Restore lung function to normal as early as possible • Plan and avoidance of future relapses • Develop a written action plan in cases of future exacerbations

    17. Management of Asthma Exacerbations • Primary therapies for exacerbations: • Repetitive administration of rapid-acting inhaled β2-agonists • Early introduction of systemic glucocorticosteroids • Oxygen supplementation • Closely monitor response to treatment with serial measures of lung function

    18. Criteria for Hospitalization • Inadequate response to therapy within 1-2 hours • Persistent PEF <50% after 1 hour of treatment • Presence of risk factors • Prolong symptoms prior to ER consult • Inadequate access to medical care and medications • Difficult home condition • Difficulty in obtaining transport to hospital in event of further deterioration

    19. Asthma Exacerbations and Hospitalization • Despite appropriate therapy ~10 to 25% of ER patients with acute asthma will require hospitalization • The response to initial treatment in the ER is a better predictor of the need for hospitalization than is severity on presentation • FEV1 or PEF appears to be more useful in adults for categorizing severity of exacerbation and response to treatment

    20. Management of Acute Exacerbations: Hospital Setting Initial Assessment: History, PE, PEF or FEV1, Sa02 • PEF or FEV1 >40% predicted (Mild to Moderate) • Oxygen to achieve Sa02 >90% • Inhaled SABA by nebulizer or MDI with valve holding chamber up to 3 doses in 1st hour • PEF or FEV1 <40% predicted (Severe) • Oxygen to achieve Sa02 >90% • High dose inhaled SABA + Ipratropium by nebulizer or MDI with valve holding chamber every 20 min or continuously for 1 hour • Impending or actual respiratory arrest • Intubation and mechanical ventilation with 100% 02 • Nebulized SABA and Ipratropium • Intravenous corticosteroids • Consider adjunct therapies Repeat Assessment: PE, PEF, Sa02, other tests as needed Admit to hospital intensive care -see below • Moderate Exacerbation: • PEF or FEV1 -40-69% predicted or personal best • PE: moderate symptoms • Treatment: • Inhaled SABA every 60 mins • Oral systemic corticosteroids • Continue treatment 1-3 hrs provided there is improvement: make decision in < 4 hours • Severe Exacerbation: • PEF or FEV1 < 40% predicted or personal best • PE: Severe symptoms at rest, accessory muscle use, chest retraction • History: high-risk for asthma related death • No improvement after initial treatment • Treatment: • Oxygen • NebulizedSABA+Ipratropium hourly or continuous • Oral systemic corticosteroids • Consider adjunct therapies

    21. Management of Acute Exacerbations: Hospital SettingCONTINUATION Moderate exacerbation Severe Exacerbation • Good Response • Response sustained for 1 hr after last treatment • No risk factors • S/Sx: no distress, normal PE • PEF > 70% predicted or personal best • Sa02 >90% • Incomplete Response • Within 1 hr &/or (+) risk factors • S/Sx: mild to moderate • PEF or FEV1 40-69% predicted or personal best • Sa02 not improving • Poor Response • Within 1 hr &/or (+) risk factors • S/Sx: severe drowsiness, confusion • PEF < 40% predicted or personal best • ABG: paC02 >42mm Hg Individualize decision re: hospitalization • Discharge Home • Continue inhaled SABA • Continue oral steroids • Consider initiation of ICS • Patient education: • Review medications, including inhaler technique • Review/ initiate action plan • Recommend close medical follow-up • Admit to ICU: • Continue inhaled SABA+ inhaled anti-cholinergic • Consider SQ,IV or IM B2-agonist • IV steroids • IV aminophylline • Continue oxygen • Possible intubation/mechanical ventilation • Admit to Hospital • Oxygen • Inhaled SABA • Systemic (oral or IV) corticosteroids • Consider adjunct therapies • Monitor vital signs, FEV1, PEF saO2 IMPROVE Discharge Home ( see below) improve

    22. Criteria for ICU Admission • Lack of response to initial therapy in ER • Presence of confusion, drowsiness, other signs of impending arrest or loss of consciousness • Impending respiratory arrest: • PaO2 < 60 mmHg on supplemental oxygen • PaCO2 > 45 mmHg

    23. Management of Acute Exacerbations: Hospital SettingCONTINUATION Admit to Hospital IMPROVE • Discharge home • -Continue inhaled SABAs • Continue oral systemic steroids • Continue on ICS • Patient education: • Review medications, including inhaler technique • Review/ initiate action plan • Recommend close medical follow-up • Before discharge, schedule follow-up appointment with primary care provider and/or asthma specialist in 1-4 weeks.

    24. Key • FEV- Forced Expiratory Volume in 1 second • ICS- Inhaled Corticosteroids • PCo2- Partial pressure Carbon Dioxide • PEF- Peak Expiratory Flow • SABA- Short Acting Beta2 agonist • SaO2- Oxygen Saturation


    26. Management of Asthma Exacerbations: Home Treatment Assess Severity Initial Treatment Inhaled SABA: up to two treatment 20 min apart of 2-6 puffs of MDI or nebulizer treatment • Good Response • No wheezing or dyspnea • PEF > 80% predicted or personal best • Contact clinician for follow-up Instructions & further management • May continue inhaled SABA over 3-4 hrs for 24-48 hrs • Consider short course of oral systemic corticosteroids • Incomplete Response • Persistent wheezing & dyspnea (tachypnea) • PEF 50-79% predicted or personal best • Add oral systemic corticosteroids • Continue inhaled SABA • Contact clinician urgently (this day) for further instructions • Poor Response • Marked Wheezing & dyspnea • PEF <50% predicted or personal best • Add oral systemic corticosteroids • Report inhaled SABA immediately • If distress is severe & non-responsive to initial treatment: call your doctor AND ambulance transport To ER

    27. REFERENCE • Philippine Concensus Report on Asthma Diagnosis and Management 2009 by PCCP Council on Bronchial Asthma

    28. PREPARED BY: • Section of Pulmonary Medicine • COORDINATED WITH: • Emergency Department