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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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clinical diagnosis of 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
  • Positive family history of asthma & atopic disease
  • Response to appropriate asthma therapy
physical examination findings in asthma
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
objective measurements in asthma diagnosis
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
lung function measurement in asthma
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
spirometry in asthma
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
pef measurement in asthma
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
pef measurement in asthma8
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%)
pef measurement in asthma9
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)
controller medications
Controller Medications
  • Inhaled glucocorticosteroids
  • Long-acting inhaled β2-agonists
  • Systemic glucocorticosteroids
  • Leukotriene modifiers
  • Theophylline
  • Cromones
  • Long-acting oral β2-agonists
  • Anti-IgE
reliever medications
Reliever Medications
  • Rapid-acting inhaled β2-agonists
  • Systemic glucocorticosteroids
  • Anticholinergics
  • Theophylline
  • Short-acting oral β2-agonists
asthma exacerbations
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
features of patients at high risk for asthma related death
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
management of asthma exacerbations
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
treatment of exacerbations
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
management of asthma exacerbations17
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
criteria for hospitalization
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
asthma exacerbations and hospitalization
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
management of acute exacerbations hospital setting
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
management of acute exacerbations hospital setting continuation
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

criteria for icu admission
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
management of acute exacerbations hospital setting continuation23
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.
slide24
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
management of asthma exacerbations home treatment
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

reference
REFERENCE
  • Philippine Concensus Report on Asthma Diagnosis and Management 2009 by PCCP Council on Bronchial Asthma
slide28

PREPARED BY:

    • Section of Pulmonary Medicine
  • COORDINATED WITH:
    • Emergency Department