Acute Asthma

ACUTE SEVERE ASTHMA WHY DO PATIENTS DIE: DISEASE FACTORS MEDICAL MANAGEMENT FACTORS PATIENTS BEHAVIOUR AND PSYCHOSOCIAL FACTORS

DISEASE FACTORS CHRONIC SEVERE B.A.

MINORITY MILD / MODERATE BRONCHIAL ASTHMA ( The severity of acute asthma attack is usually underestimated by patients, their relatives and their doctors, mainly due to failure to assess the condition objectively )

MEDICAL MANAGEMENT FACTORS INADEQUATE TREATMENT INADEQUATE OBJECTIVE MONITORING AND FOLLOW UP NOT REFERRING TO SPECIALIST INCREASING USE OF BETA2 AGONIST AND UNDERUSE OF STEROIDS

MEDICAL MANAGEMENT FACTORS CONTD. INAPPROPRIATE PRESCRIPTION OF BETABLOCKER THERAPY HEAVY SEDATION PATIENT SENSITIVE TO NSAID NOT GIVEN WRITTEN MANAGEMENT PLAN

PSYCHOSOCIAL & BEHAVIOURAL FACTORS NON-COMPLIANCE WITH TREATMENT FAILURE TO ATTEND APPOINTMENTS SELF DISCHARGE FROM HOSPITAL

AIMS OF MANAGEMENT TO PREVENT DEATH TO RELIEVE SYMPTOMS TO RESTORE PATIENTS LUNG FUNCTION TO THE BEST POSSIBLE LEVEL AS SOON AS POSSIBLE. TO PREVENT EARLY RELAPSE

ASSESSMENT NEED TO ASSESS SEVERITY RAPIDLY GIVE APPROPRIATE TREATMENT

HISTORY PHYSICAL EXAMINATION PEFR MEASUREMENT

MILD ASTHMA PERSISTENT COUGH INCREASED CHEST TIGHTNESS BREATHLESS WHEN WALKING NORMAL SPEECH PULSE RATE < 100/MIN. RESP. RATE < 25/ MIN MODERATE WHEEZE PEF > 75% OF PT’S BEST OR PREDICTED SpO2 > 95% ON ROOM AIR

MODERATE ASTHMA BREATHLESS WHEN TALKING TALKS IN PHRASES PULSE RATE 100 – 120 / MIN RESPIRATORY RATE 25 – 30 BREATHS / MIN LOUD WHEEZE PEF BETWEEN 50 T0 75 % OF PREDICTED OR BEST VALUE SPO2 91 – 95 % ( ON ROOM AIR )

SEVERE ASTHMA BREATHLESS AT REST TALKS IN WORDS PULSE RATE > 120 / MIN RESPIRATORY RATE > 30 BREATHS / MIN LOUD WHEEZE PEF < 50 % OF PREDICTED OR BEST VALUE SPO2 < 90% ( ON ROOM AIR )

Life threatening asthma CENTRAL CYANOSIS FEEBLE RESPIRATORY EFFORT SILENT CHEST BRADYCARDIA EXHAUSTION CONFUSION PEF < 30% OF BEST OR PREDICTED ABG: NORMAL OR HIGH PaCO2 SEVERE HYPOXAEMIA (60mmHG) LOW pH

• Prednisolone tablets at 30 – 60 mg should be commenced immediately. If patient is unable to tolerate orally, intravenous hydrocortisone 200 mg stat should be given.

The response to treatment is monitored by : • The patient’s symptoms • Physical findings • Measurement of PEF 15 – 30 minutes after initiating treatment.

BEFORE DISCHARGE FROM A&E REVIEW ADEQUACY OF USUAL TREATMENT & STEP UP IF NECCESARY GIVE PREDNISOLONE 30 – 60 MG DAILY FOR 7 – 14 DAYS, PLUS REGULAR INHALED STEROIDS AND INHALED BETA2 AGONIST. ENSURE PT. HAS ENOUGH SUPPLY OF MEDICATION CHECK INHALER TECHNIQUE AND CORRECT IF FAULTY FOLLOW UP WITHIN 2 WKS. OR EARLIER ADVISE PT. TO RETURN IMMEDIATELY IF ASTHMA WORSENS

MANAGEMENT IN THE WARD CONTINUE O2 >40% I.V HYDROCORTISONE 6 HRLY/ PREDNISOLONE 30-60 MG/ D. NEBULISED BETA2 AGONIST EVERY 15MIN ( 2-4HRLY ) DEPENDING ON SEVERITY + ANTICHOLINERGIC. IF STILL NO IMPROVEMENT: I.V. AMINOPHYLLINE > 0.5-0.9 MG/KG/HR. IF CONTINUED FOR MORE THAN 24 HRS MONITOR BLOOD LEVELS. ALTERNATIVE: BETA2 AGONIST INFUSION 3-20 MCG / MIN AFTER INITIAL I.V BOLUS OF 250mcg.OVER 10 MIN.

MANAGEMENT IN WARD (CONTD.) STILL INADEQUATE RESPONSE: I.V. MAGNESIUM SULPHATE 2G IN 50 ML N/SALINE INFUSED OVER 10-20 MIN.

MONITORING RESPONSE PEF. MEASUREMENT 15-30 MIN LATER MAINTAIN ARTERIAL O2 SATURATION ABOVE 92% RPT. ABG IF INITIALLY WAS NECESSARY OR IF PT. DETERIORATES. MONITOR PEF AT LEAST 4 TIMES DAILY.

OTHER INVESTIGATIONS SERUM ELECTROLYTES: HYPOKALAEMIA IS A RECOGNISED COMPLICATION OF TREATMENT WITH BETA2 AGONIST AND CORTICOSTEROIDS

E.C.G. IF INDICATED

REFERRAL TO INTENSIVE CARE DETERIORATING PEF PERSISTENT OR WORSENING HYPOXIAEMIA

HYPERCAPNIA EXHAUSTION OR FEEBLE RESPIRATION DROWSINESS OR CONFUSION COMA OR RESPIRATORY ARREST

DISCHARGE PLAN FOR HOSPITALISED PT. BEFORE DISCHARGE PT. SHOULD BE: STARTED ON INHALED STEROIDS FOR AT LEAST 48 HRS + CONTINUE ORAL STEROIDS FOR FEW DAYS MORE + BRONCHODILATORS PEF > 75%, DIURNAL VARIABILITY OF < 20% ABLE TO USE INHALER CORRECTLY, IF NECESSARY ALTERNATIVE INHALER DEVICES COULD BE PRESCRIBED.

DISCHARGE PLAN (CONTD.) PT. IS EDUCATED ON : DISCHARGE MEDICATION HOME PEF MONITORING SELF MANAGEMENT PLAN IMPORTANCE OF REGULAR FOLLOW UP.

GIVEN AN EARLY FOLLOW-UP APPOINTMENT WITHIN 2 – 4 WEEKS FOR REASSESSMENT OF THE CONDITION AND FOR ADJUSTMENT OF THE MEDICINES.