Asthma Cpg
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DR.ROHAYAH ABDULLAH FAMILY MEDICINE SPECIALIST POLIKLINIK KESIHATAN KOTA TINGGI
EPIDEMIOLOGY
Asthma is a common disease with unacceptable high morbidity and mortality Prevalence is increasing worldwide It is commonly under diagnosed and undertreated Many deaths and morbidity have been a/w inadequate treatment, under-use of objective measurement of severity and inadequate supervision
PREVALENCE OF ASTHMA IN MALAYSIA
Primary school children: 13.8% Children aged 13-14 years: 9.6% Adult (self-reported) in NHMS: 4.1% Prevalence was higher in rural (4.5%) than in Urban areas (4.0%) Prevalence was also higher in those with lower educational status (5.6%) and lower income (4.7%)
DEFINITION
Asthma, irrespective of severity, is a chronic inflammatory disorder of the airways. In susceptible individual, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough particularly at night and in the early morning This episodes are usually a/w widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.
HOW TO DIAGNOSE ASTHMA?
DIAGNOSING ASTHMA Wheezing H/o any of the following: Cough – worse particularly at night/early morning Recurrent difficulty in breathing Recurrent wheeze Recurrent chest tightness Note: Eczema, hay fever, or a family h/o asthma or atopic diseases is often a/w asthma Symptoms occur or worsen at night/early morning – awakening the patient
DIAGNOSING ASTHMA
Symptoms occur or worsen in the presence of: Exercise Animals Pollen Aerosol chemicals Dust mites (in mattress, pillows, upholastered furniture, carpets) Respiratory tract infection Smoke (tobacco, wood) Changes in temperature Drugs (aspirin, beta blockers) Strong emotional expression (laughing or crying hard)
DIAGNOSING ASTHMA
Reversible and variable airflow limitation- as measured by a PEF meter in any the following ways: PEF increases > 15%, 15 to 20 min after inhaling a short-acting beta2-agonist, or PEF varies > 20% from morning measurement upon arising to measurement 12 hours later in patient who are taking a bronchodilator (> 10% in patients who are not taking a bronchodilator), or PEF decreases >15% after 6 minutes of running or exercise
MANAGEMENT OF CHRONIC ASTHMA The aims of management are To abolish day and night symptoms of asthma To restore normal or best possible long term airway function To prevent most acute attacks To prevent mortality
APPROACH TO MANAGEMENT Educating patient and family members Identifying and avoiding trigger factors Assessing severity and monitoring response to treatment Selecting appropriate medications and using the lowest effective dose to minimise short and long term side effects
DRUG TREATMENT 3 major groups of medications: 2. Anti-inflammatory medications 3. Long-acting bronchodilators 4. Short-acting bronchodilators
Anti-inflammatory medications
Reducing the inflammation will decrease bronchial hyper-responsiveness 3 types: i) Corticosteroids - the main prophylactic drugs ii) Cromones eg. Sodium cromoglycate - It is effective in the symptomatic and prophylactic management of mild persistent asthma but less effective in more severe asthma
Antileukotrienes e.g Montelukast
i)
have some effect in controlling mild persistent asthma - Possible role as an alternative to low dose inhaled corticosteroid and as add-on therapy to inhaled corticosteroid - to reduce the requirement for high doses of inhaled corticosteroids - may also be used for aspirin sensitive asthma and exercise-induced asthma -
EDUCATION OF PATIENT AND FAMILY
Nature of asthma Preventive measure/avoidance of triggers Drugs used and their side-effects Peak flow monitoring Proper technique of using inhaled drugs Recognition of features of worsening asthma (increase in bronchodilator requirement, development of nocturnal symptoms, deteriorating PEFR) Knowledge of the difference between relieving and preventive medications Self management plan The danger of non-prescriibed self medication including certain traditional medicines
PREVENTION IS BETTER THAN CURE
ACUTE SEVERE ASTHMA
WHY DO PAITENTS DIE:
DISEASE FACTORS
MEDICAL MANAGEMENT FACTORS
PATIENTS BEHAVIOUR,PSYCHOSOCIAL FACTORS
DISEASE FACTORS
CHRONIC SEVERE B.A.
IN A MINORITY MILD OR MODERATE BRONCHIAL ASTHMA
MEDICAL MANAGEMENT FACTORS
INADEQUATE TREATMENT INADEQUATE OBJECTIVE MONITORING INADEQUATE FOLLOW UP NOT REFERRING TO SPECIALIST NOT GIVEN WRITTEN MANAGEMENT PLAN INCREASING USE OF BETA2AGONIST
MEDICAL MANAGEMENT FACTORS CONTD.
INAPPROPRIATE PRESCRIPTION OF BETABLOCKER THERAPY
HEAVY SEDATION
PATIENT SENSITIVE TO NSAID
ADVERSE PSYCHOSOCIAL & BEHAVIOURAL FACTORS
NON-COMPLIANCE WITH TT. OR MONITORING
FAILURE TO ATTEND APPOINTMENTS
SELF DISCHARGE FROM HOSPITAL
PSYCHOSIS, DEPRESSION,OTHER PSY.ILLNESS OR SELF HARM
CURRENT OR RECENT MAJOR TRANQUILISER USE
DENIAL
ALCOHOLOR DRUG ABUSE
PSYCHOSOCIAL OR BEHAVIOURAL FACTORS
OBESITY
LEARNING DIFFICULTY
EMPLOYMENT PROBLEMS
INCOME PROBLEMS
SOCIAL ISOLATION
CHILDHOOD ABUSE
SEVERE DOMESTIC, MARITAL OR LEGAL STRESS.
OTHER RISK FACTORS FOR DEVELOPING NEAR FATAL OR FATAL ASTHMA
PREVIOUS NEAR FATAL ASTHMA
PREVIOUS ADM .FOR B.A. ESPECIALLY IF IN THE LAST YEAR
REQUIRING THREE OR MORE CLASSES OF ASTHMA MEDICATION
HEAVY USE OF BETA AGONIST
RPT. ATTENDANCES @ A&E ESPECIALLY IN THE LAST YEAR
BRITTLE ASTHMA
HEALTH CARE PROFFESSIONALS MUST BE AWARE THAT PATIENTS WITH SEVERE ASTHMA & ONE OR MORE ADVERSE PSYCHOSOCIAL FACTORS ARE AT RISK OF DEATH
PREDICTION &PREVENTION OF A SEVERE ATTACK
88-92% ATTACKS DEVELOP OVER 6 HRS
80%MAY EVEN DEVELOP IT OVER 48 HRS.
THEREFORE TIME FOR EFFECTIVE ACTION `& POTENTIALTO REDUCE HOSPITAL ADMISSION
A SPECIALIST SHOULD FOLLOW UP PATIENTS ADMITTED WITH SEVERE ASTHMA FOR AT LEAST ONE YEAR AFTER ADMISSION
AIMS OF MANAGMENT
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
INITIAL ASSESSMENT
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
INCREASING SYMPTOMS
PEF >50-75% BEST OR PREDICTED
NO FEATURES OF ACUTE SEVERE ASTHMA
ACUTE SEVERE ASTHMA
ANY ONE OF: PEF33-50% BEST OR PREDICTED
RESP. RATE>25/MIN
HEART RATE.> 100/MIN.
INABILITY TO COMPLETE SENTENCES IN ONE BREATH.
Life threatening asthma
CENTRAL CYANOSIS FEEBLE RESPIRATORY EFFORT SILENT CHEST BRADYCARDIA EXHAUSTION CONFUSION PEF<30% OF BEST OR PREDICTED(<100L/MIN) ABG: NORMALORHIGH PaCO2 SEVERE HYPOXAEMIA(60mmHG) LOW pH
REFERRAL TO INTENSIVE CARE
ACUTE SEVERE OR LIFE THREATENING ASTHMA NOT RESPONDING TO THERAPY , EVIDENCED BY:
DETERIORATING PEF PERSISTENT OR WORSENING HYPOXIA
HYPERCAPNIA ABG: EXHAUSTION FEEBLE RESPIRATION DROWSINESS,CONFUSION COMA, RESPIRATORYARREST
ASSESMENT OF RESPONSE TO INITIAL TT. RESPONSE TO TT. IS MONITORED BY:
SYMPTOMS
PHYSICAL FINDINGS
PEF MEASUREMENT 15-30 MIN. AFTER INITIAL TT.
RESPONSE TO INITIAL TT. GOOD RESPONSE IS:
RELIEVED OF DYSPNOEA IMPROVED CLINICAL STATUS POST TT. PEF >75% OF BEST O PREDICTED VALUE.
INCOMPLETE RESPONSE:
PERSISTENT SYMPTOMS & SIGNS PEF50-75% OF BEST OR PREDICTED VALUE
RESPONSE TO INITIAL TT. POOR RESPONSE:
PERSISTENT OR DETERIORATING SYMPTOMS & SIGNS
PEF<50%
BEFORE DISCHARGE FROM A&E
REVIEW ADEQUACY OF USUAL TT. &STEP UP IF NECCESARY
ENSURE PT. HAS ENOUGH SUPPLY OF
MEDICATION CHECK INHALER TECHNIQUE 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 30-60MG DLY. NEBULISED BETA AGONIST EVERY 15MIN--24HRLYDEPENDING ON SEVERITY + ANTICHOLINERGIC. IF STILL NO IMPROVEMENT: I.V. AMINOPHYLLINE>0.5-0.9MG/KG/HR. IF CONTINUED FOR MORE THAN 24 HRS MONITOR BLOOD LEVELS. ALTERNATIVE : BETA AGONIST INFUSION 3-20mcg./MIN AFTER INITIAL I.V.BOLUS OF 250mcg.OVER 10 MIN.
MANAGEMENT IN WARD (CONTD.) STILL INADEQUATE RESPONSE:
MAY GIVE I.V. MAGNESIUM SULPHATE 2G.IN 50ML. 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 TT. WITH BETA AGONIST &CORTICOSTEROIDS
E.C.G. IF INDICATED
REFERRAL TO INTENSIVE CARE
ACUTE SEVERE OR LIFE THREATENING ASTHMA NOT RESPONDING TO THERAPY , EVIDENCED BY:
DETERIORATING PEF PERSISTENT OR WORSENING HYPOXIA
HYPERCAPNIA ABG: EXHAUSTION FEEBLE RESPIRATION
DROWSINESS,CONFUSION
COMA, RESPIRATORYARREST
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
STABLE ON MEDICATIONS PT. IS GOING TO TAKE OUTSIDE THE HOSP. FOR AT LEAST 24 HRS.
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(FOR SELECTED, MOTIVATED PTS.)
IMPORTANCE OF REGULAR FOLLOW UP.
EARLY F.U : REASSESSMENT OF MEDICATION
&
MOTIVATION
EPIDEMIOLOGY
Asthma is a common disease with unacceptable high morbidity and mortality Prevalence is increasing worldwide It is commonly under diagnosed and undertreated Many deaths and morbidity have been a/w inadequate treatment, under-use of objective measurement of severity and inadequate supervision
PREVALENCE OF ASTHMA IN MALAYSIA
Primary school children: 13.8% Children aged 13-14 years: 9.6% Adult (self-reported) in NHMS: 4.1% Prevalence was higher in rural (4.5%) than in Urban areas (4.0%) Prevalence was also higher in those with lower educational status (5.6%) and lower income (4.7%)
DEFINITION
Asthma, irrespective of severity, is a chronic inflammatory disorder of the airways. In susceptible individual, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough particularly at night and in the early morning This episodes are usually a/w widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.
HOW TO DIAGNOSE ASTHMA?
DIAGNOSING ASTHMA Wheezing H/o any of the following: Cough – worse particularly at night/early morning Recurrent difficulty in breathing Recurrent wheeze Recurrent chest tightness Note: Eczema, hay fever, or a family h/o asthma or atopic diseases is often a/w asthma Symptoms occur or worsen at night/early morning – awakening the patient
DIAGNOSING ASTHMA
Symptoms occur or worsen in the presence of: Exercise Animals Pollen Aerosol chemicals Dust mites (in mattress, pillows, upholastered furniture, carpets) Respiratory tract infection Smoke (tobacco, wood) Changes in temperature Drugs (aspirin, beta blockers) Strong emotional expression (laughing or crying hard)
DIAGNOSING ASTHMA
Reversible and variable airflow limitation- as measured by a PEF meter in any the following ways: PEF increases > 15%, 15 to 20 min after inhaling a short-acting beta2-agonist, or PEF varies > 20% from morning measurement upon arising to measurement 12 hours later in patient who are taking a bronchodilator (> 10% in patients who are not taking a bronchodilator), or PEF decreases >15% after 6 minutes of running or exercise
MANAGEMENT OF CHRONIC ASTHMA The aims of management are To abolish day and night symptoms of asthma To restore normal or best possible long term airway function To prevent most acute attacks To prevent mortality
APPROACH TO MANAGEMENT Educating patient and family members Identifying and avoiding trigger factors Assessing severity and monitoring response to treatment Selecting appropriate medications and using the lowest effective dose to minimise short and long term side effects
DRUG TREATMENT 3 major groups of medications: 2. Anti-inflammatory medications 3. Long-acting bronchodilators 4. Short-acting bronchodilators
Anti-inflammatory medications
Reducing the inflammation will decrease bronchial hyper-responsiveness 3 types: i) Corticosteroids - the main prophylactic drugs ii) Cromones eg. Sodium cromoglycate - It is effective in the symptomatic and prophylactic management of mild persistent asthma but less effective in more severe asthma
Antileukotrienes e.g Montelukast
i)
have some effect in controlling mild persistent asthma - Possible role as an alternative to low dose inhaled corticosteroid and as add-on therapy to inhaled corticosteroid - to reduce the requirement for high doses of inhaled corticosteroids - may also be used for aspirin sensitive asthma and exercise-induced asthma -
EDUCATION OF PATIENT AND FAMILY
Nature of asthma Preventive measure/avoidance of triggers Drugs used and their side-effects Peak flow monitoring Proper technique of using inhaled drugs Recognition of features of worsening asthma (increase in bronchodilator requirement, development of nocturnal symptoms, deteriorating PEFR) Knowledge of the difference between relieving and preventive medications Self management plan The danger of non-prescriibed self medication including certain traditional medicines
PREVENTION IS BETTER THAN CURE
ACUTE SEVERE ASTHMA
WHY DO PAITENTS DIE:
DISEASE FACTORS
MEDICAL MANAGEMENT FACTORS
PATIENTS BEHAVIOUR,PSYCHOSOCIAL FACTORS
DISEASE FACTORS
CHRONIC SEVERE B.A.
IN A MINORITY MILD OR MODERATE BRONCHIAL ASTHMA
MEDICAL MANAGEMENT FACTORS
INADEQUATE TREATMENT INADEQUATE OBJECTIVE MONITORING INADEQUATE FOLLOW UP NOT REFERRING TO SPECIALIST NOT GIVEN WRITTEN MANAGEMENT PLAN INCREASING USE OF BETA2AGONIST
MEDICAL MANAGEMENT FACTORS CONTD.
INAPPROPRIATE PRESCRIPTION OF BETABLOCKER THERAPY
HEAVY SEDATION
PATIENT SENSITIVE TO NSAID
ADVERSE PSYCHOSOCIAL & BEHAVIOURAL FACTORS
NON-COMPLIANCE WITH TT. OR MONITORING
FAILURE TO ATTEND APPOINTMENTS
SELF DISCHARGE FROM HOSPITAL
PSYCHOSIS, DEPRESSION,OTHER PSY.ILLNESS OR SELF HARM
CURRENT OR RECENT MAJOR TRANQUILISER USE
DENIAL
ALCOHOLOR DRUG ABUSE
PSYCHOSOCIAL OR BEHAVIOURAL FACTORS
OBESITY
LEARNING DIFFICULTY
EMPLOYMENT PROBLEMS
INCOME PROBLEMS
SOCIAL ISOLATION
CHILDHOOD ABUSE
SEVERE DOMESTIC, MARITAL OR LEGAL STRESS.
OTHER RISK FACTORS FOR DEVELOPING NEAR FATAL OR FATAL ASTHMA
PREVIOUS NEAR FATAL ASTHMA
PREVIOUS ADM .FOR B.A. ESPECIALLY IF IN THE LAST YEAR
REQUIRING THREE OR MORE CLASSES OF ASTHMA MEDICATION
HEAVY USE OF BETA AGONIST
RPT. ATTENDANCES @ A&E ESPECIALLY IN THE LAST YEAR
BRITTLE ASTHMA
HEALTH CARE PROFFESSIONALS MUST BE AWARE THAT PATIENTS WITH SEVERE ASTHMA & ONE OR MORE ADVERSE PSYCHOSOCIAL FACTORS ARE AT RISK OF DEATH
PREDICTION &PREVENTION OF A SEVERE ATTACK
88-92% ATTACKS DEVELOP OVER 6 HRS
80%MAY EVEN DEVELOP IT OVER 48 HRS.
THEREFORE TIME FOR EFFECTIVE ACTION `& POTENTIALTO REDUCE HOSPITAL ADMISSION
A SPECIALIST SHOULD FOLLOW UP PATIENTS ADMITTED WITH SEVERE ASTHMA FOR AT LEAST ONE YEAR AFTER ADMISSION
AIMS OF MANAGMENT
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
INITIAL ASSESSMENT
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
INCREASING SYMPTOMS
PEF >50-75% BEST OR PREDICTED
NO FEATURES OF ACUTE SEVERE ASTHMA
ACUTE SEVERE ASTHMA
ANY ONE OF: PEF33-50% BEST OR PREDICTED
RESP. RATE>25/MIN
HEART RATE.> 100/MIN.
INABILITY TO COMPLETE SENTENCES IN ONE BREATH.
Life threatening asthma
CENTRAL CYANOSIS FEEBLE RESPIRATORY EFFORT SILENT CHEST BRADYCARDIA EXHAUSTION CONFUSION PEF<30% OF BEST OR PREDICTED(<100L/MIN) ABG: NORMALORHIGH PaCO2 SEVERE HYPOXAEMIA(60mmHG) LOW pH
REFERRAL TO INTENSIVE CARE
ACUTE SEVERE OR LIFE THREATENING ASTHMA NOT RESPONDING TO THERAPY , EVIDENCED BY:
DETERIORATING PEF PERSISTENT OR WORSENING HYPOXIA
HYPERCAPNIA ABG: EXHAUSTION FEEBLE RESPIRATION DROWSINESS,CONFUSION COMA, RESPIRATORYARREST
ASSESMENT OF RESPONSE TO INITIAL TT. RESPONSE TO TT. IS MONITORED BY:
SYMPTOMS
PHYSICAL FINDINGS
PEF MEASUREMENT 15-30 MIN. AFTER INITIAL TT.
RESPONSE TO INITIAL TT. GOOD RESPONSE IS:
RELIEVED OF DYSPNOEA IMPROVED CLINICAL STATUS POST TT. PEF >75% OF BEST O PREDICTED VALUE.
INCOMPLETE RESPONSE:
PERSISTENT SYMPTOMS & SIGNS PEF50-75% OF BEST OR PREDICTED VALUE
RESPONSE TO INITIAL TT. POOR RESPONSE:
PERSISTENT OR DETERIORATING SYMPTOMS & SIGNS
PEF<50%
BEFORE DISCHARGE FROM A&E
REVIEW ADEQUACY OF USUAL TT. &STEP UP IF NECCESARY
ENSURE PT. HAS ENOUGH SUPPLY OF
MEDICATION CHECK INHALER TECHNIQUE 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 30-60MG DLY. NEBULISED BETA AGONIST EVERY 15MIN--24HRLYDEPENDING ON SEVERITY + ANTICHOLINERGIC. IF STILL NO IMPROVEMENT: I.V. AMINOPHYLLINE>0.5-0.9MG/KG/HR. IF CONTINUED FOR MORE THAN 24 HRS MONITOR BLOOD LEVELS. ALTERNATIVE : BETA AGONIST INFUSION 3-20mcg./MIN AFTER INITIAL I.V.BOLUS OF 250mcg.OVER 10 MIN.
MANAGEMENT IN WARD (CONTD.) STILL INADEQUATE RESPONSE:
MAY GIVE I.V. MAGNESIUM SULPHATE 2G.IN 50ML. 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 TT. WITH BETA AGONIST &CORTICOSTEROIDS
E.C.G. IF INDICATED
REFERRAL TO INTENSIVE CARE
ACUTE SEVERE OR LIFE THREATENING ASTHMA NOT RESPONDING TO THERAPY , EVIDENCED BY:
DETERIORATING PEF PERSISTENT OR WORSENING HYPOXIA
HYPERCAPNIA ABG: EXHAUSTION FEEBLE RESPIRATION
DROWSINESS,CONFUSION
COMA, RESPIRATORYARREST
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
STABLE ON MEDICATIONS PT. IS GOING TO TAKE OUTSIDE THE HOSP. FOR AT LEAST 24 HRS.
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(FOR SELECTED, MOTIVATED PTS.)
IMPORTANCE OF REGULAR FOLLOW UP.
EARLY F.U : REASSESSMENT OF MEDICATION
&
MOTIVATION
