850- Acute Asthma and COPD

Question 1

What is an Asthma Exacerbation?

Answer 1

– Represents a change from the patient’s usual status that requires a change in treatment
– Progressively worsening asthma symptoms
• Shortness of breath, cough, wheezing, and chest tightness
• Can be combination of symptoms
– Decreases in expiratory airflow
• Quantified by measurements of lung function
1. Peak expiratory flow (PEF)
2. Forced expiratory volume in 1 second (FEV1)
– Poorly responsive to usual bronchodilator therapy

Question 2

Risk Factors for Death From Asthma

Answer 2

1. Previous severe exacerbation
2. Hospitalization or emergency care visit for asthma in the past year
3. Current or recent use of oral corticosteroids (OCS)
4. Use of >1 canisters of inhaled short-acting β2-agonist (SABA) per month
5. History of psychiatric disease, CV disease
6. Poor adherence with asthma medications and/or written asthma action plan
7. Not currently using inhaled corticosteroids
8. Food allergy inpatient with asthma

Question 3

Asthma Exacerbation Clinical Presentation:

Answer 3

• General
1. Anxious, acute distress
2. Dyspnea, wheezing, cough
3. Chest tightness/burning
4. Oftentimes only able to say a few words with each breath
5. Pale/cyanotic skin
6 Supraclavicular and intercostal retractions
7. Increased respiratory rate, heart rate

Question 4

Information to Collect

History

Answer 4

– Time of onset and cause
– Severity of symptoms; limiting exercise/sleep?
– Any symptoms of anaphylaxis
– Risk factors for asthma-related death
– All current reliever and controller medications
• Doses, devices, adherence

Question 5

Information to Collect

Physical exam & Objective measures

Answer 5

> > Physical exam«
1. Signs of exacerbation severity
• Vitals, level of consciousness, ability to complete sentences, use of accessory muscles
2. Complicating factors
• Anaphylaxis, pneumonia, pneumothorax etc

> > Objective measurements«
1. Lung function tests (PEF or FEV1)
2. Oxygen saturation
• Decreased oxygen saturation, mixed respiratory and metabolic acidosis if severe exacerbation

Question 6

Typical Clinical Course Based on Severity:

MILD

Answer 6

• Home management
• Prompt relief with inhaled SABA
• Possible short course oral corticosteroids

Question 7

Typical Clinical Course Based on Severity:

MODERATE

Answer 7

• Office or ED management
• Relief from frequent inhaled SABA
• Oral corticosteroids, symptoms lasting 1-2 days

Question 8

Typical Clinical Course Based on Severity:

SEVERE

Answer 8

• ED visit and hospital admission
• Partial relief from frequent inhaled SABA
• Oral corticosteroids, symptoms lasting > 3 days
• Adjunctive therapies are helpful

Question 9

Typical Clinical Course Based on Severity:

LIFE-THREATENING

Answer 9

• Possible ICU admission
• Minimal or no relief from frequent inhaled SABA
• IV corticosteroids
• Adjunctive therapies are helpful

Question 10

Management: Home Treatment

Assess severity

Answer 10

– Patients at high risk for fatal attack require immediate medical attention after initial treatment
– Signs and symptoms suggestive of more serious exacerbation should result in initial treatment with clinician consultation
• Marked breathlessness, inability to speak more than short phrases, use of accessory muscles, drowsiness
– If available, measure PEF
– Have medications at home

Question 11

Management - Home Treatment:

Initial Treatment

Answer 11

-Inhaled SABA, 2 treatments (20 minutes apart) of 2-6 puffs by MDI with spacer or neb treatment

Question 12

Management - Home Treatment:

Good Response

Answer 12

• No wheezing or dyspnea
• PEF ≥ 80%
• Contact clinician for follow-up
• May continue SABA every 3-4 hours X 24-48 hours
• Consider oral steroid burst

Question 13

Management - Home Treatment:

Incomplete Response

Answer 13

• Persistent wheezing or dyspnea
• PEF 50-79%
• Add oral steroid burst
• Continue SABA
• Contact clinician urgently (that day)

Question 14

Management - Home Treatment:

Poor Response

Answer 14

• Marked wheezing or dyspnea
• PEF < 50%
• Repeat SABA immediately
• Add oral steroid burst
• If distress severe and nonresponsive: call clinician AND go to ED, consider 911

Question 15

Management - Home Treatment:

Pharmacologic therapy

Answer 15

– Increase frequency of SABA treatment
– Initiate oral systemic corticosteroid burst
• 1-2 mg/kg/day (max 50-60 mg/day); 3-10 days
– Continue more intensive treatment for several days

Question 16

Management - Home Treatment:

Not recommended

Answer 16

1. Not recommended
– Drinking large volumes of liquid
– Breathing warm, moist air
– Using OTC products
• Antihistamines
• Cough and cold products
– Pursed-lip and controlled breathing
• May help maintain calm but does not improve lung function

(No studies demonstrate effectiveness and may delay getting appropriate care)

Question 17

Management (Emergency

Department - Drug Therapy)

Answer 17

1. Inhaled SABA for all patients
   – MDI or nebulizer, every 20 minutes or continuously
2. Albuterol
   – MDI (90 mcg/puff)
   • 4-8 puffs every 20 minutes X 1 hour, then every 1- 4 hours as needed
   • Same efficacy as nebulizer if done correctly, use with valved holding chamber
   – Nebulizer
   • 2.5-5 mg every 20 minutes for 3 doses, then 2.5- 10 mg every 1-4 hours as needed
   • 10-15 mg/hr continuously
   – Use higher dose for severe exacerbation

Question 18

SABA Dosing Considerations:

Answer 18

1. Dry powder inhalers not recommended
2. Dose-response curve shifted to right, decreased duration of effect
   – Higher and more frequent doses needed during acute exacerbation
3. AEs
   – Tachycardia, hyperglycemia, hypokalemia, tremors, restlessness, anxiety
   – Tachycardia also seen with asthma exacerbation and may resolve with appropriate disease treatment

Question 19

Management - Emergency Department:

Oral corticosteroids

Answer 19

– Severe exacerbation
– Initial SABA treatment fails to achieve lasting improvement in symptoms
– Patient is taking oral corticosteroids
– Patient has a history of previous exacerbations requiring oral corticosteroids
– Oral as effective as intravenous
• IV if patient can’t tolerate po meds

Question 20

Corticosteroid Dosing Considerations:

Answer 20

1. Emergency department/hospitalization
   – 40-80 mg/day (peds: max 60 mg)
   – Continue until PEF is 70% of predicted or personal best (3-10 days)
2. AEs
   – Insomnia, glucose intolerance, mood alteration, increased appetite, GI distress

Question 21

Management - Emergency Department:

Ipratropium

Answer 21

• Not first line therapy or sole bronchodilator
• Can mix solution for nebulization with albuterol
• In moderate to severe exacerbations
– Associated with fewer hospitalizations and greater improvement in lung function compared with SABA alone
• Questionable benefit once the patient is hospitalized

Question 22

Ipratropium Dosing Considerations:

Answer 22

• MDI (17 mcg/puff)
– 8 puffs every 20 minutes as needed up to 3 hours

• Nebulizer
– 0.5 mg every 20 minutes for 3 doses, then every 2-4 hours as needed

• AEs
– Quaternary ammonium compound, poorly absorbed from lungs/GI
– Systemic effects are rare, contact with eye produces pupillary dilation and decreased accommodation

Question 23

Management - Emergency Department:

Other Treatments

Answer 23

1. IV magnesium sulfate
   • Not initial therapy
   • Can reduce hospitalizations
   – Adults with FEV1 < 25-30% of predicted
   – Adults and kids that fail to respond to initial therapy
   – Kids whose FEV1 < 60% after 1 hour of treatment
   • 2 g infusion over 20 minutes

Question 24

Management: ED and Hospital

Not recommended

Answer 24

1. Methylxanthines
2. Antibiotics (unless infection present)
3. Aggressive hydration
4. Mucolytics
5. Sedation
6. Chest physical therapy

Question 25

Monitoring: ED and Hospital

Answer 25

1. Serial assessments
2. No single measure is best for assessing severity or predicting hospital admission, use all of following if possible
   – FEV1 or PEF
   • May not be obtainable during exacerbation
   – Pulse oximetry
   • Oxygen saturation < 92-94% after 1 hour of treatment in ED is predictive of need for hospitalization in children
   – Signs and symptoms
   • Presence of drowsiness predicts impending respiratory failure

Question 26

Asthma Exacerbation Discharge

Answer 26

1. Prior to discharge adjust medications to outpatient regimen
2. Discharge medications
   – SABA
   – Complete course of oral corticosteroids
   – Long-term control therapy
   • Consider inhaled corticosteroids therapy
3. Patient Education

Question 27

COPD Exacerbations

Answer 27

1. Acute worsening of respiratory symptoms that results in additional therapy
2. Most common cause is respiratory tract infection
   – Usually viral
3. Goal of treatment
   – Minimize negative impact of current exacerbation
   – Prevent subsequent events

Question 28

Exacerbation Classification

Mild

Answer 28

– Treated with short-acting bronchodilators

Question 29

Exacerbation Classification

Moderate

Answer 29

– Treated with short-acting bronchodilators + antibiotics and/or oral steroids

Question 30

Exacerbation Classification

Severe

Answer 30

– Patient requires hospitalization or ED visit

– May be associated with acute respiratory distress

Question 31

Exacerbation Assessment - Indications for hospital admission?

(Yes)

Answer 31

1. Indications for ICU Admission?

-No: Inpatient Floor Management 
• Outpatient PLUS 
• O2 or noninvasive ventilation
• Pseudomonas coverage?
• Thromboembolic prophylaxis
• Treat associated conditions

-Yes: Inpatient ICU Management
• Inpatient floor PLUS
• Invasive mechanical ventilation
• Vasopressors

Question 32

Exacerbation Assessment - Indications for hospital admission?

(No)

Answer 32

1. Outpatient Management:
• Bronchodilators
• Steroid burst
• ± Antibiotics
• ± Titrate home O2
• ± Diuretics

Question 33

Indications for Hospital Admission:

Answer 33

1. Severe symptoms
   – e.g. sudden worsening of resting dyspnea, high respiratory rate, decreased oxygen saturation, confusion, drowsiness
2. Acute respiratory failure
3. Onset of new physical findings
   – e.g. cyanosis or peripheral edema
4. Failure to respond to initial medical management
5. Presence of serious comorbidities
   – e.g. heart failure, newly occurring arrhythmia
6. Insufficient home support

Question 34

Indications for ICU Admission:

Answer 34

1. Severe dyspnea that responds inadequately to initial emergency therapy
2. Changes in mental status
   – Confusion, lethargy, coma
3. Persistent or worsening hypoxemia and/or respiratory acidosis despite O2 and noninvasive ventilation
4. Need for invasive mechanical ventilation
5. Need for vasopressors

Question 35

Acute Exacerbation – Outpatient Management

Answer 35

1. Bronchodilators (SABA±SAMA)
   – Symptom improvement not affected by route of
   delivery
2. Corticosteroids
   – Prednisone 40 mg PO once daily x 5 days
3. Antibiotics if indicated
   – Common pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis
   – Duration: 5-7 days
4. May escalate home oxygen (goal O2 Sat 88-92%)
5. Diuretics if fluid overload due to comorbidities

Question 36

Acute Exacerbation – Inpatient Management

Answer 36

1. Supplemental oxygen (goal: 88-92%)
2. Bronchodilators
   – Increase doses and/or frequency
   – SABA + SAMA
3. Oral corticosteroids
4. Antibiotics if indicated
5. Noninvasive mechanical ventilation if needed
6. Monitor fluid balance
7. Consider thromboembolism prophylaxis
8. Identify and treat associated conditions
   – Heart failure, arrhythmias, pulmonary embolism etc.
9. If admitted to ICU
   – Invasive mechanical ventilation
   – Vasopressors

Question 37

Indications for Antibiotic Therapy

Answer 37

• Patients with increased dyspnea, sputum volume, and sputum purulence
• Patients with increased sputum purulence AND increased dyspnea
• Patients with increased sputum purulence AND increased sputum volume
• Patients requiring mechanical ventilation

Question 38

Acute Exacerbation Discharge:

Answer 38

1. Check maintenance therapy and understanding
2. Reassess inhaler technique
3. Ensure understanding of withdrawal of acute medications (steroids and/or antibiotics)
4. Assess need for continuing oxygen
5. Provide management of comorbidities
6. Follow-up in ~ 4 weeks