850- Acute Asthma and COPD Flashcards
What is an Asthma Exacerbation?
– 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
Risk Factors for Death From Asthma
- Previous severe exacerbation
- Hospitalization or emergency care visit for asthma in the past year
- Current or recent use of oral corticosteroids (OCS)
- Use of >1 canisters of inhaled short-acting β2-agonist (SABA) per month
- History of psychiatric disease, CV disease
- Poor adherence with asthma medications and/or written asthma action plan
- Not currently using inhaled corticosteroids
- Food allergy inpatient with asthma
Asthma Exacerbation Clinical Presentation:
• 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
Information to Collect
History
– 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
Information to Collect
Physical exam & Objective measures
> > 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
Typical Clinical Course Based on Severity:
MILD
- Home management
- Prompt relief with inhaled SABA
- Possible short course oral corticosteroids
Typical Clinical Course Based on Severity:
MODERATE
- Office or ED management
- Relief from frequent inhaled SABA
- Oral corticosteroids, symptoms lasting 1-2 days
Typical Clinical Course Based on Severity:
SEVERE
- ED visit and hospital admission
- Partial relief from frequent inhaled SABA
- Oral corticosteroids, symptoms lasting > 3 days
- Adjunctive therapies are helpful
Typical Clinical Course Based on Severity:
LIFE-THREATENING
- Possible ICU admission
- Minimal or no relief from frequent inhaled SABA
- IV corticosteroids
- Adjunctive therapies are helpful
Management: Home Treatment
Assess severity
– 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
Management - Home Treatment:
Initial Treatment
-Inhaled SABA, 2 treatments (20 minutes apart) of 2-6 puffs by MDI with spacer or neb treatment
Management - Home Treatment:
Good Response
- 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
Management - Home Treatment:
Incomplete Response
- Persistent wheezing or dyspnea
- PEF 50-79%
- Add oral steroid burst
- Continue SABA
- Contact clinician urgently (that day)
Management - Home Treatment:
Poor Response
- 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
Management - Home Treatment:
Pharmacologic therapy
– 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
Management - Home Treatment:
Not recommended
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)
Management (Emergency
Department - Drug Therapy)
- Inhaled SABA for all patients
– MDI or nebulizer, every 20 minutes or continuously - 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
SABA Dosing Considerations:
- Dry powder inhalers not recommended
- Dose-response curve shifted to right, decreased duration of effect
– Higher and more frequent doses needed during acute exacerbation - AEs
– Tachycardia, hyperglycemia, hypokalemia, tremors, restlessness, anxiety
– Tachycardia also seen with asthma exacerbation and may resolve with appropriate disease treatment
Management - Emergency Department:
Oral corticosteroids
– 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
Corticosteroid Dosing Considerations:
- Emergency department/hospitalization
– 40-80 mg/day (peds: max 60 mg)
– Continue until PEF is 70% of predicted or personal best (3-10 days) - AEs
– Insomnia, glucose intolerance, mood alteration, increased appetite, GI distress
Management - Emergency Department:
Ipratropium
• 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
Ipratropium Dosing Considerations:
• 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
Management - Emergency Department:
Other Treatments
- 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
Management: ED and Hospital
Not recommended
- Methylxanthines
- Antibiotics (unless infection present)
- Aggressive hydration
- Mucolytics
- Sedation
- Chest physical therapy
Monitoring: ED and Hospital
- Serial assessments
- 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
Asthma Exacerbation Discharge
- Prior to discharge adjust medications to outpatient regimen
- Discharge medications
– SABA
– Complete course of oral corticosteroids
– Long-term control therapy
• Consider inhaled corticosteroids therapy - Patient Education
COPD Exacerbations
- Acute worsening of respiratory symptoms that results in additional therapy
- Most common cause is respiratory tract infection
– Usually viral - Goal of treatment
– Minimize negative impact of current exacerbation
– Prevent subsequent events
Exacerbation Classification
Mild
– Treated with short-acting bronchodilators
Exacerbation Classification
Moderate
– Treated with short-acting bronchodilators + antibiotics and/or oral steroids
Exacerbation Classification
Severe
– Patient requires hospitalization or ED visit
– May be associated with acute respiratory distress
Exacerbation Assessment - Indications for hospital admission?
(Yes)
- 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
Exacerbation Assessment - Indications for hospital admission?
(No)
1. Outpatient Management: • Bronchodilators • Steroid burst • ± Antibiotics • ± Titrate home O2 • ± Diuretics
Indications for Hospital Admission:
- Severe symptoms
– e.g. sudden worsening of resting dyspnea, high respiratory rate, decreased oxygen saturation, confusion, drowsiness - Acute respiratory failure
- Onset of new physical findings
– e.g. cyanosis or peripheral edema - Failure to respond to initial medical management
- Presence of serious comorbidities
– e.g. heart failure, newly occurring arrhythmia - Insufficient home support
Indications for ICU Admission:
- Severe dyspnea that responds inadequately to initial emergency therapy
- Changes in mental status
– Confusion, lethargy, coma - Persistent or worsening hypoxemia and/or respiratory acidosis despite O2 and noninvasive ventilation
- Need for invasive mechanical ventilation
- Need for vasopressors
Acute Exacerbation – Outpatient Management
- Bronchodilators (SABA±SAMA)
– Symptom improvement not affected by route of
delivery - Corticosteroids
– Prednisone 40 mg PO once daily x 5 days - Antibiotics if indicated
– Common pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis
– Duration: 5-7 days - May escalate home oxygen (goal O2 Sat 88-92%)
- Diuretics if fluid overload due to comorbidities
Acute Exacerbation – Inpatient Management
- Supplemental oxygen (goal: 88-92%)
- Bronchodilators
– Increase doses and/or frequency
– SABA + SAMA - Oral corticosteroids
- Antibiotics if indicated
- Noninvasive mechanical ventilation if needed
- Monitor fluid balance
- Consider thromboembolism prophylaxis
- Identify and treat associated conditions
– Heart failure, arrhythmias, pulmonary embolism etc. - If admitted to ICU
– Invasive mechanical ventilation
– Vasopressors
Indications for Antibiotic Therapy
- 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
Acute Exacerbation Discharge:
- Check maintenance therapy and understanding
- Reassess inhaler technique
- Ensure understanding of withdrawal of acute medications (steroids and/or antibiotics)
- Assess need for continuing oxygen
- Provide management of comorbidities
- Follow-up in ~ 4 weeks
