Acute Asthma/COPD Exacerbation Flashcards
1
Q
Asthma Exacerbation
A
- Represents a change from patient’s usual status that requires a treatment change
- Progressively worsening asthma symptoms: SoB, cough, wheezing, and chest tightness (can be combination)
- Decreases in expiratory airflow: PEF, FEV1
- Poorly responsive to usual bronchodilator therapy
2
Q
Asthma Exacerbation Triggers
A
- Medications: ASA, NSAIDs, B-blockers
- Environmental: cold air, tobacco, and wood smoke
- Respiratory infections: viral
- Allergens: Pollens, dust mites, animal dander, fungal spores, cockroaches
3
Q
Asthma Death Risk Factors
A
- Previous severe exacerbation
- Hospitalization/emergency care visit for asthma in past year
- Current/recent use of oral corticosteroids
- Use of >1 canister of inhaled SABA per month
- History of psychiatric or CV disease
- Poor adherence with asthma meds or action plan
- Not currently using inhaled corticosteroids
- Food allergy
4
Q
General Asthma Exacerbation Presentation
A
- Anxious, acute distress
- Dyspnea, wheezing, cough
- Chest tightness/burning
- Only saying a few words with each breath
- Pale/cyanotic skin
- Supraclavicular and intercostal retractions
- Increased respiratory rate/HR
5
Q
History to Collect
A
- Time of onset/cause
- Severity of symptoms - limits exercise/sleep
- Any symptoms of anaphylaxis
- Risk factors for asthma-related death
- All current reliever and controller medications: doses, devices, adherence
6
Q
Physical Exam
A
- Signs of exacerbation severity: vitals, level of consciousness, ability to complete sentences, use of accessory muscles
- Complicating factors: anaphylaxis, pneumonia, pneumothorax
7
Q
Objective Measurements
A
- Lung fxn tests: PEF or FEV1
- Oxygen saturation: decreased oxygen saturation, mixed respiratory and metabolic acidosis if severe exacerbation
8
Q
Mild Clinical Course
A
- Home management
- Prompt relief with inhaled SABA
- Possible short course oral corticosteroids
9
Q
Moderate Clinical Course
A
- Office or ED management
- Relief from frequent inhaled SABA
- Oral corticosteroids, symptoms lasting 1-2 days
10
Q
Severe Clinical Course
A
- ED visit and hospital admission
- Partial relief from frequent inhaled SABA
- Oral corticosteroids, symptoms lasting > 3 day
- Adjunctive therapies are helpful
11
Q
Life-threatening Clinical Course
A
- Possible ICU admission
- Minimal or no relief from frequent inhaled SABA
- IV corticosteroids
- Adjunctive therapies are helpful
12
Q
Home Treatment
A
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 clinical consultation
- Marked breathlessness, inability to speak more than short phrases, use of accessory muscles, drowsiness
- If available measure PEF
- Have medications at home
13
Q
Home Treatment Pharm Therapy
A
- Increase frequency of SABA treatment
- Initiate oral systemic corticosteroid burst (1-2mg/kg/day for 3-10 days)
- Continue more intensive treatment for several days
14
Q
Not Recommended for Home Treatment
A
- Drinking large volumes of liquid
- Breathing warm, moist air
- Using OTC: antihistamines, cough/cold products
- Pursed-lip and controlled breathing: may help maintain calm but doesn’t improve lung fxn
- No studies demonstrate effectiveness and may delay getting appropriate care
15
Q
ED Management
A
- Inhaled SABA for all patients: MDI or nebulizer, every 20 minutes or continuously
- Albuterol: MDI, 4-8 puffs every 20 minutes x 1 hours then every 1-4 hours PRN (same efficacy as nebulizer if done right), can use nebulizer too
- Use higher dose for severe exacerbation
16
Q
SABA Dosing Consideration
A
- Dry powder not recommended
- Dose-response curse shifted to right, decreased duration of effect
- Need higher and more frequent doses during acute exacerbation
- AE: tachycardia, hyperglycemia, hypokalemia, tremors, restlessness, anxiety
- Tachycardia also seen with asthma exacerbation, may resolve with appropriate disease treatment
17
Q
ED + Oral Corticosteroids
A
- Severe exacerbation
- Initial SABA treatment fails to achieve lasting improvement in symptoms
- Patient is taking oral corticosteroids
- History of previous exacerbations requiring oral corticosteroids
- Oral as effective as intravenous: used if PO isn’t tolerated
18
Q
Corticosteroid Dosing/AE
A
- ED/Hospital: 40-80 mg/day (peds: max of 60 mg)
- Continue until PER is 70% of predicted or personal best (3-10 days)
- AEs: Insomnia, glucose tolerance, mood alteration, increased appetite, GI distress
19
Q
Ipratropium + ED
A
- Not first line therapy or sole bronchodilator
- Can mix solution for nebulization with albuterol
- Moderate-severe: fewer hospitalizations and greater improvement in lung fxn compared to SABA alone
- Questionable benefit once patient is hospitalized
20
Q
Ipratropium Dosing/AE
A
- MDI: 8 puffs every 20 minutes PRN for up to 3 hours
- Nebulizer: every 20 minutes for 3 doses, then every 2-4 hours PRN
- AE: quaternary ammonium compound, poorly absorbed from lungs/GI, systemic effects are rare
21
Q
Other ED Treatments
A
- IV Magnesium sulfate: not initial, can reduce hospitalizations
- 2 g infusion over 20 minutes
22
Q
Not Recommended for ED/Hospital
A
- Methylxanthines
- Antibiotics (unless infection present)
- Aggressive hydration
- Mucolytics
- Sedation
- Chest physical therapy
23
Q
Monitoring in ED/Hospitalization
A
- Serial assessments
- No single measure is best for assessing severity or predicting hospital admission
- Use all if possible
- FEV1 or PEF, pulse oximetry, signs and symptoms
24
Q
Asthma Discharge
A
- Prior to discharge adjust medications to outpatient regimen
- Discharge meds: SABA, complete course of oral corticosteroids, long-term control therapy (inhaled corticosteroids may be considered)
- Patient education
25
Q
COPD Exacerbations
A
- Acute worsening of respiratory symptoms needing additional therapy
- Most common cause is RTI (usually viral)
- Goals: Minimize negative impact of current exacerbation, prevent subsequent events
26
Q
Exacerbation Classifications
A
- Mild: Treat with short-acting bronchodilators
- Moderate: Same as mild + antibiotics and/or oral steroids
- Severe: Patient requires hospitalization/ED, may be associated with acute respiratory distress
27
Q
Indications to COPD Hospitalization
A
- Severe symptoms: sudden worsening of resting dyspnea, high respiratory rate, decreased O2 sat, confusion, drowsiness
- Acute respiratory failure
- Onset of new physical findings: cyanosis or peripheral edema
- Failure to respond to initial medical management
- Presence of serious comorbidities: heart failure, newly occurring arrhythmia
- Insufficient home support
28
Q
Indications for COPD ICU Admission
A
- 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 to invasive mechanical ventilation
- Need for vasopressors
29
Q
COPD Exacerbation Outpatient Management
A
- SABA +/- SAMA: symptom improvement not affect by route of delivery
- Corticosteroid: Prednisone 40 mg PO QD x 5 days
- Antibiotics if indications: 5-7 days, use effective antibiotic based on pathogen
- May escalate home oxygen (goal: O2 Sat of 88-92%)
- Diuretics if fluid overload due to comorbidities
30
Q
COPD Exacerbation Inpatient Management
A
-Supplemental oxygen (same goal)
-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
-Identify and treat associated conditions: heart failure, arrhythmias, pulmonary embolism etc.
31
Q
COPD Exacerbation Management in ICU
A
- Invasive mechanical ventilation
- Vasopressors
32
Q
Antibiotic Indications
A
- 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
33
Q
COPD Exacerbation Discharge
A
- 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
