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850 > Acute Asthma/COPD Exacerbation > Flashcards

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
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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
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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
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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
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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
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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
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7
Q

Objective Measurements

A
  • Lung fxn tests: PEF or FEV1

- Oxygen saturation: decreased oxygen saturation, mixed respiratory and metabolic acidosis if severe exacerbation

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8
Q

Mild Clinical Course

A
  • Home management
  • Prompt relief with inhaled SABA
  • Possible short course oral corticosteroids
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9
Q

Moderate Clinical Course

A
  • Office or ED management
  • Relief from frequent inhaled SABA
  • Oral corticosteroids, symptoms lasting 1-2 days
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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
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11
Q

Life-threatening Clinical Course

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

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