ASTHMA EXACERBATION Flashcards
History
Symptoms
Triggers
History of ED Visits
History of Hospital or ICU Admission
History of Intubation
Medications Used and Frequency
Current Cigarette Use
DDX: Wheezing
COPD
CHF
Anaphylaxis
PNA
Bronchiolitis
Foreign body
PE
Pulmonary Edema
Critical DDx
Foreign Body Aspiration
CHF
Anaphylaxis
Angioedema
Pneumonia
Pneumothorax
Pulmonary Embolism
Clinical Features
Breathlessness
Chest Tightness
Wheezing
Cough
External Triggers for asthma (7)
Cold air
Exercise
Viral illness
Allergens
Smoking
Poor air quality
Sulphites in foods
Beta blockers
NSAIDS
Strong emotions
Investigations
CXR
+/-ABG if fatigue, C02 retention, respiratory acidosis suspected
Spirometry (Peak Flow or FEV1)
Diagnosis of asthma
Recurrent episodes of breathlessness
Chest Tightness
Wheezing / Cough
Spirometry:
Fev1/FVC ratio <0.75 (COPD is 0.7)
FEV1 12% increase post bronchodilator (COPD is not reversible)
Mild - Moderate Clinical Features
02 Sats > 92%
Speaks in full sentences
PEF >40-60% predicted
Severe Asthma Clinical Features
02 Sats < 92%
Difficulty Speaking
Accessory Muscle Use
Not improving with initial treatment
PEF < 40% predicted or unable to complete
Management
Intubate if asthma is life threatening or refractory to treament
O2 target > 92%
Salbutamol MDI + Spacer (4-8 puffs q 20 min x 3 THEN 1-4 hrs)
OR
Nebulized 2.5-5 mg q 20 min x 3
Iprotropium MDI + Spacer (4-8 puffs q 20 min x 3 then PRN)
OR
Nebulized 250-500 ug q 20 min x 3
Prednisone 40-60 mg PO daily for 5-10 days
OR
methypredisolone 125 mg IV Single Dose
OR
Dexamethasone 10 mg IV, repeat in 24 hrs
Ongoing symptoms refractory to treatment:
Adult: Mg SO4 2g IV over 20 min
Peds: Magnesium sulfate 50-75 mg/kg intravenous over 20 to 60 minutes (maximum dose 2,000 mg).
Give IVF for hypotension due to Mg
Frequent Reassessment of patient
Rescue: Epinephrine 0.3-0.5 mg intramuscular to anterolateral thigh
Intubation if respiratory failure
Disposition: Home
Mild symptoms
Mild to moderate symptoms that responsed well for >1 hr after treatment
Rx Ventolin, Flovent
Disposition: hospital admission
Pt remains symptomatic despite ED management for several hours
Risk factors for early relapse
Post treatment PEFR < 40 % predicted value
Management of Mild Outpatient Exacerbations
Increase symbicort by 4x
Prednisolone 50 mg /day x 5 days
Guidelines for intubation
Utilize permissive hypercapnia as a strategy to prevent barotrauma and allow adequate exhalation. Set the tidal volume to 6 mL/kg at a rate approximately half of normal for the patient’s age. Change the I:E (inspiratory:expiratory) time to 1:3 or longer. Keep pCO2 <90-100 mm Hg (<12-13.3 kPa) and pH >7.15-7.2.
