EMERGENCY MANAGEMENT OF ASTHMA

INTRODUCTION Inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are associated with widespread but variable airflow obstruction that is reversible either spontaneously, or with treatment.

TYPES OF ASTHMA
Acute Asthma

Chronic Asthma

CLASSIFICATION OF ASTHMA Symptomatic Asthma Asymptommatic Asthma Seasonal Asthma Nocturnal Asthma Exercise induced Asthma Occupational Asthma Drug induced Asthma

SIGNS & SYMPTOMS Cough Shortness of breath(SOB) Wheezing COMPLICATIONS It might lead to: Chronic obstructive pulmonarydisease(COPD) Emphysema Lung failure Cardiac arrest Chest tightness Paradoxical pulse Use of accesory muscles

ETIOLOGY OF ASTHMA The exact etiology or causes of asthma is still unknown. It is known that some triggers induce an asthma attack if exposed to the inflamed airways. Therefore, the management plan for asthma is directed towards prevention of inflammation of the airway and avoidance of triggers for the better control of symptoms.

Trigger
Asthmatic people have airways that are highly sensitive to certain things which do not bother people without asthma. These things are called triggers. When an asthmatic comes in contact with them, an asthma episode starts. The airways become swollen, produce too much mucus, and are tightened up.

Classification of trigger
Allergens (Individual specific) Outdoor allergens Pollens - from grass & trees Molds - of some fungi Indoor Allergens House dust mites Dander (or flakes) -from the skin, hair or feathers of warm - blooded pets (dogs, cats, birds, rodents, etc.) Molds -harboured in Vacuum cleaners, Air-con- ditioners, Humidifiers. Insects -Cockroach Food Allergens Beef, Prawn, Hilsha and some other fishes, sea-foods, duck egg, some vegetables, nuts, etc. Food additives, e.g. metabisulphite, tartrazine Irritants (More generalized) Tobacco smoke Wood smoke Strong odours, perfumes and sprays, cosmetics, paints, cooking (especially with spices) Air-pollutants - Smoke and toxic gases from automobiles and factories. Upper respiratory tract infection - viral infections, common cold Exercise - strenuous physical activities. Certain Drugs - e.g. b-blockers (even eye drops), Aspirin, NSAIDS etc Changes in season, weather and temperature- An asthma attack is likely if temperature lowers for 30C or more than the previous day. Stress Emotion - e.g. Laughing, Sobbing, Mental depression Surgery Pregnancy PATHOPHYSIOLOGY In asthma,constriction of airways occur due to bronchoconstriction and bronchial inflammation. Bronchoconstriction is narrowing of the airwaysin the lung due to the tightening of surrounding smooth muscles. Bronchial inflammation also causes due to narrowing due to edema and swelling caused by an immune response to allergens. During an asthma episode inflamed airways respond to the triggers. The airways narrows and produce excess mucous,making it difficult to breathe. In essence asthma is the result of an immune response in the bronchial airways. In both asthmatics and non-asthmatics,inhaled allergens that find the way to inner airways are ingested by the type of cell known as antigen presenting cells,APCs. APCs then present pieces of allergens to other immune cells. In most people, these other immune cell (helper T cells) check and usually

ignore the allergen molecules. In asthmatics however these cells transformed to the other type of cells (TH-2) cellsfor reasons that are not well understood. These cells activate another important part of immune system,known as humoral immune system. This system produces antibodies against the inhaled allergens.later when human again expose to these allergens the antibodies recognize these allergens and activate the humoral response. The result of this is airway inflammation.bronchoconstriction,and increase mucous production. INITIAL ASSESSMENT AND DIAGNOSIS OF ASTHMA A careful medical history Physical examination Pulmonary function tests History of any of the following Cough, worse at night Recurrent wheeze Recurrent difficulty in breathing Recurrent chest tightness Reversible airflow limitation as measured by using a peak flow meter.

PULMONARY FUNCTION TESTING Spirometry measurements (FEV1, FVC, FEV1/FVC) before and after bronchodialator helps determine whether there is airflow obstruction and whether it is reversible over the short term Forced Vital Capacity (FVC), forced expiratory volume in 1 second (FEV1) PFT (Pulmonary Function Test) FEV (forced expiratory volume) ratio of FEV1 to FVC The volume of air that can be forced out taking a deep breath, an important measure of pulmonary function PFR (Peak flow rate) The maximum flow rate that can be forced during expiration FVC : Forced Vital Capacity (FVC) is the volume of air that can forcibly be blown out after full inspiration, measured in liters. DIAGNOSTIC TESTING Be used to diagnose asthma in every patient. Diagnostic trial of anti-inflammatory medication (preferably corticosteroids) or an inhaled bronchodilator Especially helpful in very young children unable to cooperate with other diagnostic testing There is no one single test or measure that can definitively

BRONCHOPROVOCATION Bronchoprovocation with methacholine, histamine, or exercise challenge may be useful when asthma is suspected and spirometry is normal or near normal. Chest x-ray (to exclude other diagnosis) Allergy testing Evaluation of the nose for nasal polyps and sinuses for sinus disease. Evaluation for gastroesophageal reflux.

TREATMENT OF ASTHMA 1.Long-acting beta2-agonists (LABA) Beta2-receptors are the predominant receptors in bronchial smooth muscle Stimulate ATP-cAMP which leads to relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity Inhibits release of mast cell mediators such as histamine, leukotrienes, and prostaglandin-D2 2.Short-acting beta2-agonist ATP to cAMP leads to relaxation of bronchial smooth muscle, inhibition of release of mediators of immediate hypersensitivity from cells, especially mast cells Prior to exercise or known exposure to triggers Up to every 4 hours during acute exacerbation 3.Inhaled Corticosteroids Anti-inflammatory Not intended to be used as rescue medication Benefits may not be fully realized for 1-2 weeks Preferred treatment in persistent asthma 4.Mast cell stabilizers (cromolyn/nedocromil) Inhibits release of mediators from mast cells (degranulation) after exposure to specific antigens Blocks Ca2+ ions from entering the mast cell Safe for pediatrics (including infants) Should be started 2-4 weeks before allergy season when symptoms are expected to be effective Can be used before exercise (not as good as ICS) Alternate med for persistent asthma 5.Leukotriene receptor antagonists Leukotriene-mediated effects include Airway edema Smooth muscle contraction Altered cellular activity associated with the inflammatory process Receptors have been found in airway smooth muscle cells and macrophages and nasal mucosa 6.Theophylline Narrow therapeutic index/Maintain 5-20 mcg/mL Variability in clearance leads to a range of doses that vary 4-fold in order to reach a therapeutic dose MECHANISM OF ACTION Smooth muscle relaxation (bronchodilation) Suppression of the response of the airways to stimuli Increase force of contraction of diaphragmatic muscles Interacts with many other drugs Step-wise pharmacotherapy treatment program for varying severities of asthma Mild Intermittent (Step 1) Mild Persistent (Step 2) Moderate Persistent (Step 3) Severe Persistent (Step 4) Patient fits into the highest category that they meet one of the criteria for Mild Intermittent Asthma Day time symptoms < 2 times q week Night time symptoms < 2 times q month

 PEF or FEV1 > 80% of predicted PEF variability < 20% PEF and FEV1 values are only for adults and for children over the age of 5 Mild Persistent Asthma Day time symptoms > 2/week, but < 1/day Night time symptoms < 1 night q week PEF or FEV1 > 80% of predicted PEF variability 20%-30% Moderate Persistent Asthma Day time symptoms q day Night time symptoms > 1 night q week PEF or FEV1 60%-80% of predicted PEF variability >30% Severe Persistent Asthma Day time symptoms: continual Night time symptoms: frequent PEF or FEV1 < 60% of predicted PEF variability > 30%

EMERGENCY MANAGEMENT OF ASTHMA Prehospital Care Supplemental oxygen and Inhaled bronchodilators. The latter treatment most often involves Inhaled beta2-agonists given by hand-held nebulizer or using a metered-dose inhaler (mdi) with spacer. If these delivery devices are not available, subcutaneous epinephrine or terbutaline can be given for severe exacerbations Emergency Department Care The mainstay of ED therapy for acute asthma is inhaled beta2-agonists. The most effective particle sizes are 1-5 m

Standard delivery systems and routes are as follows: Salbutamol 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed. Dilution of 2.5 mg in 3-4 ml of saline or use of premixed nebules is standard. Oxygen or compressed air delivery of the inhaled beta-agonists should be at a rate of 6-8 l/min. For children: Use 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses then 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed. An equivalent method of beta-agonist delivery in mild-to-moderate exacerbations is the MDI used in conjunction with a spacer or holding chamber For severe exacerbations : Nebulizer or mdi can be used the dose is 4-8 puffs every 20 minutes up to 4 hours, then every 1-4 hours as needed. For children this method is reserved for severe asthma at an albuterol dose of 0.5 mg/kg/h Respond poorly or not at all to an inhaler Parenteral beta 2-agonists, such as 0.25 mg terbutaline or 0.3 mg of 1:1000 concentration of epinephrine administered subcutaneously. This treatment should be reserved for patients who are seriously ill and not responding to serial treatments with inhaled beta-agonist/anticholinergic therapy and other more established therapies. Ipratropium 0.5 mg has had variable benefit in controlled trials demonstrating most consistent efficacy in children and smokers with comorbid COPD Intravenous magnesium sulfate has been shown to be beneficial. Doses: The usual dose is 2 g over 20 minutes Heliox is a helium-oxygen (80:20 or 70:30) mixture that may provide dramatic benefit for patients with severe exacerbations. Helium is about 25% as dense as room air and, consequently, it travels more easily down narrowed passages. This property makes heliox of particular value to patients at risk of intubationby quickly decreasing the work of breathing and, when the gas mixture is used to drive the nebulizer, by better delivery of the inhaled bronchodilator Despite the best efforts, some patients will require endotracheal intubation MANAGEMENT OF ASTHMA Educate patients to develop a partnership in asthma management Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible Avoid exposure to risk factors Establish medication plans for chronic management in children and adults Establish individual plans for managing exacerbations Provide regular follow-up care

DRUG
Prednisone

DOSING
Adult dose: 40-60 mg PO Ped dose: 1-2 mg/kg PO qd (maximum 60 mg/d) for 3- 10 d Adult 2.5-5 mg via hand-held nebulizer or metered-dose inhaler (MDI) with spacer q20min for 3 doses Pediatric 0.15 mg/kg (minimum dose 2.5 mg) Adult Nebulizer: 0.5 mg q20min fo3 doses then prn MDI: 8 puffs q20min pr up to 3 h Pediatric Nebulizer: 0.25-5 mg q20mi for 3 doses, then prn MDI: 4-8 puffs q20min up t 3h

INTERACTION

CONTRAINDICATION

estrogens may decrease clearance; Documented concurrent use with digoxin may cause ypersensitivity;. viral, h digitalis toxicity secondary fungal, connective to hypokalemia phenobarbital, tissue, or tubercular phenytoin, skin infections; peptic and rifampin may increase ulcer disease; hepatic metabolism dysfunction; GI disease Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, or sympathomimetic agents Drugs with anticholinergic properties, such as dronabinol, may increase toxicity Documente hypersenstivity

Salbutamol

Ipratropium (Atrovent)

Documente hypersenstivity

Theophylline Adult Carbamazepine (Aminophylline) Loading dose: 6 mg/kg lean Fluconazole body weight IV over 20-30 min Ketoconazole Drip (1 g in 250 mL D5W) 0.5- Varapamil 0.7 mg/kg/h IV Azithromycin Pediatric Clarithromycin. 1 mg/kg/h IV Dosing carbamazepine

Documented hypersensitivity; uncontrolled arrhythmias; peptic ulcers; hyperthyroidism; uncontrolled seizure disorders

PATIENT COUNSELLING Relaxing in order to breathe more easily is not easy in a situation where fear, anxiety, and anger are natural feelings. But it can be done with practice: Start by sitting comfortably in a chair. Do not lie down. Relax shoulders and neck. Concentrate on not gasping for air while dropping shoulders. Breathe in slowly through your nose. Concentrate. Purse your lips together tightly and blow out slowly through mouth. Take as much time as possible to exhale in this way. Relax. Keep using the pursed-lip breathing until the breathless feeling goes away. Rest between breaths if feel dizzy.

Inhalers: Many of the drugs given to prevent and treat asthma are inhaled. Several different inhaler devices are available to suit the needs of different people with different kinds of asthma. The basic kinds of inhaler delivery systems available for adults with asthma are: Metered-dose inhaler Metered-dose inhaler with spacer Dry powder inhaler Nebulizer The Peak Flow Meter Peak flow measurements provide a very simple way of measuring how quickly air can be forced out of the lungs How do I use the peak flow meter?Have an empty mouth...no gum or food. Stand up, if possible. Set the meter at "zero." Hold the meter correctly, so fingers don't get in the way. Take a really deep breath, Close lips around the mouthpiece, with the tongue out of the way. Blow as hard and fast as possible. The arrow will move until it points to a number on the scale. This is the peak flow number. Make a note of the peak flow value next to the indicator (or the zone color on the meter Repeat the entire process two more times and write down best of three numbers in the daily record chart.

What Do The Numbers Mean?

Zone
Green Yellow Red

Reading
71- 100% normal PFR 50- 70% normal PFR <50% PFR of of

Description
Asthma is under good control. Indicates caution. It may mean respiratory airways are narrowing and additional medication may be required Indicates a medical emergency. Severe airway narrowing may be occurring and immediate action needs to be taken. This would usually involve contacting a doctor or hospital.

normal

Asthma action plan: A list of the triggers responsible for asthma and how to avoid them. A list of peak flow meter readings and zones based on personal best. A list of routine symptoms such as coughing, wheezing, tightness in the chest, shortness of breath, and excess mucus production, and what should be done if these symptoms occur. What should be done if nighttime asthma symptoms awaken you. A list of more serious asthma symptoms such as decreased effectiveness of your reliever medicine and breathlessness, and what you should do if these symptoms occur. The name and dose of the preventer medication that needs to be taken, even when there are no symptoms, and the name and dose of the reliever medication that needs to be taken when you are having an asthma attack. Emergency telephone numbers and locations of emergency care. Instructions about when to contact doctor, and a list of where to get emergency treatment. Information about asthma organizations and support groups.