Managing Asthmatic Attacks Christopher H. Fanta, M.D. Partners - - PDF document

Managing Asthmatic Attacks

Christopher H. Fanta, M.D.

Partners Asthma Center Brigham and Women’s Hospital Harvard Medical School

Objectives

• Consider strategies for prevention of severe

asthmatic attacks.

• Discuss treatments for asthmatic attacks that

require emergency care.

• Address patient education opportunities prior

to discharge home.

Case History: Chief Complaint

• Five days after developing an upper

respiratory infection, a 35-year old woman with long-standing asthma presented to the Emergency Department with severe shortness

• f breath and wheezing.

Case History: Recent History

• Her 3-year old son and then her husband had

come down with similar “colds.” With her illness, she had progressively worsened despite increasing her inhaled budesonide from 4 to 8 inhalations/day. Last night she slept little due to cough and wheezing.

Case History: Physical Exam

• In the Emergency Department she appeared

in respiratory distress. RR 28/min with accessory muscle use. BP 140/70 mm Hg with 20 mm Hg paradoxical pulse. HR 112/min, regular. T 99.1o F. Chest: diffuse

• insp. and exp. wheezes.
• PEFR = 150 L/min (33% of normal).

The Best Management Is Prevention

“Treatment of status asthmaticus is best started 3 days prior to the attack.”

• - Thomas Petty, M.D

Preventive Strategies

• Early recognition of deterioration
• Prompt patient-provider communication
• Written “asthma action” plan
• Intensification of anti-asthma medications,
• ften including a short course of oral

corticosteroids

Patient Assessment

• History
• Physical exam
• Peak flow determination
• (Chest X-ray)
• (Arterial blood gases)

Principles of Care for Acute Asthma

• Principal goal: rapid reversal of airflow
• bstruction
• Repetitive administration of inhaled beta-

agonists (+ ipratropium bromide)

• Early addition of systemic corticosteroids
• Correction of hypoxemia
• Close monitoring, including serial measurements
• f lung function

Treatment of Acute Asthma: Overview

Problem Treatment

• Bronchoconstriction

Frequent inhaled beta-agonist bronchodilator

• Airway swelling and

Systemic mucus plugging corticosteroids

Initial Treatment

• Nebulized albuterol 2.5 mg every 20 minutes
• Alternatives:
• Albuterol by MDI with spacer 4 puffs every 10 min
• Continuous nebulization of albuterol
• Nebulized albuterol 5 mg every 20 min.
• Nebulized levalbuterol 1.25 mg every 20 min

MDI and Nebulizer Equivalence

Turner JR, et al., Chest 1988 Time (min)

30 60 90 30 60 90 0.4 0.8 1.2 1.6

MDI (n=27) Neb (n=28)

10 2 6 8 4

Dyspnea (Borg scale) FEV1 (L)

30 60 90

Patterns of Response to Albuterol

Strauss L, et al. Am J Respir Crit Care Med 1997; 155:454.

Additional Bronchodilators in Acute, Severe Asthma

• Ipratropium bromide
• Magnesium sulfate
• 2 gm i.v. over 20 min
• Additional sympathomimetics
• Epinephrine 0.3 mg s.c.
• (Intravenous montelukast)

Steroids in Acute, Severe Asthma

• Systemic steroids (tablets/liquid, intramuscular,

intravenous) speed the resolution of asthma attacks and reduce the likelihood of recurrences (“relapses”).

• Inhaled steroids begun at the time of ED

discharge decrease the likelihood of recurrent attacks.

Oral vs. Intravenous Corticosteroids

When given in comparable doses, there is no difference in efficacy between oral and intravenous corticosteroids for acute, severe asthma.

Systemic Steroids for Hospitalized Patients

• Oral prednisone 40 – 80 mg/day
• Exception: vomiting or other GI

intolerance

The Outpatient “Steroid Burst”

• No specific schedule proven better than

another

• Taper not necessary if treatment continued

until lung function has recovered to normal or near-normal

• Risk of recurrent asthmatic symptoms reduced

by use of inhaled steroids

The Outpatient “Steroid Burst”

• One example: prednisone 40 mg/day for 4

days; 30 mg/day for 4 days, 20 mg/day for 4 days; 10 mg/day for 4 days

• Oral steroids can be administered once daily

Antibiotics for Acute, Severe Asthma

• Empiric antibiotics of no proven benefit

in hospitalized patients with acute attacks

Other Therapies of Unproven/Unlikely Benefit

• Hydration
• Chest physiotherapy
• Mucolytics
• Antihistamines

Controversial Therapies in Acute, Severe Asthma

• Helium-oxygen gas mixture
• CPAP/Non-invasive mask ventilation

Indications for Intubation and Mechanical Ventilation

• Respiratory arrest/agonal respirations
• Acute respiratory acidosis (PCO2 >55 mm Hg;

pH <7.28) in patient:

• Who is in respiratory distress;
• Whose PCO2 is rising despite aggressive treatment;
• r
• Who cannot or will not cooperate with
• ther therapies

Patients at High-Risk for Severe Attacks

• On daily prednisone prior to admission
• >2 E.D. visits in last 6 months
• >1 prior hosp’ns in last 12 months
• Ever intubated for asthma
• Severe psychosocial problems

Patient Education Prior to Hospital Discharge

• Proper use of inhalers
• Indications for different medications
• Use of spacers
• Peak flow monitoring
• Individualized “asthma action plan”
• Discussion of environmental control issues

Conclusions

• Early intervention (by patients and providers)

can often prevent asthmatic attacks from becoming severe.

• Key elements of treatment of asthmatic attacks

are intensive use of inhaled beta-agonist bronchodilators plus systemic corticosteroids.

Conclusions

• Peak flow monitoring is useful in assessing the

severity of attacks and response to treatment.

• An asthmatic attack represents a “teachable

moment” for the asthma educator, with

• pportunities to improve patient

understanding and co-management skills.