ACUTE SEVERE
ASTHMA /COPD
• The definition of severe asthma requires that one or
both of the following levels of treatment for the
previous year has been needed to prevent asthma from
becoming uncontrolled or asthma that remains
uncontrolled despite this level of treatment:
• Treatment with GINA step 4-5 Asthma high dose inhaled
glucocorticoids and long acting beta agonist or leuckotriene modifier
for the previous year
• Treatment with systemic glucocotcoids for more than 50 percent of
the year
CLASSIFICATION OF ASTHMA
SEVERITY
• Proposed definitions of asthma severity – The Global
Initiative for Asthma (GINA) and an American Thoracic
Society research committee have questioned the distinction
previously made between "intermittent" and "persistent"
asthma as lacking in biologic basis and evidence This
dichotomy may have provided false reassurance that
patients with infrequent symptoms were at low risk of
exacerbations. These issues, among others, have led to the
following recommended definitions of asthma severity
• Mild asthma – Defined by minimal symptoms and minimal
risk of exacerbations in patients who are not using inhaled
therapies, who are using reliever therapy alone, or who are
using low-dose inhaled glucocorticoids along with reliever
therapy
• Moderate asthma – Defined by good asthma control with
medium-dose inhaled glucocorticoids or low-medium-dose
inhaled glucocorticoids with additional controller therapies.
• Severe asthma – Defined by asthma requiring high-dose
inhaled glucocorticoids with additional controller agents to
maintain good control
• By these retrospective definitions, asthma severity can only
be assessed after achieving good control and stepping
down therapy to find the minimum effective controller
therapy (or unless asthma remains uncontrolled despite
maximized therapy).
• Assessment of asthma symptom control and risk of exacerbations
• DAY TIME SYMPTOMS MORE THAN TWICE/PER WEEK
• ANY NIGHT AWAKENING DUE TO ASTHMA
• SABA RELIVER NEEDED MORE THAN TWICE /WEEK
• ANY ACTIVITY LIMITATION DUE TO ASTHMA
• WELL CONTROLLED –HAVING NON OF ABOVE
• PARTIALLY CONTROLLED HAVING 1 OR 2 FEATURES
• POORLY CONTROLLED 3 OR 4 OF ABOVE
RISK FACTORS FOR POOR
OUTCOMES
• Medications: ICS not prescribed; poor adherence; incorrect
inhaler technique; high SABA use
• Comorbidities: obesity; chronic rhinosinusitis; gastroesophageal
reflux disease; confirmed food allergy; anxiety; depression;
pregnancy
• Exposures: smokingΔ; allergen exposure if sensitized; air pollution
• Setting: major socioeconomic problems
• Lung function: low FEV1, especially if <60% predicted; higher
reversibility
• Other tests: sputum/blood eosinophilia; elevated FENO in allergic
adults on IC
CLINICAL FEATURES
• Signs of a severe exacerbation
• Tachypnea (>30 breaths/min)
• tachycardia >120 beats/min
• use of accessory muscles of inspiration
• Diaphoresis
• inability to speak in full sentences or phrases,
• inability to lie supine due to breathlessness
• pulsus paradoxus
• primary goals of therapy for acute severe asthma are the
rapid reversal of airflow limitation and the correction, if
necessary, of hypercapnia or hypoxemia.
• Inhaled beta agonist: give albuterol 2.5 to 5 mg by
nebulization every 20 minutes for three doses, then 2.5 to 5
mg every one to four hours as needed, or give 4 to 8 puffs
by metered dose inhaler (MDI) with spacer every 20 minutes
for three doses, then every one to four hours as needed.
• Oxygen: give sufficient oxygen to maintain SpO2 ≥92%
(>95% in pregnancy
• IV: establish intravenous access; give IV boluses of isotonic
saline if patient is dehydrated due to reduced intake and
prolonged episode
• Ipratropium bromide: give 500 mcg by nebulization every
20 minutes for 3 doses OR 4 to 8 puffs by MDI with spacer
every 20 minutes for 3 doses; then may administer
additional doses hourly as needed for up to 3 hours
• Systemic glucocorticoids: for patients with impending
respiratory failure, give methylprednisolone 60 to 125 mg IV.
For the majority of less severe asthma exacerbations, give
prednisone 40 to 60 mg orally; alternatives include:
dexamethasone 6 to 10 mg IV or hydrocortisone 150 to 200
mg IV; glucocorticoids may be given IM or orally if IV access
is unavailable.
• Magnesium sulfate: give 2 g (8 mmol) IV over 20 minutes
for life-threatening exacerbations and severe exacerbations
that are unimproved after one hour of intensive
bronchodilator therapy
• Additional treatments
• Epinephrine: for patients suspected of having an
anaphylactic reaction or unable to use inhaled
bronchodilators for severe asthma exacerbation, give
epinephrine 0.3 to 0.5 mg IM (eg, 0.3 to 0.5 mL of 1 mg/mL
[may be labeled 1:1000] solution) into the mid-outer thigh
(vastus lateralis muscle); if needed can repeat every 20
minutes for up to 3 doses; give epinephrine OR terbutaline
but not both
• The decision to intubate during the first few minutes of a
severe asthma attack is clinical.
• Slowing of the respiratory rate,
• depressed mental status,
• inability to maintain respiratory effort,
• or severe hypoxemia suggests the patient requires
intubation.
Other therapies for LIFe threatning
asthma
• Noninvasive ventilation (NIV) is increasingly used in patients
with severe asthma exacerbations in hopes of avoiding
invasive mechanical ventilation, although its role in asthma
is not as well studied as in chronic obstructive pulmonary
disease (COPD) and heart failure.
• A short trial of NIV may be appropriate in cooperative
patients not responding to medical therapy who do not
require immediate intubation.
• Nonstandard therapies — Modalities, such as anesthetic
agents (eg, ketamine, isoflurane), enoximone (available in
Europe), helium-oxygen mixtures, extracorporeal membrane
oxygenation (ECMO), and rarely parenteral beta-agonists,
may be helpful in individual patients, but cannot be
recommended for routine use due to insufficient evidence
of efficacy.
In Patient care and discharge
• Medications — In general, inpatient management of
asthma exacerbations is a continuation of emergency
department or intensive care unit treatment, followed by a
transition to a regimen close to their discharge regimen
• The majority of patients improve over the next 24 to 48
hours as inhaled short-acting beta-agonists (SABAs) are
gradually tapered from hourly to every four to six hours and
a transition is made to use of metered dose inhalers
• Systemic glucocorticoids are continued; if intravenous
administration was given initially, a transition to oral therapy
is generally made as soon as the patient is able to take
medications orally
Failure to respond to therapy
• Viral bronchitis and bronchiolitis, such as with influenza or
respiratory syncytial virus, and less commonly other
infectious bronchitis (eg, Mycoplasma
pneumoniae, Chlamydia pneumoniae, Bordetella pertussis) can
provoke severe and prolonged airway inflammation.
• Bronchiectasis (including allergic bronchopulmonary
aspergillosis), rhinosinusitis, and pneumonia can intensify
asthmatic symptoms and delay recovery.
• Patients with underlying chronic airflow obstruction (asthma
with irreversible airflow obstruction and asthma-chronic
obstructive pulmonary disease [COPD] overlap) may clear
airway secretions and inflammation more slowly due to
structural airway abnormalities
• Gastroesophageal reflux (GER) may intensify asthmatic
symptoms and delay recovery. In general, patients will
report symptoms of GER, such as heartburn or
regurgitation, although some patients will attribute chest
tightness to asthma when it is actually caused by GER.
• cardiac dysfunction with volume overload, especially heart
failure with a preserved ejection fraction, can mimic asthma
and may be difficult to diagnose.
• Other processes such as disseminated
• strongyloidiasis,
• pulmonary thromboembolism
• , eosinophilic granulomatosis with polyangiitis (Churg-
Strauss syndrome),
• oropharyngeal aspiration, and
• tracheobronchomalacia are less common reasons for
failure to improve.
INEFFECTIVE THERAPIES
•
Leukotriene receptor antagonists – Leukotriene receptor
antagonists are an established therapy for chronic asthma and
are continued during an exacerbation (for those patients
already on this therapy), but a systematic review did not find
sufficient evidence to support acute initiation of these
medications at the time of an exacerbation . do not administer
leukotriene receptor antagonists as part of routine treatment of
acute exacerbations, except in patients whose exacerbation was
triggered by ingestion of aspirin or a nonsteroidal anti-
inflammatory drug (NSAID), events associated with dramatic
overproduction of leukotrienes.
• Methylxanthines – The use of intravenous methylxanthines (eg,
theophylline, aminophylline), once the standard of care for severe
asthmatic attacks, has been shown to be relatively ineffective and is
no longer recommended in this setting
• Empiric antibiotics – Clinical practice guidelines
recommend against empiric antibiotic therapy for the
treatment of an asthma exacerbation, because most
respiratory infections that trigger an exacerbation of
asthma are viral rather than bacterial
EXACERBATION OF COPD
• exacerbation of chronic obstructive pulmonary disease
(COPD) as "an event characterized by dyspnea and/or cough
and sputum that worsens over ≤14 days,
• which may be accompanied by tachypnea and/or
tachycardia and is often associated with increased local and
systemic inflammation caused by airway infection, pollution,
or other insult to the airways"
Severity of exacerbation
• Mild – Dyspnea <5 on a visual analog (1-10) scale (VAS);
respiratory rate <24 breaths per minute;
• heart rate <95 beats per minute;
• resting SaO2 ≥92 percent breathing ambient air or the
patient's usual oxygen prescription and change in
saturation ≤3 percent from baseline (if known);
• CRP<10 mg/L (if obtained).
• Treatment with short-acting bronchodilators is often
sufficient for mild exacerbations
• Moderate – Three out of five of the following:
• Dyspnea ≥5 on VAS;
• respiratory rate ≥24 breaths per minute,
• heart rate ≥95 beats per minute;
• resting SaO2 <92 percent breathing ambient air or the
patient's usual oxygen prescription and/or change in
saturation >3 percent from baseline (if known);
• CRP ≥10 mg/L (if obtained).
• Treatment of moderate exacerbations generally includes
short-acting bronchodilators plus antibiotics and/or oral
glucocorticoids
• Severe –
• Meets moderate criteria combined with hypercapnia and
acidosis on ABG (PaCO2 >45 mmHg and pH <7.35).
• Treatment of severe exacerbations includes,
• short-acting bronchodilators,
• antibiotics, and oral or
• intravenous glucocorticoids.
• Severe exacerbations may be associated with respiratory
failure and require noninvasive or invasive ventilation
DIFFERENTIAL DIAGNOSIS
• Heart failure
• Cardiac arrhythmias
• Pneumonia
• Pneumothorax
• Pulmonary embolism
• MILD –Treated with short acting bronchodilators
• MODERATE- SABA ,steroids and antibiotics
• SEVERE-Patient Require visit to emergency room
CRITERIA FOR HOSPITAL ADMISSION
• Inadequate response to outpatient or emergency department
management
• Onset of new signs (eg, cyanosis, altered mental status, peripheral edema)
• Marked increase in intensity of symptoms over baseline (eg, new onset
resting dyspnea) accompanied by increased oxygen requirement
• Signs of respiratory distress (use of accessory respiratory muscles or
paradoxical chest wall movements, or both)
• Serious comorbidities including pneumonia, cardiac arrhythmia, heart
failure, diabetes mellitus, renal failure, or liver failure
• Hemodynamic instability
• Insufficient home support
EMERGENCY DEPARTMENT AND
HOSPITAL MANAGEMENT
• For patients who are admitted to the hospital, the severity of the
exacerbation is classified based on clinical signs
• No respiratory failure –
• Respiratory rate ≤24 breaths per minute;
• heart rate (HR) <95 beats per minute;
• no use of accessory respiratory muscles;
• no change in mental status;
• pulse oxygen saturation (SpO2) 88 to 92 percent with Venturi
mask 24 to 35 percent inspired oxygen (or equivalent);
• no hypercapnia
Acute nonlife-threatening
respiratory failure
• Respiratory rate >24 breaths per minute;
• use of accessory muscles of respiration;
• no change in mental status;
• SpO2 88 to 92 percent with Venturi mask 24 to 35 percent
(or equivalent);
• arterial tension of carbon dioxide (PaCO2) 50 to 60 mmHg or
increased over baseline
Acute life-threatening
respiratory failure
• Respiratory rate >24 breaths per minute;
• use of accessory muscles of respiration;
• acute change in mental status;
• requiring fraction of inspired oxygen (FiO2) ≥40 percent to
maintain SpO2 88 to 92 percent;
• PaCO2 increased compared with baseline or >60 mmHg or
associated with acidosis (pH ≤7.25).
PHARMACOTHERAPY SEVERE but
NOT LIFE THREATNING COPD
• Inhaled beta agonist:
• Combine with Short acting muscarinic antagonist
• Consider Using long acting bronchodilator when patient is
stable
• consider oral or Intravenous glucocorticoid
• Antibiotic therapy*: Appropriate for majority of severe COPD
exacerbations; based on likelihood of particular pathogens
• No Pseudomonas risk factor(s)¶:
• Ceftriaxone 1 to 2 grams IV,
• or cefotaxime 1 to 2 grams IV,
• or levofloxacin 500 mg IV or orally,
• or moxifloxacin 400 mg IV or orally
• Pseudomonas risk factor(s)¶: Piperacillin-tazobactam 4.5 grams
IV, or cefepime 2 grams IV, or ceftazidime 2 grams IV
• Antiviral therapy (influenza suspected)*: Oseltamivir 75 mg
orally every 12 hours or peramivir 600 mg IV once (for
patients unable to take oral medication).
• Magnesium sulfate — For patients who present with a
severe exacerbation that is not responding promptly to
short-acting inhaled bronchodilators, magnesium sulfate (2
g infused over 20 minutes). Intravenous magnesium sulfate
has bronchodilator activity thought to arise from inhibition
of calcium influx into airway smooth muscle cells
Monitoring
Perform continual monitoring of oxygen saturation, blood pressure, heart rate, respiratory rate.
Close monitoring of respiratory status.
Continuous ECG monitoring.
Monitor blood glucose.
INDICATIONS FOR RESPIRATORY OR
MEDICAL ICU
• SEVERE DYSPONEA THAT NORT RESPONDING TO INITIAL MEDICAL
THERAPY
• CHANGES IN MENTAL STATUS –CONFUSION,LETHARGY .COMA
• PERSISTING WORSENING HYPOXEMIA Pao2 -40mmhg, Woresning
respiratory acidosis
• Need for invasive ventilation
• Hemodynamic instability
Indications For non invasive
Mechanical Ventilation
• At least one of the following
• Respiartory acidosis Paco2 more than 45mmhg/ PH less than 7.35
• Severe Dysponea with respiratory muscle fatigue increased work of
breathing- use of accessory muscle for respiration retraction of
intercostal muscles
• Persistanat hypoxemia despite 02 threapy
INDICATIONS FOR INVASIVE
VENTILATION
• Unable to tolerate NIV or NIV failure
• Post respiratory or cardiac arrest
• Diminshed Consciousness with psychomotor agitation
• Massive aspiration or persistant Vomiting
• Severe Ventricular or supra ventricular Arrhytmias
• Severe hemodynamic instability without respond to fluids or
vasoactive substances
