Acute severe Asthma case presentation

Acute severe Asthma case
presentation
February 2016
SIGN 141 • British guideline on the
management of asthma 2014
By Rania elashkar
Queens Belfast university

History
Patient 30 years old female own pets ,diagnosed with
asthma since she was 8 years old
medication history : an inhaled corticosteroid in
combination with a LABA , theophylline, an
anticholinergic agent and an inhaled short-acting β2
agonists. patients best peak flow at the clinic is 405
L/minute. admitted to hospital with an acute asthma
exacerbation. had two other admissions for asthma in
the last few months
Symptoms increasing wheeze, cough, yellow sputum and
chest tightness. PF 150 L/minute,.

Examination on admission at hospital
 HIGH respiratory rate of 30/min
 HIGH pulse rate of 145/ minute
(60 pulse)
 peak flow of 100 L/minute.
 LOW PO2 of 8.4kPa (12-14
kPa)
 HIGH PCO2 of 7.2kPa (4.5-6.0
kPa)
 decreased pH 7.29 Normal
(7.35-7.45)

Features of acute severe asthma
• Peak expiratory flow (PEF) 33-50% of best
(use % predicted if recent best unknown)
• Can’t complete sentences in one breath
• Respirations ≥25 breaths/min
• Pulse ≥110 beats/min

• Blood gas markers of a life threatening
attack:
• ‘Normal’ (4.6-6 kPa, 35-45 mmHg) PaCO2
• Severe hypoxia: PaO2 <8 kPa
• Low PH

IMMEDIATE TREATMENT
• ƒOxygen to maintain SpO2 94-98%
• ƒSalbutamol 5 mg or terbutaline 10 mg via
an oxygen-driven nebuliser
• Ipratropium bromide 0.5 mg via an oxygen-
driven nebuliser
• Prednisolone tablets 40-50 mg or IV
hydrocortisone 100 mg

IMMEDIATE TREATMENT
IF LIFE THREATENING FEATURES ARE
PRESENT:
• Discuss with senior clinician and ICU team
•Consider IV magnesium sulphate 1.2-2 g infusion
over 20 minutes (unless already given)
• Give nebulised β2 agonist more frequently e.g.
salbutamol 5 mg up to every 15-30 minutes or 10 mg
per hour via continuous nebulisation (requires special
nebuliser)

SUBSEQUENT MANAGEMENT
IF PATIENT IS IMPROVING continue:
•Oxygen to maintain SpO2 94-98%
•Prednisolone 40-50mg daily or IV hydrocortisone 100 mg 6
hourly
•Nebulised β2 agonist and ipratropium 4-6 hourly
IF PATIENT NOT IMPROVING AFTER 15-30 MINUTES:
•Continue oxygen and steroids
•use continuous nebulisation of salbutamol at 5-10 mg/hour if
an appropriate nebuliser is available. Otherwise give
nebulised salbutamol 5 mg every 15-30 minutes
•Continue ipratropium 0.5 mg 4-6 hourly until patient is
improving

SUBSEQUENT
MANAGEMENT
IF PATIENT IS STILL NOT IMPROVING:
•Discuss patient with senior clinician and ICU
team ƒ
•Consider IV magnesium sulphate 1.2-2 g
over 20 minutes (unless already give
• Senior clinician may consider use of IV β2
agonist or IV aminophylline or progression to
mechanical ventilation

MONITORING
• Repeat measurement of PEF 15-30 minutes after starting
treatment
• Oximetry: maintain SpO2 >94-98%
• repeat blood gas measurements within 1 hour of starting
treatment if: - initial PaO2 92% - PaCO2 normal or raised -
patient deteriorates
• Chart PEF before and after giving β2 agonists and at least
4 times daily throughout hospital stay
Transfer to ICU accompanied by a doctor prepared to
intubate if:
Deteriorating PEF, worsening or persisting hypoxia, or
hypercapnea ƒExhaustion, altered consciousness Poor
respiratory effort or respiratory arrest

DISCHARGE
• discharge medication for 12-24 hours and
inhaler technique checked and recorded
• PEF >75% of best or predicted and PEF
diurnal variability
• Treatment with oral & inhaled steroids
&bronchodilators.
• Own PEF meter & written asthma action
plan
• Follow up within 2 days & 4 weeks RC

Features that increase the
probability of asthma
 symptoms: wheeze, breathlessness, chest
tightness and cough,
 symptoms worse at night / in the early
morning , exercise, allergen exposure and cold
air , taking aspirin or beta blockers
 History of atopic disorder , Family history of
asthma and/or atopic disorder
 low FEV1 or PEF

Factors that Exacerbate Asthma
 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
© Global Initiative for Asthma

Patients at risk of developing
near-fatal or fatal asthma
• previous near-fatal asthma
• previous admission for asthma
• requiring three or more classes of asthma
medication
• heavy use of β2 agonist
• adverse behavioural or psychosocial
features

Is it Asthma?
 Recurrent episodes of wheezing
 Troublesome cough at night
 Cough or wheeze after exercise
 Cough, wheeze or chest tightness after
exposure to airborne allergens or
pollutants
 Colds “go to the chest” or take more than
10 days to clear

Asthma Diagnosis
 History and patterns of symptoms
 Measurements of lung function
- Spirometry
- Peak expiratory flow
 Measurement of airway responsiveness
 Measurements of allergic status to identify risk
factors

Typical Spirometric (FEV1)
Tracings
11
Time (sec)
22 33 44 55
FEV1
Volume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements

Measuring Variability of Peak
Expiratory Flow

Measuring Airway
Responsiveness

VIDEO ON HOW TO USE peak
flow and spirometry

1. Develop Patient/Doctor
Partnership
2. Identify and Reduce Exposure
to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma
Exacerbations
5. Special Considerations
Asthma Management and Prevention
Program: Five Components

Asthma Management and Prevention Program
Goals of Long-term Management
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including
exercise
 Maintain pulmonary function as close to
normal levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma
medications
 Prevent asthma mortality

Asthma Management and
Prevention Program
 Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
 Early intervention to stop exposure to the
risk factors that sensitized the airway may
help improve the control of asthma and
reduce medication needs.
.

Asthma Management and
Prevention Program
 Although there is no cure for asthma,
appropriate management that includes
a partnership between the physician
and the patient/family most often
results in the achievement of control

Part 1: Educate Patients to
Develop a Partnership
 Guidelines on asthma management
should be available but adapted and
adopted for local use by local asthma
planning teams
 Clear communication between health
care professionals and asthma patients
is key to enhancing compliance

Component 1: Develop
Patient/Doctor Partnership
 Educate continually
 Include the family
 Provide information about asthma
 Provide training on self-management skills
 Emphasize a partnership among health
care providers, the patient, and the patient’s
family

Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENT
Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need
to step up your treatment.
HOW TO INCREASE TREATMENT
STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.
Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL
If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical help.

Factors Involved in Non-Adherence
Medication Usage
 Difficulties associated
with inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Cost
 Distance to pharmacies
Non-Medication Factors
 Misunderstanding/lack of
information
 Fears about side-effects
 Inappropriate expectations
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication

 Reduce exposure to indoor allergens
 Avoid tobacco smoke
 Avoid vehicle emission
 Identify irritants in the workplace
 Explore role of infections on asthma
development, especially in children and
young infants

The goal of asthma treatment, to
achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional

Levels of Asthma Control
(Assess patient impairment)
Assessment of Future Risk (risk of exacerbations, instability, rapid
decline in lung function, side effects)

Assess Patient Risk
Features that are associated with increased
risk of adverse events in the future include:
 Poor clinical control
 Frequent exacerbations in past year
 Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke, high
dose medications

Assessment of Future Risk
Risk of exacerbations, instability, rapid decline
in lung function, side effects
Features that are associated with increased
risk of adverse events in the future include:
 Poor clinical control
 Frequent exacerbations in past year
 Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke, high
dose medications
Any exacerbation should
prompt review of maintenance
treatment

preventer Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists in combination
with inhaled glucocorticosteroids
 Systemic glucocorticosteroids
 Theophylline
 Cromones
 Anti-IgE

Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (µg) Medium Daily Dose (µg) High Daily Dose (µg)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-
200
600-1000 >200-400 >1000 >400
Budesonide-Neb
Inhalation Suspension
250-
500
500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-
750
>1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-
200
>250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-
200
> 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-
800
>1000-2000 >800-1200 >2000 >1200

Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists

Shaded green - preferred controller options
TO STEP 3 TREATMENT,
SELECT ONE OR MORE:
TO STEP 4 TREATMENT,
ADD EITHER

controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCEINCREASE

Acute severe Asthma case presentation

Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
preventer treatment (step 2 or higher)
Treating to Achieve Asthma
Control

Step 2 – Reliever medication plus a single
preventer
 A low-dose inhaled glucocorticosteroid is
recommended as the initial preventer
treatment for patients of all ages (Evidence
A)
 Alternative preventor medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
Control

Step 3 – Reliever medication plus one or two
preventer
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
Control

Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
Control

Step 4 – Reliever medication plus two or more
preventer
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
Control

Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist (Evidence B)
Control

Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)

Treating to Maintain Asthma Control
 When control as been achieved,
ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient

Stepping down treatment when asthma is controlled
 When controlled on medium- to high-
dose inhaled glucocorticosteroids: 50%
dose reduction at 3 month intervals
(Evidence B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)

Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
(Evidence B)
 If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)

Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or long-
acting inhaled β2-agonist
bronchodilators provide temporary
relief.
 Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy

Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
 Doubling the dose of inhaled glucocortico-
steroids is not effective, and is not
recommended (Evidence A)

Component 4: Manage Asthma
Exacerbations
 Exacerbations of asthma are episodes of
progressive increase in shortness of breath,
cough, wheezing, or chest tightness
 Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
 Severe exacerbations are potentially life-
threatening and treatment requires close
supervision

Exacerbations
Treatment of exacerbations depends on:
 The patient
 Experience of the health care professional
 Therapies that are the most effective for
the particular patient
 Availability of medications
 Emergency facilities

Exacerbations
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled
β2-agonist
• Early introduction of systemic
glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function

Acute severe Asthma case presentation

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Editor's Notes