E-Med exam 1 - Acute asthma and Status Asthmaticus

chronic inflammatory d/o. inc responsiveness of the airways bc of multiple stimuli. inflammation causes recurrent wheezing, breathlessness, chest tightness, and coughing, usually at night or in early am.

asthma

the pathophysiologic hallmark of asthma

reduction of airway diameter bc of smooth muscle contraction, vascular congestion, bronchial wall edema, thick secretions. this is bc of an accumulation of eosinophils, lymphocytes, mast cells, etc that all inc inflammation.

exaggerated airway response to variety of external exposures

acute asthma

what are some triggers for acute asthma

viral URI, exercise, environmental, occupational exposures, ASA, beta blockers, NSAIDs (COX1 inhibitor = overproduction of leukotrienes to inc inflammatory response). also endocrine factors like pregnancy or perimenstral asthma, emotions

majority of acute asthma is triggered by

viral URIs

thigns to ask acute asthmatic pt

coughing, wheezzing, chest tightness, fever (maybe its triggered from PNA), pattern of attacks, HPI. is this how your acute asthma usually presents? cig smoking, steroids, meds. ***has ur asthma ever req you to be in the hospital and have you ever been intubated? done to know reactivity of their condition

what to look for when a pt with acute asthma presents to the ER

assess for use of accessory muscles (abdominal retraction, ICS muscles or abdominal muscles, supraclavicular muscles). look to see if they can speak in a full sentence. pulsus paradoxus, level of consciousness. also look at vitals, auscultate (you shlould hear wheezing, if severe airflow obstruction then you hear no wheezing), obstructions.

what do you see on a PE in a pt with acute asthma

tachypnea, tachycardia, o2 sat. auscultation can show wheezing but isn’t a marker of airflow obstruction. silent chest without wheezing = severe airflow obstruction. also look for other illness like an upper airway obstruction from foreign bodies and vocal cord dysfunction. also nasal mucosal swelling, increased secretions, and polyps (allergic sx)

sampter’s triad of aspirin exacerbated respiratory disease (AERD)

asthma, nasal polyps, intolerance of aspirin or NSAIDs

how to workup for asthma

pulse ox, ABG needed if they have severe asthma, inc CO2 and resp acidosis indicates impending respiratory failure, you need to intervene. you aren’t blowing out enough CO2 and then pts get lethargic bc they hold a lot of CO2. called CO2 narcosis.

what can an EKG show you in pt with asthma

right ventricle strain, abnl P waves, or nonspecific ST and T wave abnormalities that resolve with treatment. cardiac monitoring in older pts and in coexisting heart dz pts.

what is the preferred initial therapy for acute bronchospasm

SABAs like albuterol or levalbuterol given via inhalation nebulizer back to back. provides good bronchodilation and vasodilation. it inhibits the mediator release that causes inflammation

most common SE of SABAs

skeletal muscle tremor.

after you gave pt SABA nebulizers for acute asthma what do you do

give CCS 1 hr when arrival. PO prednisone or IV methylprednisone. send pts home on prednisone for 5-10 days OR PO dexamethasone for 2 days

how do anticholinergics help asthma pts

CCS act on small airways and anticholinergics act on large airways. ipratropium bromide given in combo with albuterol in neb, given in ER.

side effects of anticholinergic drugs

dry af. tachy, irritable, blurry vision

how do we know to discharge an asthma pt

their peak flow machine is >70%

how do we know to keep an asthma pt in the ED

if their peak flow meter or FEV is <40%

how to counsel a pt with acute asthma when they are about to be discharged

schedule a follow up with your PCP or asthma specialist in 1-4 wks. educate on asthma triggers and discuss the meds they’re taking home

pts acute asthma is getting worse and isn’t improving with the usual doses of bronchodilators and CCS. hypoxemia, tachypnea, tachycardic, accessory muscle use, wheezing OR pt is not wheezing and you hear no air in chest.

status asthmaticus

acute severe asthma sx

RR >30, labored breathing and accessory muscle use, can’t speak in full sentences, tripoding, can’t lie flat, paradoxical breathing, where the abdomen and chest move at the same time.

worsening hypoxemia in a pt with acute severe asthma indicates what

mmucus plugging or atelectasis bc of respiratory failure

bradycardia in a pt with acute severe asthma indicates what

impending respiratory arrest

how to tx status asthmaticus

once all other meds are exhausted (3 albuterol ipratropium nebs, PO or IV CCS), then give mag sulfate to bronchodilate by blocking Ca channels, so that airways open and expand. it is anti inflammatory bc it dec inflammation in airways by stabilizing mast cells and T cells, and inc nitric oxide production.

when using magnesium make sure to montior

BP and deep tendon reflexes during administration, bc HoTN or neuromuscular blockade can happen. this is why it’s only used in status asthmaticus

RR >30 , gave all meds for asthma and it didn’t work.

give magnesium

what do you give to a pt that failed all tx including Magnesium

Noninvasive positive pressure ventilation (BiPAP). different pressures depending on if you’re inhaling or exhaling. highest at inhalation and low at exhalation.

why not CPAP for acute asthma

gives the pt too much air. bc they have narrow airways, it can trap air leading to overinflation causing inc pressure leading to lung injury (barotrauma) and pneumothorax. and bc asthma pts can’t fully exhale, adding more air to their lungs can make their exhalation even worse when the air gets trapped

how to tx status asthmaticus

BiPAP and ketamine. mechanical ventilation if pt has progressive hypercarbia or acidosis

pt is lethargic after recieving asthma tx what do oyu do

intubate cannot BIPAP. if a pt is on a BIPAP they need to be conscious.

how does ketamine help status asthmaticus

promotes bronchodilation. good for pts that are likely to need intubation

if pt has hypercarbia (inc co2, i can’t exhale the CO2 causing resp acidosis) and now pt is tired and confused what do you do

need to intubate. doesn’t fix the airflow obstruction, but reduces work of breathing and lets pt rest while the other meds relieve the obstruction. while intubated give IV steroids and Mg or nebulizer.

tx pathway for mild-moderate acute asthma

bronchodilators with ipratropium, dose of CCS, then reassess. if peak flow >70 good to go. if you hear wheezing still and bad peak flow <40% give magnesium. if its better still send home w steroids. if not getting better and inc work of breathing BIPAP. if on BIPAP and you’re nodding off then you need to intubate them.