Acute Severe Asthma Exacerbation

exacerbations

can be life-threatening andcan occur in patients at ANY level of asthma severity (intermittent, or mild, moderate, orsevere persistent asthma)

prevention of life-threatening asthmaby early recognition of signs of deterioration and early intervention

What is the goal in asthma tx?

reliever ICS/form or ICS/SABA asthma action plan

-Do not have to increase maintenance

-Just continue and give prn of reliever

SABA reliever asthma action plan

-Quadruple ICS Maintenace for 1-2 weeks

-For SABA reliever give 2 inhalation every 4-6hours

common exacerbation triggers

-Viral resp infection (rhino, influenza, adeno, pertussis, RSV)

-Allergen exposure (grass pollen, soybean dust, fungal spores)

-Food allergy

-Outdoor air pollution

-Seasonal changes and/or returning to school in fall

-Poor adherence with ICS

asthma related risk factors for death

-History of near-fatal asthma requiring intubation and mechanical ventilation

-Hospitalization or emergency care in past year

-Current or recent use of oral corticosteroids

-No current use of ICSs

-Poor medication adherence

-Overuse of SABA (more than 1 canister per month)

-History of psychiatric disease or psychosocial problems

-Lack of written asthma action plan

-Food allergy in patient with asthma

-Comorbidities like PNA, diabetes, and arrhythmias

exam and assessments for asthma exacerbations

-Lung function in adults if possible

-Oxygen sats by pulse oximetry

-ABGs-poor response

-Chest xray if infection suspected or foreign body aspiration

93-95%

What is the Oxygen goal for most?

94-98%

What is the oxygen goal for school aged kids and pregnancy and those with heart disease?

DPI

not used for acute severe asthma exacerbations due to higher inspiratory flows required for adequate drug delivery

infants and kids < 5 yrs old

-Will need pMDI w/ spacer or facemask and not mouthpiece for delivery

-Greater risk of respiratory failure

-Treat w/ 2-6 puffs of albuterol every 20 minutes for 3 doses with reassessment at end of treatment

primary tx of acute severe asthma exacerbations

-oxygen

-repetitive or continuous SABA and inhaled ipratropium

-systemic corticosteroids IV or PO

oxygen

reverses hypoxemia

repetitive or continuous SABA and inhaled ipratropium

reverse airway constriction rapidly

ipratropium

severe exacerbations; ED setting

weight based

Albuterol is ___________ dosing.

-Magnesium sulfate

-Epinephrine

-Terbutaline

-Ketamine

-Aminophylline/theophylline

-heliox

What are some adjunctive therapies for exacerbations?

electrolytes

What should you monitor during acute severe asthma exacerbations?

SABA

-can decrease: K, Mg, Phos

-increase HR

SABA and systemic corticosteroids

can lead to elevation in glucose and lactic acid

-Reverse cholinergic mediated bronchoconstriction

-b/c different mechanism can combine w/ SABA

Why should you add a SAMA to SABA for acute exacerbation?

Magnesium

-bronchodilator and relaxes smooth muscle and may have anti-inflammatory effects

-FEV1 < 25-50% predicted upon arrival in ED

-children/adults with persistent hypoxemia after standard tx

-children whos FEV1 remains < 60% after 1 hr of standard tx

AEs of Magnesium

hypotension, facial flushing, sweating, depressed deep tendon reflex, hypothermia, cardiac or CNS or respiratory depression

discharge after acute severe asthma exacerbation

-ICS (prefer MART)

-duration of systemic steroids are 3-7 days

-follow up btw 2-7 days post discharge

-referral to specialist