Management of Acute Asthma

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Management of Acute Asthma

• Ri ???
• Date 12/24/2007

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Asthma

• Chronic Inflammatory disorder of bronchi
  characterized by Episodic, reversible
  bronchospasm resulting from an exaggerated
  bronchoconstrictor response (hyperreactivity) to
  various stimuli (allergy)
• Hyperreactivity ? obstruction of airways,
  severity widely variable in the same individual
• Affects 10 of children 5-7 adults

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Asthma? airway obstruction, hyperinflation, and
airflow limitation Airway remodeling
Subepithelial fibrosis, Sm m. hypertrophy,
submucosal gl hypertrophy, airway wall thickening
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Emergency Department Management

• History-- Recent ER visit, current oral
  corticosteroid use ? AE-- Previous resp.
  failure, progressive worsening of symptoms,
  seizures with asthma attacks ? severe,
  potentially fatal asthma

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Emergency Department Management

• PE-- Resp. distress at rest, difficulty in
  speaking in sentences, diaphoresis, agitation--
  RRgt28, HRgt110, pulse paradoxusgt25 mmHg-- Use of
  accessory muscles ? severe airflow obstruction--
  Presence of SCM / suprasternal retractions ?
  impairment in lung function

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Asthma Attack Evolution
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Thorax 200762447-458
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Thorax 200762447-458
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Thorax 200762447-458
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ICU Management

• Pt simply require additional time for resp.
  function to improve
• In the past, mainstay of Rx for pt progressing
  to resp. failure from asthma was intubation and
  mechanical ventilation
• Alternatives to intubation
• NIPPV (Noninvasive Positive Pressure Ventilation)
  
• Inhaled general anesthetics
• Continuation of pharmacotherapy

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NIPPV

• Potentially beneficial effects result from
• Reduction in the increased work of breathing
• Decrease in inspiratory threshold load
• Demonstrated significant reductions in PaCO2
  early in pt with AA
• Improved lung function and decreased
  hospitalization rate

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NIPPV

• Successful use first identified pt as high
  risk, pt education, coordination with breathing
  circuit
• If with only marginal improvement, removal may
  precipitate rapid deterioration
• Initial ventilator setting
• PEEP 5 cmH2O
• Pressure support 8 cmH2O

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NIPPV

• With largest possible ETT
• Mechanical ventilation follows cardiorespiratory
  collapse in approximately 20 of episodes
• Pulmonary hyperinflation, hypovolemia, sedation
• ? Slowly bagging (Apnea test), intravascular
  fluid supplement, sedation for synchronization of
  pt with ventilation
• If pt not improve with slow manual bagging?
  tension pneumothorax s/b considered

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Sedatives and Neuromuscular Blockers

• Usually concurrent opiate, morphine or fentanyl,
  is required for adequate sedation
• Avoid NM blocker in pt with asthma
• Post-paralytic myopathy
• Can be avoided if adequate sedatives and
  analgesics are given

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Take Home Message

• Determine the severity of attack? gauge the
  response to treatment
• Initial Rx with oxygen, nebulised ß-agonist and
  oral corticosteroid is sufficient
• NIPPV or ventilator may be required prior to
  treatment to optimize therapeutic outcome

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Thank you for the attention!