Term
acute or subacute episodes of progressively worsening:
shortness of breath
cough
wheezing
chest tightness
progressively worsening lung function documented by decrease in expiratory airflow:
FEV1
PEF
Objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms, however may not be attainable |
|
Definition
| definition of an asthma exacerbation |
|
|
Term
asthma attack prevalence:
greater with females
greater with Puerto Ricans and American Indians
greater in children aged 0-17 years
asthma ED visits:
similar between males and females
greater with AA
greater with children aged 0-17
asthma hospitalizations:
greater with females
greater with AA
greater with children aged 0-17 years |
|
Definition
| epidemiology trends of asthma attack prevalence, asthma ED visits, asthma hospitalizations |
|
|
Term
| none: any person with asthma is at an increased risk or mortality |
|
Definition
| which asthma classification (severe, moderate, mild) is at greatest risk for mortality? |
|
|
Term
ASTHMA HISTORY
history of severe exacerbations (ICU admission/intubation)
>/= 2 hospitalizations in previous year
> 3 ER visits in previous year
using > 2 canisters of SABA per month
poor understanding of asthma symptoms/severity
SOCIAL HISTORY
low socioeconomic status
inner-city residence
illicit drug use
major psychosocial problems
COMORBIDITIES
cardiovascular disease
other chronic lung disease
chronic psychiatric disease |
|
Definition
| risk factors for increased asthma mortality |
|
|
Term
[image]
Early Asthmatic Response:
related to the release of mast cell mediators and macrophages
mediators include: histamine, prostaglandins, leukotrienes, platelet activating factor
immediate effects on bronchial smooth muscle leads to bronchospasm
begins in minutes and lasts about 2 hours
PRIMARY DISORDER IS BRONCHOCONSTRICTION
Late Asthmatic Response:
caused by an increase in: inflammatory mediators, eosinophils, CD4+ T cells, neutrophils, macrophages
T-cell activation leads to release of Th2 cells
begins 6-9 hours after an exposure and takes hours to resolve
PRIMARY DISORDER IS INFLAMMATION
MAY SEE BIMODAL PHASE OF SYMPTOMS
DROP IN FEV1 TWICE IN AN ASTHMA ATTACK |
|
Definition
| early asthmatic response and late asthmatic response |
|
|
Term
EAT
E = environment
A = adherence
T = technique |
|
Definition
| what 3 things should always be assessed before initiating treatment for an acute asthma attack? |
|
|
Term
MILD
signs and symptoms:
dyspnea only with activity (assess tachypnea in young children)
breathlessness while walking
talks in sentences
respiratory rate increased
usually no use of accessory muscles
moderate wheezing, often only end expiratory
pulse < 100
PCO2 < 42
SaO2 > 95%
initial PEF or FEV1:
PEF >/= 70% predicted or personal best |
|
Definition
| signs and symptoms and initial PEF or FEV1 of a mild acute asthma exacerbation |
|
|
Term
usually cared for at home
prompt relief with inhaled SABA
possible short course of oral systemic corticosteroids |
|
Definition
| clinical course of a mild asthma exacerbation |
|
|
Term
MODERATE
signs and symptoms:
dyspnea interferes with or limits usual activity
breathlessness while at rest (infant - softer, shorter cry, difficulty feeding)
talks in phrases
respiratory rate increased
commonly use of accessory muscles
wheeze is loud throughout exhalation
pulse 100-120
PCO2 < 42
SaO2 90-95%
initial PEF or FEV1:
PEF 40-69% predicted or personal best |
|
Definition
| signs and symptoms and initial PEF or FEV1 for a moderate asthma exacerbation |
|
|
Term
usually requires office or ED visit
relief from frequent inhaled SABA
oral systemic corticosteroids
some symptoms last for 1-2 days after treatment is begun |
|
Definition
| clinical course for a moderate asthma exacerbatiion |
|
|
Term
SEVERE
signs and symptoms:
dyspnea at rest, interferes with conversation
breathlessness while at rest (infant - stops feeding)
talks in words
respiratory rate often DECREASED
usually use of accessory muscles
wheeze usually loud throughout inhalation and exhalation
pulse > 120
PCO2 > 42, possible respiratory failure
SaO2 < 90%
initial PEF or FEV1:
PEF < 40% predicted or personal best |
|
Definition
| signs and symptoms and initial PEF or FEV1 for a severe asthma exacerbation |
|
|
Term
usually requires ED visit and likely hospitalization
partial relief from frequent inhaled SABA
oral systemic corticosteroids
some symptoms last for > 3 days after treatment is begun
adjunctive therapies are helpful |
|
Definition
| clinical course for a severe asthma exacerbation |
|
|
Term
LIFE THREATENING
signs and symptoms:
too dyspneic to speak, perspiring
drowsy or confused
ABSENCE OF WHEEZE
BRADYCARDIA
PCO2 > 42, possible respiratory failure
SaO2 < 90%
initial PEF or FEV1:
PEF < 25% predicted or personal best |
|
Definition
| signs and symptoms and initial PEF or FEV1 for a life threatening asthma exacerbation |
|
|
Term
requires ED/hospitalization; possible ICU
minimal or no relief from frequent inhaled SABA
IV corticosteroids
adjunctive therapies are helpful |
|
Definition
| clinical course for a life threatening asthma exacerbation |
|
|
Term
correct hypoxemia
O2 SATUREATION SHOULD BE ABOVE 90%
reverse airway obstruction:
repetitive or continuous SABA (to counteract early asthma response - bronchoconstriction)
systemic corticosteroids in moderate-severe exacerbations or failed response to SABA (helps with obstruction and inflammation)
reduce the potential for relapse/recurrence by intensifying therapy |
|
Definition
| treatment goals of an acute asthma exacerbation |
|
|
Term
oral corticosteroids - prolong duration
ICS - double the dose for one week
doubling the ICS is not effective at reducing the severity or preventing progression of exacerbations but will help decrease further exacerbations
schedule SABA - for several days |
|
Definition
| what is intensifying therapy? |
|
|
Term
written action plan
early recognition or worsening PEF
intensification of therapy (short course systemic corticosteroids, increase ICS, schedule SABA)
removal of allergic or irritant precipitants
communication between patient and clinician about symptoms/PEF, decreased responsiveness to SABA |
|
Definition
| early treatment of asthma exacerbation |
|
|
Term
large liquid volumes
breathing warm moist air
using OTC products such as antihistamines, cold remedies (need to be able to monitor the cough of an asthma patient), bronchodilators |
|
Definition
| acute asthma exacerbation treatments that should be avoided |
|
|
Term
education on self-monitoring and action plan are essential
treatment:
increase SABA frequency
initiate oral corticosteroids as defined by action plan
seek medical attention when:
severe asthma exacerbation
lack of rapid, sustained improvement with therapy
further deterioration |
|
Definition
| home management of asthma exacerbation |
|
|
Term
obtain brief history:
time of onset and severity of symptoms
precipitation factors
current medications and time of last dose
prior ER, hospitalization, intubation (in past year)
concurrent disease states
physical exam:
respiratory rate, heart rate
lung sounds, use of accessory muscles
identify complications (pneumothorax, pneumonia) or associated comorbidities (sinusitis)
rule out upper airway obstruction (epiglottitis, vocal cord dysfuction)
functional assessment (avoid is life threatening):
PEF - before and after bronchodilator therapy
increase risk of respiratory failure if initial PEF < 25% predicted and improves < 10% post SABA
pulse oximetry
labs:
ABG - increased risk of respiratory failure if NORMAL CO2 (may indicate respiratory failure b/c respiratory drive is typically increased in asthma exacerbations)
CBC
CXR |
|
Definition
| ER assessment of an asthma exacerbation |
|
|
Term
FEV1 for PEF >/= 40%
TREATMENT
oxygen to achieve SaO2 >/= 90%
inhaled SABA by NEBULIZER OR MDI with valved holding chamber, up to 3 doses in first hour
oral systemic corticosteroids if no immediate response or if patient recently took oral systemic corticosteroids |
|
Definition
| classification and treatment of mild to moderate asthma exacerbation in hospital ED |
|
|
Term
FEV1 or PEF < 40%
TREATMENT
oxygen to achieve SaO2 >/= 90%
HIGH DOSE inhaled SABA PLUS IPRATROPIUM by NEBULIZER OR MDI plus valved holding chamber, EVERY 20 MINUTES OR CONTINUOUSLY FOR 1 HOUR
oral systemic corticosteroids |
|
Definition
| classification and treatment of severe asthma exacerbation in hospital ED |
|
|
Term
FEV1 or PEF < 25%
TREATMENT
intubation and mechanical ventilation with 100% oxygen
NEBULIZED SABA PLUS IPRATROPIUM
IV CORTICOSTEROIDS
consider adjunctive therapies
ADMIT TO HOSPITAL ICU |
|
Definition
| classification and treatment of impending or actual respiratory arrest in hospital ED |
|
|
Term
FEV1 or PEF 40-69% predicted
physical exam: moderate symptoms
TREATMENT
inhaled SABA every 60 minutes
ORAL systemic corticosteroids
continue treatment 1-3 hours, provided there is improvement; make admit decision in < 4 hours |
|
Definition
| after 1 hour of initial treatment in hospital ED a patient with a moderate exacerbation has what FEV1 and what treatment? |
|
|
Term
FEV1 or PEF < 40% predicted
physical exam: severe symptoms at rest, accessory muscle use, chest retraction
history: high-risk patient
no improvement after initial treatment
TREATMENT
oxygen
NEBULIZED SABA PLUS IPRATROPIUM hourly or continuously
ORAL systemic corticosteroids
consider adjuntive therapies |
|
Definition
| after 1 hour of initial treatment in hospital ED a patient with a severe exacerbation has what FEV1 and what treatment? |
|
|
Term
| initial FEV1 or PEF at 1 hour after initial treatment |
|
Definition
| strongest predictor of hospitalization in adults |
|
|
Term
good response:
FEV1 or PEF >/= 70%
response sustained 60 minutes after last treatment
no distress
physical exam normal |
|
Definition
| when can a patient be discharged home after an asthma exacerbation? |
|
|
Term
FEV1 or PEF 40-69%
mild to moderate symptoms
TREATMENT
ADMIT TO HOSPITAL WARD
oxygen
inhaled SABA
systemic (oral or IV) corticosteroid
consider adjunctive therapies
monitor vital signs: FEV1 or PEF, SaO2
if improvement, discharge home |
|
Definition
patient in ED is found to have an incomplete response after asthma exacerbation treatment.
what is the classification and treatment? |
|
|
Term
FEV1 or PEF < 40%
PCO2 >/= 42
physical exam: symptoms severe, drowsiness, confusion
TREATMENT
oxygen
inhaled SABA HOURLY OR CONTINUOUSLY
IV CORTICOSTEROIDS
consider adjunctive therapies
possible intubation and mechanical ventilation
if improvement, may be discharged home |
|
Definition
patient in ED is found to have a poor response after asthma exacerbation treatment.
what is the classification and treatment? |
|
|
Term
continue treatment with inhaled SABAs
continue course of systemic oral corticosteroids
continue ICS. for those not on long-term controller therapy, consider initiation of an ICS
patient education: review medications, including inhaler technique and whenever possible environmental control measures; review/initiate action plan; recommend close medical follow up
BEFORE DISCHARGE, SCHEDULE FOLLOW-UP APPOINTMENT WITH PCP AND/OR ASTHMA SPECIALIST IN 1-4 WEEKS |
|
Definition
| discharge instructions following asthma exacerbation |
|
|
Term
relieve hypoxemia
recommended for treatment of significant hypoxemia or patients with FEV1 or PEF < 40% predicted
maintain SaO2 > 90% |
|
Definition
|
|
Term
RECOMMENDED FOR ALL
role: relieve airflow obstruction
route: MDI or nebulized in equivalent doses
NEBULIZER FOR LIFE-THREATENING EXACERBATIONS!
repetitive or continuous treatments given until control achieved
3 treatments spaced every 20-30 minutes or continuous nebulization (usually patients respond to this initial treatment in the ED and will be sufficient for discharge) |
|
Definition
|
|
Term
RECOMMENDED FOR MOST
mild exacerbations that respond to SABA do NOT need systemic corticosteroids
role: reverse and suppress airway inflammation
route: IV/IM or PO therapy
IV for life-threatening, oral for everyone else
pulse therapy preferred:
DOSE: 1 mg/kg/day in 1-2 divided doses (DNE 60 mg/day for child or 80 mg/day for adult)
duration: until PEF reaches 70% predicted; from ER 5-10 days; from hospital 3-10 days
high dose ICS versus systemic is controversial
doubling the dose of ICS is not effective, multiple high doses of an ICS may be beneficial if given early |
|
Definition
| role of systemic corticosteroids |
|
|
Term
magnesium
IV or nebulized
ADE: hypotension; MONITOR BP!
recommended for patients who remain severe after 1 hour or intensive conventional therapy
interferes with Ca transport, causes bronchodilation
heliox-driven albuterol therapy
recommended for patient who remain severe after 1 hour of intensive conventional therapy
anticholinergics:
for patients with severe exacerbation or life-threatening
not FDA approved
in ER - produces additional bronchodilation, resulting in fewer hospital admissions
at home/in hospital - no significant benefit |
|
Definition
| other therapies used to reduce risk of intubation in asthma exacerbation |
|
|
Term
symptom improvement is gradual
moderate exacerbation takes 1-2 days
severe exacerbation takes >/= 3 days
continue more intensive treatment (scheduled SABA, systemic corticosteroid, increased dose of ICS) for several days |
|
Definition
| expected symptom improvement for moderate and severe asthma exacerbations |
|
|
Term
1) educate on purpose of each asthma medication
2) instruct on proper inhaler technique
3) monitor asthma medication use and refill history
4) encourage physician consult regarding OTC asthma medication use
5) educate on use of peak flow meters
6) help increase understanding of action plan |
|
Definition
| pharmacist's role in asthma management |
|
|
