Asthma

Topics: Asthma, Myocardial infarction, Chronic obstructive pulmonary disease Pages: 26 (555 words) Published: April 4, 2015
Asthma in Emergency
setting
St. Georges Hospital Emergency
Department
Cezar Darwiche FY1

Asthma
 Chronic inflammatory disease of the

airways

 Episodic cough, wheezing, dyspnea
 Type I hypersensitivity reaction (Ag cross

links IgE on pre-sensitized mast cells and
basophils triggering release of vasoactive
amines)

Types







Extrinsic
- Onset in childhood
-Triggered by inhaled allergen exposure:
Dust mites
Cockroaches
Cat antigen
Molds and pollens

Types
 Intrinsic

Early adulthood
• Triggered by viral infections, nonspecific
irritants
• Obesity risk factor


Types
 Exercise-induced

Bronchospasm lasting 10-20 mins after
exercise
• Triggered by drying/ cooling of airways
• Requires prophylaxis


Types
 Triad Asthma

Samter’s Syndrome
• Asthma
• Nasal polyps
• Aspirin or NSAID sensitivity


Types
 Cough-variant asthma

May present with cough in absence of
wheezing
• One of the 3 most common causes of
chronic cough (GERD, postnasal drip)


Types
 Occupational asthma

“Monday morning” symptoms which abate
during weekends
• Worse in the evening after work
• Commonly epoxy resins, plastics and
rubber, metals, lab animals


Types










Refractory asthma
Chronic unremitting
Chronic exposure
B-blockers (even Timolol eye drops)
Aspirin containing drugs
GERD
Fungal infections
ABPA
Churg-strauss

Types









Disorders that mimic asthma
Congestive heart failure
Mitral stenosis
Laryngeal tumors
Subglottic stenosis
Wegener’s
Vocal cord dysfunction
Left atrial enlargement with vagus impingement

Diagnosis
 History of wheezing with specific triggers
 Obstructive lung disease on PFTs that

normalize when asymptomatic
 DLCO normal between episodes
 Negative Methacoline challenge test
effectively rules out asthma

Treatment
 Goals

Avoid symptoms
• Minimize use of short-acting
bronchodilators
• Prevent nocturnal awakening
• Minimize side-effects


Treatment
 Four components

Monitor symptoms and pulmonary function
• Control environmental exposures
• Educate patient on trigger avoidance and
treament
• Drugs


Emergency management
 Acute severe asthma

Peak flow (PEF) 33-50% best or predicted
• RR>25/min
• HR>110/min
• Inability to complete sentences in 1 breath


Emergency management










Life threatening asthma
Peak flow (PEF) Cyanosis
Bradycardia, arrthymia, hypotension
Confusion, coma

Emergency management








Management
Sit patient up (beware COPD exacerbation)
High flow O2 (100% non-rebreathing)
High dose nebulized B2 agonist (salbutamol
5mg or terbutaline 10mg)
WITH nebulized anticholinergic (Ipratropium
Bromide 0.5mg) for acute severe or life
threatening
Here given as Combivent

Emergency management
 Management

Corticosteroids
• Prednisolone 40-60mg PO
• Or Hydrocortisone 100mg IV
• Consider IV Aminophylline if poor
response


Emergency management
 Obtain CXR if:






Suspected pneumothorax
Suspected consolidation
Life-threatening asthma
Failure to respond satisfactorily
Requirement for ventilation

Emergency management
 If improving

40-60% O2
• prednisolone 40-50mg/ 24hrs PO
• Nebulized salbutamol every 4hrs
• Monitor peak flow


Emergency management
 If not improving after 15mins

Continue 100% O2
• Repeat steroids
• Salbutamol nebulizers every 15min or
10mg continuous per hour
• Ipratropium 0.5mg every 4-6hrs


Emergency management
 If patient still not improving at >30mins

Consider MgSO4 1.2-2g IV over 20mins
• Aminophylline IV
• Transfer to ICU for ventilation


Emergency management
 Monitoring

Repeat PEF 15-30mins after treatment
• Pulse oximetry monitoring maintain SaO2
>92%
• ABG within...
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