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NEAR FATAL ASTHMA

NEAR FATAL ASTHMA. DANIEL A. NADER, D.O., F.C.C.P., F.A.C.P. NEAR FATAL ASTHMA. 5,000 DEATHS PER YEAR LIFE THREATENING ATTACKS MORE COMMON AFRICAN-AMERICANS, WOMEN, INNER-CITY PATIENTS AT GREATEST RISK LARGELY PREVENTABLE, MAY OCURR IN ANY ASTHMATIC. PREDISPOSING RISK FACTORS.

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NEAR FATAL ASTHMA

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  1. NEAR FATAL ASTHMA DANIEL A. NADER, D.O., F.C.C.P., F.A.C.P.

  2. NEAR FATAL ASTHMA • 5,000 DEATHS PER YEAR • LIFE THREATENING ATTACKS MORE COMMON • AFRICAN-AMERICANS, WOMEN, INNER-CITY PATIENTS AT GREATEST RISK • LARGELY PREVENTABLE, MAY OCURR IN ANY ASTHMATIC

  3. PREDISPOSING RISK FACTORS • PRIOR SEVERE ATTACKS (ESPICIALLY THOSE REQUIRING ASSISTED VENTILATION) • NONADHERANCE TO THERAPY • AGE > 40 YEARS • TOBACCO SMOKING

  4. RISK FACTORS • INADEQUATE USE OF INHALED STEROIDS • HOSPITALIZATION DESPITE CHRONIC ORAL STEROID USE • PSYCHIATRIC ILLNESS • RECREATIONAL DRUG AND ALCOHOL ABUSE • DIMINSHED ABILITY TO SENSE AND RESPOND TO AIRWAY OBSTRUCTION

  5. RISK FACTORS • FREQUENT USE OF BETA AGONIST DRUGS • INDEPENDENT RISK FACTOR • FREQUENT USE IDENTIFIES POORLY CONTROLLED DISEASE

  6. PATHOPHYSIOLOGY • MUCOUS PLUGGING • VASCULAR DILATATION • AIRWAY EDEMA • DESQUAMATION OF AIRWAY EPITHELIAL CELLS • BRONCHIAL SMOOTH MUSCLE HYPERTROPHY • INFLAMMATORY CELLULAR INFILTATE

  7. PATHOPHYSIOLOGY • DEATH FROM ASPHYXIA • MUCOUS PLUGGING, BRONCHOCONSTRICTION, AIRWAY EDEMA • HYPERINFLATION, AIR TRAPPING • HYPOXIA: V/Q MISMATCH • HYPERCARBIA: RESPIRATORY MUSCLE FATIGUE

  8. CLINICAL PRESENTATION • VIRAL URI’S • HEAVY ALLERGEN EXPOSURE • NONADHEARANCE TO THERAPY • AIR POLLUTION • WEATHER CHANGE • EMOTIONAL STRESS • DRUGS: ASPIRIN, BETA BLOCKERS

  9. CLINICAL PRESENTATION • 90% PRESNET AFTER SEVERAL DAYS OF WORSENING SYMPTOMS • 10% RAPID DETERIORATION IN MINUTES OR HOURS

  10. CLINICAL PRESENTATION • DYSPNEIC, ANXIOUS, DIAPHORETIC • SITTING UPRIGHT • TACHYCARDIC, TACHYPNEIC • WHEEZING TO ABSENT BREATH SOUNDS • USE OF ACCESSORY MUSCLES

  11. LABORATORY • ELEVATED WBC • INCREASED EOSINOPHILES • INCREASED LACTIC ACID • ABG VARIABLE

  12. CHEST RADIOGRAPH • HYPERINFLATION • EXCLUDE INFILTRATES, PULMONARY VASCULAR CONGESTION • PNEUMOTHORAX, PNEUMOMEDIASTINUM

  13. HYPERINFLATION

  14. PEAK FLOWS • USUALLY < 30 TO 50% OF PATIENT’S PERSONAL BEST • USE CARE IN PERFORMING PEAK FLOW AS IT MAY WORSEN BRONCHOSPASM • FAILURE TO IMPROVE PF AFTER 30 MINUTES OF TREATMENT USUALLY REQUIRES HOSPITALIZATION

  15. DIFFERENTIAL DIAGNOSIS • CHF • PE • COPD • VOCAL CORD DYSFUNCTION • HYPERVENTIALTION • ACUTE BRONCHITIS/PNEUMONIA • UPPER AIRWAY OBSTRUCTION

  16. ICU ADMISSION • RESPIRATORY ARREST • DEPRESSED MENTAL STATUS • ARRHYTHMIA • INTENSITY OF TREATMENT • INCREASED FRQUENCY OF NEBULIZED BETA AGONIST SIGNIFIES A PATIENT AT RISK FOR DETERIORATION

  17. MANAGEMENT • BRONCHODILATORS • OXYGEN • CORTICOSTEROIDS • ADJUNCT THERAPY • MECHANICAL VENTIALTION

  18. BRONCHODILATORS • ALBUTEROL 2.5MG NEBULIZED EVERY 20 MINUTES • AIRWAY NARROWING ADVERSLY AFFECTS THE DOSE-RESPONSE CURVE AND DURATION OF ACTION • CONTINOUS NEBULIZTION IS AS EFFECTIVE AS BOLUS NEBULIZATION

  19. BRONCHODIALTORS • IPRATROPIUM 0.5 MG COMBINED WITH ALBUTEROL PROVIDES IMPROVED BRONCHODILATION • THEOPHYLLINE HELPFUL WHEN PATIENT NOT RESPONDING TO BETA AGONIST AND STEROIDS

  20. THEOPHYLLINE • 5 MG/KG LOADING DOSE FOLLOWED BY CONTINOUS INFUSION AT 0.4 TO 0.7 MG/KG/HOUR • ANTI-INFLAMMATORY • IMPROVES MUCOCILIARY CLEARANCE • DIAPHRAGMATIC MUSCLE FUNCTION • ACCESSORY MUSCLE FUNCTION • RIGHT VENTRICULAR PERFORMANCE

  21. CORTICOSTEROIDS • ORAL AS EFFECTIVE AS INJECTABLE • METHYLPREDNISOLONE 40 TO 125 MG EVERY 6 HOURS • LOW DOSE AS EFFECTIVE AS HIGH DOSE • PREDNISONE 40 TO 50 MG DAILY UNTIL CLINICAL RESPONSE, THEN TAPER

  22. ADJUNCT THERAPY • HELIOX: 80:20, 70:30, LESS DENSE GAS MAY ASSIST VENTILATION. AIRFLOW ACROSS NARROWED AIRWAYS IS LAMINAR AND LESS TURBULENT • MAY BUY SOME TIME

  23. ADJUNCT THERAPY • MAGNESIUM 2 GRAMS OVER 20 MINUTES • MAY INTERFERE WITH CALCIUM MEDIATED SMOOTH MUSCLE CONTRACTION • TOXIC LEVELS MAY PRECIPITATE HYPOTENSION AND LOSS OF DEEP TENDON REFLEXES

  24. ADJUNCT THERAPY • LEUKOTRIENE RECEPTOR ANTAGONISTS MAY BE HELPFUL • FURTHER STUDIES NEEDED BEFORE THEY CAN BE RECOMMENDED IN NEAR FATAL ASTHMA

  25. ADJUNCT THERAPY • OXYGEN • POTASSIUM • PROTON PUMP INHIBITORS OR H2 BLOCKERS • DVT PROPHALAXIS

  26. OTHER MANGEMENT • ANTIBIOTICS, MOST COMMON IFECTION WHICH PRECIPITATES ASTHMA IS VIRAL • INTRAVENOUS FLUIDS, REPLACEMENT ONLY • MUCOLYTICS • ANTIHISTAMINES

  27. MECHANICAL VENTILATION • CONSIDER NON-INVASIVE VENTIALTION (NIPPV) • DISADVANTAGES: LACK OF AIRWAY CONTROL, SKIN PRESSURE ULCERATION, VOMINTIN/ASPIRATION • ADVANTAGES: COMFORT, DECREASE NEED FOR SEDATION, LOWER RISK FOR VAP

  28. INTUBATION INDICATIONS • PROGRESSIVE RESPIRATORY FAILURE • ALTERED MENTAL STATUS • HEMODYNAMIC INSTABILITY, REGARDLESS OF ABG

  29. DYNAMIC HYPERINFLATION • INSUFFICINET EXPIRATORY TIME • END EXHALATION VOLUME RISES • HEMODYNAMIC COMPROMISE AND BAROTRAUMA

  30. MECHANICAL VENTILATION • ENSURE OXYGENATION • AVOID DYNAMIC HYPERINFLATION • PHYSICAL EXAM AND CXR DO NOT CORRELATE WELL WITH DHI • PLATEAU PRESSURES, PEAK AIRWAY PRESSURES, INTRINSIC (AUTO) PEEP

  31. MECHANICAL VENTIALTION • PLATEAU PRESSURE: AT END INSPIRATORY HOLD (30-35 CM H20) • PEAK FLOW RATE: CORRELATES POORLY WITH RISK OF DHI • AUTO-PEEP: PRESSURE MEASURED AT END EXPIRATORY HOLD. REFLECTS DEGREE OF DHI POORLY, UNDERESTIMATES DHI

  32. MECHANICAL VENTILATION • MINIMIZE DHI BY ENSURING SUFFICIENT EXPIRATORY TIME • 1. INCREASE INSPIRATORY FLOW RATE • 2. DECREASE RESPIRATORY RATE • 3. DECREASE TIDAL VOLUME

  33. MECHANICAL VENTILATION • HYPERCAPNIA MAY BE A CONSEQUENCE OF PROTECTIVE VENTIALTION • PERMISSIVE HYPERCAPNIA • HYPERCAPNIA SIDE EFFECTS: CEREBRAL EDEMA,DECREASED MYOCARDIAL CONTRACTILITY, SYSTEMIC VASODILATATION, PULMONARY VASOCONSTRICTION

  34. MECHANICAL VENTIALTION • REQUIRES HEAVEY SEDATION • NARCOTIC PLUS BENZODIAZEPINE • PROPOFOL • NEUROMUSCULAR BLOCKADE

  35. COMPLICATIONS • NOSOCOMIAL PNEUMONIA • STRESS GASTRITIS • DVT • PE • MALNUTRITION • SEPSIS/MULTISYSTEM ORGAN FAILURE

  36. OUTCOMES • USING PRESENTED VENTILATION TECHNIQUES: 0 TO 4% MORTALITY • 21% MORTALITY WITH MV REALTED TO: TENSION PNEUMONTHORAX, CARDIAC ARREST, NOSOCOMIAL INFECTION, MULTISYSTEM ORGAN FAILURE • EXCESSIVELY AGGRESSIVE POSITIVE PRESSURE VENTIALTON

  37. FOLLOW-UP • MORTALITY POST MV HOSPITALIZATION: • YEAR 1: 10.1% • YEAR 3: 14.4% • YEAR 6: 22.6%

  38. FOLLOW-UP • CLOSE PHYSICIAN COMMUNICATION • PATIENT EDUCATION • THERAPUETIC PLAN CENTERED AROUND INHALED CORTICOSTEROIDS

  39. QUESTIONS ???

  40. NEAR FATAL ASTHMA

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