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Asthma in Emergency room

Asthma in Emergency room. ผศ.นพ.วัชรา บุญสวัสดิ์ พบ. Ph.D ภาควิชาอายุรศาสตร์ คณะแพทย์ศาสตร์ มหาวิทยาลัยขอนแก่น. Contents . epidemiology pathophysiology of asthma management of asthma at ER prevention of asthma exacerbation. Asthma morbidity in the past year.

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Asthma in Emergency room

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  1. Asthma in Emergency room ผศ.นพ.วัชรา บุญสวัสดิ์ พบ. Ph.D ภาควิชาอายุรศาสตร์ คณะแพทย์ศาสตร์ มหาวิทยาลัยขอนแก่น

  2. Contents • epidemiology • pathophysiology of asthma • management of asthma at ER • prevention of asthma exacerbation

  3. Asthma morbidity in the past year Boonsawat et al.Survey of asthma control in Thailand 2001

  4. Admission and ER visit due to asthma in the past year according to severity classification

  5. Asthma admission in Thailand (excluding Bangkok) Health Information Division, Bureau of Health Policy and Planing

  6. ER visit at Srinagarind hospital(Teaching hospital)

  7. ER visit at Nampong hospital (district hospital)

  8. Mechanism of airway obstruction in severe asthma

  9. Airway obstruction Uneven ventilation Hyperinflation Work of breathing V/Q mismatching Wasted ventilation VO2 ,VCO2 Hypoxemia, hypercapnia Respiratory acidosis Metabolic acidosis

  10. Management of asthma at ER Step1. Diagnosis Step 2. Assess the severity Step 3. Treatment Step 4. Assess the response

  11. Step1. Diagnosis Upper airway obstruction ? Asthma ? COPD exacerbate ? Congestive heart failure ?

  12. Step 2. Assess the severity

  13. Assess the severity • History • near fatal asthma requiring mechanical ventilation • long duration of current attack • deterioration despite oral steroids

  14. Assess the severity • Physical examination • inability to lie supine • impaired sensorium • inability to speak • use of accessory muscle • RR >30 • PR >120

  15. Assess the severity • Lab • PEFR < 100L/M. FEV1 < 700 cc • ABG • CXR

  16. Predicitive Index • Fischl’s index • PR > 120 • RR > 30 • Pulsus paradox >= 18 • PEFR < 120 • Dyspnea • accessory-muscle use • Wheezing N Engl J Med 1981;305:783-9

  17. Step 3. Treatment • goal of treatment: • correction of hypoxemia • rapid reversal of airflow obstruction with minimum side effect

  18. Treatment • Oxygen • Bronchodilators • Corticosteroids

  19. Rapid –acting inhaled b2-agonists • Nebulization • MDI with spacer

  20. Classes of b2-agonists Speed of onset RESCUE MEDICATION fast onset, short duration fast onset, long duration M AINTENANCE fast inhaled formoterol inhaled terbutaline inhaled salbutamol slow onset, short duration slow onset, long duration oral terbutaline oral salbutamol oral formoterol slow inhaled salmeterol oral bambuterol Duration of action short long

  21. Nebulized versus intravenous albuterol in hypercapnic acute asthma • 47 patients admitted with severe asthma • PEF<150 L/m and PaCO2 > 40 • nebulize 5 mgx2 vs IV 0.5 mg salbutamol in 1hr • 86% of nebulize gr had been treat successfully(vs 48 % in IV gr) • increase PEF, decrease PaCO2 greater in neulize gr • nebulize route has a greater efficacy and fewer side effect than intravenous route Salmeron S.Am J Respir Crit Care Med 1994;149:1466-70

  22. Nebulization • MDI with spacer

  23. Ipratropium bromide

  24. The effect of adding Ipratropium bromide to salbutamol in the treatment of acute asthma Chang in mean FEV1 at 45 min 200 Total 55 (2-107) N=977 100 IB+S better 0 S better TOTAL CA NZ US -100 SF Lanes. Chest 1988;114:365-372

  25. risk of hospitalization CA NZ US TOTAL IB+S S IB+S S IB+S S IB+S S Patients 171 171 171 167 192 192 534 530 hospitalized 16 23 35 42 24 28 75 93 risk ratio 0.70 0.81 0.86 0.80 95%CI (0.38-1.27) 0.53-1.21 (0.52-1.42) (0.61-1.06)

  26. Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al.NEJM1988;339:1030-5

  27. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albutterol in the emergency department • 180 patients, FEV1<50% • albuterol MDI vs. albuterol and IB • subjects who received IB had an overall 20.5% greater improvement in PEFR • reduce the risk of hospital admission 49% (39% vs 20%) RR=0.51(95%CI 0.31-0.83) • Five patients (95% CI 3-17) would need to be treated with IB to prevent a single admission Rodrigo et al. Am J Respir Crit Care Med 2000;161:1862-8

  28. A Meta-analysis of the effect of Ipratropium bromide in adult with acute asthma • 10 studies including 1483 adults with acute asthma • improve lung function • reduction in rate of hospital admission Rodrigo et al. Am J Med1999;107:363-370

  29. Should inhaled anticholinergics should be added to b2 agonist for treating acute childhood and adolescent asthma? A systematic review • reduce the risk of hospitalization by 30% (RR 0.72 95%CI 0.53-0.99) • Eleven children would need to be treated to avoid one admission • improve lung function • no increase side effect Plotnick LH.BMJ1998;317:971-977

  30. Addition of Ipratropium bromide to b2-agonist • improve lung function • reduce hospitalization • no additional side effects

  31. การรักษาอื่นๆที่ยังไม่ใช่การรักษามาตรฐานการรักษาอื่นๆที่ยังไม่ใช่การรักษามาตรฐาน • Magnesium • Helium Oxygen therapy (Heliox ) • general anesthesia • Montelukast

  32. Step 4. Assess the response • Dyspnea • PE • PR, RR, Accessory muscle use, • PEFR

  33. Predicitive Index Poor Response • PEFR at 30 min after treatment<40% predicted • Change in PEFR at 30 min after treatment <60 L/Min Chest 1998; 114: 1016-1021

  34. Acute Severe Asthma B2-agonist (Neb or MDI) q 15-30 min + Corticosteroid Improve B2-agonist q 1-2h Not improve add anticholinergic Admit PEFR > 70 % Discharge

  35. Acute Severe Asthma PEF<50% PEF>50% B2-agonist q 20 min + Corticosteroid B2-agonist +IB q 20 min + Corticosteroid Not improve add anticholinergic Improve B2-agonist q 1-2h Admit PEFR > 70 % Discharge NIH.NAEPP 1997

  36. Prevent future relapses

  37. Symptoms Airway inflammation Stimuli Remodelling Airway Hyperresponsiveness

  38. Facilitated referral to asthma spectialist reduces relapses in asthma emergency room visits • 50 % reduction in asthma ER relapses • greater use of inhaled corticosteroids J Allergy Clin Immunol 1991;87:1160-8

  39. Results of a program to reduce admissions for adult asthma 104 asthmatic required multiple hospitalization • Intensive outpatient treatment • inhaled corticosteroid • peak flow monitor • management plan Threefold reduction in readmission Mayo PH.Ann Internal Med 1990;112:864-871

  40. conclusions • asthma exacerbation is common in ER • bronchospasm mucosal edema inflammation is the cause of obstruction • coticosteroid,b2 agonist, anticholinergic is first line drugs • asthma in ER indicate poor asthma control

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