Acute exacerbation of asthma

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1. ACUTE EXACERBATION OF ASTHMA

2. ASTHMA Asthma is a chronic inflammatory disorder of the airways characterized by three distinct components: R ecurrent episodes of airway obstruction that resolve spontaneously or as a result of treatment . Exaggerated bronchoconstrictor responses to stimuli that have little or no effect in normal individual, known as airway hyper-reactivity. I nflammation of the airways

3. Pathophysiology

4. CLINICAL FEATURES The characteristic symptoms of asthma are wheezing, dyspnea, and coughing. Dyspnea may occur only with exercise (exercise-induced asthma), after aspirin ingestion (aspirin-exacerbated respiratory disease), Symptoms may be worse at night and patients typically awake in the early morning hours. Some patients, particularly children, may present with a predominant nonproductive cough (“cough-variant asthma”). There may be no abnormal physical findings when asthma is under control.

5. TREATMENT

6. Acute Exacerbation of Asthma

7. Asthmatic patients are at risk of acute exacerbation, marked worsening of their symptoms,  d eterioration in lung function, and an increase in airway inflammatio n, that requires emergency treatment. Usually in association with viral respiratory infections, but also allergen exposure, air pollution or withdrawal of treatment Most attacks are characterised by a gradual deterioration over several hours to days but some appear to occur with little or no warning: so-called brittle asthma.

8. History patient can not complete sentences in one breathing. Frequent emergency hospital admission. Frequent use of inhaler Examination Central cyanosis Sinus tachycardia Pulsus paradoxus Silent chest Mental confusion

9. Indications for 'rescue' courses include: Symptoms and PEF progressively worsening day by day Fall of PEF below 60% of the patient's personal best recording Onset or worsening of sleep disturbance by asthma Persistence of morning symptoms until midday Progressively diminishing response to an inhaled bronchodilator Symptoms severe enough to require treatment with nebulised or injected bronchodilators

10. Assessment of exacerbation of asthma Measurement of PEF is mandatory Arterial blood gas analysis is essential to determine the PaCO2, a normal or elevated level being particularly dangerous. A chest X-ray is not immediately necessary, unless pneumothorax is suspected.

11. Management of acute sever asthma 1-Oxygen %40 High concentration of oxygen 2- B ro n chodilators Short acting B2 agonist Salbutamol 5 mg or Terbutaline 2.5mg Ipratropium bromide 500ug Anticholinergic should add to salbutamol in pt Acute sever asthma or life threatening by O2 driven nebulizer.

12. 3- Systemic corticosteroids Reduce inflammatory response & hasten the resolution of exacerbation . Hydrocortisone 200 mg I.v if pt not stable vomiting or unable to swallow Orall prednisolone can use when pt is stable

13. 4- Intravenous fluid (correct fluid & electrolyte) Many pt are dehydrated due to high insesible water loss . Potassium supplement may be necessary bcz repeated doses of salbutamol can low serium Potassium

14. 5- Subsequent management If patient fail to improve a number of further option may be considered I.v magnesium sulphate 1.2 – 2 g over 20 minute Smooth muscle relaxant may provide additional bronchdilation in pt whose presenting PEF < 30 % predicted or some pt benefit from the use of I.v Aminophylline but carefully monitoring is required.

15. Prognosis The outcome from acute sever asthma is generally good . Death from a acute sever asthma is fortunately rare Prior to discharge Patient should be stable on discharge medication nebulizer therapy should have discontinued for at least 24 hrs and PEF should have reached 75%

16. Indications for assisted ventilation in acute sever asthma 1- Coma 2- Respiratory arrest 3- Deterioration of arterial blood Gas tensions despite optimal therapy 🔹️ PaO2 < 8 kpa ( 60 mmHg) and falling 🔹️ PaCO2 > 6kpa ( 40 mmHg) and raising 🔹️ PH low and falling 4- Exhaustion, confusion , drowsiness.