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5 risk factors for death
- History of asthma
- Hospitalization / ED visits
- Medication use
- Co-morbidity factors
- Other
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Risk: History of asthma
- Prior intubation for asthma
- Prior ICU for asthma
- HX of severe exacerbations
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Risk: Hospitalization / ED visits
- 2 or more hospitalizations in the past year
- 3 or more ED visits in the past year
- Hospitalization or ED visit in the last month
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Risk: Medication use
- Currently using systemic steroids
- Recently withdrawn from systemic steroids
- More than 2 SABA B2 per month
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Risk: Co-morbidity factors
- Allergic rhinitis and sinusitis
- Obesity
- Stress / depression
- OSA
- GE reflux
- Allergic bronchopulmonary aspergillosis
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Risk: Other
- Low socioeconomic status
- Inner-city residence
- Illegal drug use
- Poor symptom / severity perception
- Sensitivity to alternaria (mold)
- Lack of a written asthma action plan
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Emergency tx at home
PF 50-79%
- MDI: 2 tx of 2-6 puff 20 minutes apart
- HHN: 2 tx 20 minutes apart
- Reassess PF - Good response > 80%
- Contact MD for FU
- Continue SABA 24-48 hrs, consider systemic steroids
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Emergency tx at home
Incomplete Response
- PF remains 50-79% and continue wheezing / dyspnea
- Contact MD immediately
- Continue SABA / add systemic steroids
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Emergency tx at home
Poor Response
- PF < 50% with marked wheezing / dyspnea
- Repeat SABA immediately
- Start oral systemic steroids immediately
- If distress not relieved, ED or 911
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EMS tx of asthma
- O2
- Albulterol (MDI c spacer or HHN)
- If no Albuterol available, SUB terbutalin or epinephrine
- Up to 3 txs per hr, then 1 per hr
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ED visits often indicate:
Inadequate asthma management or plan for exacerbation
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ED goal for tx asthma exacerbation
- Correct hypoxemia
- Reverse airflow obstruction
- Reduce likelihood of recurrence
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What to assess in ED
- Brief hx
- Physical exam
- Lung function (FEV1 or PEF)
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Assessment: RR
- Mild: increased
- Mod: increased
- Severe: > 30 / min
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Assessment: HR
- Mild: < 100
- Mod: 100-120
- Severe: > 120
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Assessment: Speach
- Mild: sentences
- Mod: phrases
- Severe: words
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Assessment: Accessory muscle use
- Mild: not typical
- Mod: present
- Severe: present
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Assessment: Breathlessness
- Mild: when walking
- Mod: when talking
- Severe: at rest
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ED tx: 6 steps
- 1. O2
- 2. SpO2
- 3. SABA
- 4. Anticholinergics
- 5. Steroids
- 6. Repeat assessments
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ED tx: O2
- to pt with significant hypoxemia
- to pt with PEF or FEV1 < 40%
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ED tx: SpO2
- tks > 90%
- if pregnant, infant or heart disease, tks > 95%
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ED tx: SABA
- Albuterol, Levalbuterol or Pirbuterol x 3, Q 20-30 min
- MDI with spacer normal
- For children or severe obstruction, use HHN
- Repeat Lung Function 15-20 min post each tx
- If FEV1/PEF < 25% and <10% response, monitor for respiratory failure
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ED tx: Anthicholinergics
- For pt with sever exacerbation or resp failure
- Ipratropium Bromide
- Not recommended if pt is hospitalized
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ED tx: Steroids
- For moderate to severe asthma exacerbation
- For pt not responding to SABA
- For pt admitted to the hospital
- Enhances recovery / reduces recurrence
- Onset: 4-6 hrs
- At discharge, 5-10 day course or oral steroids
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ED tx: Reassessment
- After 3 doses of SABA
- Include: subj symp, phys ex, lung func, SpO2 and ABG
- If still 40-69% PEF, continue ED tx
- Consider adjunct therapy if < 40% of PEF
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ED tx: labs
- If severe, start tx first!
- ABG
- CBC
- Serum theophylline levels
- Serum electrolytes
- CXR
- ECG
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ABG
- Acute asthma: inc RR, dec PCO2
- Normal PCO2 w inc RR = severe obstruction and increased risk of respiratory failure
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CBC
- Consider if fever or purulent sputum
- Corticosteroids commonly cause leukocytosis (>WBC)
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Serum theolphylline levels
Therapeutic Range: 5-20 mcg/mL
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Serum electrolytes
- If pt takes diuretic or has cardiovascular disease
- SABA decreases potassium, magnesium and phosphate
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CXR
Not routinely performed
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ECG
- Recommended if > 50 years
- Recommended if hx of heart disease
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6 Adjunct Therapies
- 1. IV magnesium sulfate
- 2. Heliox
- 3. IV B-agonist
- 4. IV luekotrience receptor agonist
- 5. Non-invasive PPV
- 6. Mechanical ventilation
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IV magnesium sulfate
- If life-threatening or severe > 1 hr after therapy
- Adult dose: 2g
- Children dose: 25-75 mg/kg up to 2g
- Inhibits calcium channels, thus reduces release of acetylcholine to improve respiratory muscle function
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Heliox
- If life-threatening or servere > 1 hr after therapy
- Makes airflow laminar, reduces airway resistance
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IV B-agonist
i.e. isoproterenol
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IV Leukotriene receptor agonist
i.e. montelukast
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Noninvasive PPV
5 - 7.5 cmH2O to reduce accessory muscle workload
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Mechanical ventilation
Pemissive hypercapnia to reduce excessive lung distension
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Children / Infant Consideration
- Infants rapidly regress
- Dec SpO2 sign of severe airway obstruction
- Hospitalize if SpO2 < 92% after 1 hr of tx
- PCO2 by arterial or capillary
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Children / Infant Consideration after initial tx
- RSV infection
- Foreign body obstruction
- BPD Bronchopulmonary Dysplasia
- CF
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Do Not Use in exacerbation:
- 1. Sub epinephrine or terbutaline
- 2. Theophylline / aminophylline
- 3. CPT
- 4. Mucolytics
- 5. Anxiolytic and hypnotic drugs
- 6. Antibiotics ? Unless asthma assc with bact pneum
- 7. Aggressive hydration
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Respiratory Failure Signs and Symptoms
- 1. Decreased mental status
- 2. Worsening fatigue
- 3. PCO2 => 42
- 4. Inability to speak
- 5. Intercostal retractions
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Admission Considerations
- 1. Response to ED tx
- 2. Duration of symptoms
- 3. Severity of symptoms
- 4. Severity of airflow obstruction
- 5. Course of prior exacerbations
- 6. Access to medical care / medications
- 7. Support system
- 8. Phychiatric illness
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Discharge: PEF or FEV1
= > 70% and symptoms are nominal
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Discharge: Medications
- Written instructions
- Wean to levels pt will be using at home
- Monitor at these levels x 24 hours
- Make sure they have enough to complete regimen
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Discharge: Provide
- PF to 5yrs and older
- Review of MDI technique and environment controls
- Referral to asthma specialist
- FU appt 1-4 wks after discharge
- List of local asthma education programs
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