Acute Severe Asthma in Children 2

8/7/2019 Acute Severe Asthma in Children 2

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Acute Severe Asthma inAcute Severe Asthma in

ChildrenChildrenAjay GoenkaAjay Goenka


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It is a life threatening form of asthma

defined as : a condition in which a

progressively worsening attack isunresponsive to the usual

appropriate therapy that leads to

pulmonary insufficiency.

Definition


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Mechanisms of Status Asthmaticus

MucousMucous

HypersecretionHypersecretion

BronchospasmBronchospasm

Mucosal edemaMucosal edema

Increased resistance to air flowIncreased resistance to air flow

AtelectasisAtelectasis UnevenUneven

ventilationventilation

AbnormalAbnormalV/QV/Q

HyperinflationHyperinflation

deadspacedeadspace compliancecompliance

alveolaralveolar

hypoventilationhypoventilation WOBWOB

pCOpCO22

pOpO22


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Initial assessment of acute asthma inInitial assessment of acute asthma inchildren aged >2 years in A&Echildren aged >2 years in A&E

ModerateModerateexacerbationexacerbation

SevereSevereexacerbationexacerbation

Life threateningLife threateningasthmaasthma

SpOSpO22 uu92%92%PEFPEF uu50% best/ predicted50% best/ predicted

(>5 years)(>5 years)

No clinical features of severeNo clinical features of severeasthmaasthma

Heart rate:Heart rate:-- ee130/min (2130/min (2--5 years)5 years)

-- ee120/min (>5 years)120/min (>5 years)

Respiratory rate:Respiratory rate:-- ee50/min (250/min (2--5 years)5 years)

-- ee30/min (>5 years)30/min (>5 years)

SpOSpO22 130/min (2130/min (2--5 years)5 years)

-- >>120/min (>5 years)120/min (>5 years)

Respiratory rate:Respiratory rate:-- >>50/min (250/min (2--5 years)5 years)

-- >>30/min (>5 years)30/min (>5 years)

Use of accessory neckUse of accessory neckmusclesmuscles

SpOSpO22


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1-May-116

_____________________________________________________________________________

Asthma score:

0 1 2

1. PaO2 70-100 in air < 70 in air < 70 in 40%

2. Cyanosis none in air in 40%

3. Inspir. BS none unequal Dec. to absent

4. Access. Mus. none moderate maximal

5. Exp. Wheeze none moderate marked

6. Cerebral normal depressed Coma

or agitated

_____________________________________________________________________________


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Asthma score: Clinical asthma score > 5 signifies

impending respiratory failure

Clinical asthma score > 7 plus PCO2 >

65 signifies existing respiratory

failure.


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Status Asthmaticus

Oxygen Relative hypoxemia:

V/Q mismatch

hypoventilation Hypoxemia bronchoconstriction

F agonists impair hypoxic pulmonary

vasoconstriction shunt Oxygen to keep pulse ox > 92%


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Status AsthmaticusBeta2 Agonist Therapy

Mainstay oftherapy

Rapid onset Selective F 2:

Metaproterenol

Terbutaline Albuterol

Mode of delivery: Inhaled vs

Systemic Intermittent vs

Continuous

Nonintubated vs

Intubated


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Intravenous F

Agonists Most studies: inhaled therapy > to IV F agonist

Greater side effects with IV Potential benefit severe bronchospasm

Experience anecdotal with severe SA

IV Terbutaline: bolus 10 mcq/kg

infusion 0.1-4.0 mcq/kg/min


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Status AsthmaticusSubcutaneous F Agonists

Epinephrine/Terbutaline

No advantage over inhaled F agonists

Increased side effects Indications:

inability to cooperate with inhalation

therapy rapidly decompensating patient

failure to respond to inhaled beta-agonists


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Status AsthmaticusAnticholinergics

FF agonistagonist

SympatheticSympathetic

VagolyticsVagolytics

ParasympathetiParasympatheticcXX

AirwayAirway


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Status Asthmaticus

IV or oral Corticosteroids Recommended dose

Prednisone or methylprednisolone

suggested initial dose 2 mg/kg 1 mg/kg IV q 6 hours (max 60 mg) x48

hours,

then 1mg/kg q 12 hours for 3-5 days


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Status Asthmaticus

IV Theophylline

Phosphodiesterase inhibitor

Randomized trials (x2) - nobenefitover standard F2agonists and/orcorticosteroids

Uncertainbenefit inepisodes

unresponsivetoall other therapy


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Management of acute asthmaManagement of acute asthmain children aged >in children aged >22 years in A&Eyears in A&E

ModerateModerateexacerbationexacerbation

SevereSevereexacerbationexacerbation

Life threateningLife threateningexacerbationexacerbation

22 agonist 2agonist 2--10 puffs via10 puffs viaspacerspacer facemaskfacemask

Reassess after 15 minutesReassess after 15 minutes

Give nebulised Give nebulised 22 agonist:agonist:salbutamol (2salbutamol (2--5 years: 2.5mg; >5 years: 5mg) or terbutaline5 years: 2.5mg; >5 years: 5mg) or terbutaline

(2(2--5 years: 5mg; >5 years: 10mg) with oxygen as driving gas5 years: 5mg; >5 years: 10mg) with oxygen as driving gas

Continue oxygen via facemask/nasal prongsContinue oxygen via facemask/nasal prongs

Give prednisolone (2Give prednisolone (2--5 years: 20mg; >5 years 305 years: 20mg; >5 years 30--40mg) or40mg) orIV hydrocortisone (2IV hydrocortisone (2--5 years: 50mg; >5 years: 100mg)5 years: 50mg; >5 years: 100mg)

RESPONDINGRESPONDING

Continue inhaledContinue inhaled22 agonistsagonists11--4 hourly4 hourly

Add soluble oralAdd soluble oralprednisoloneprednisolone

-- 20mg (220mg (2--5 years)5 years)

-- 3030--40mg40mg

(>5 years)(>5 years)

NOTRESPONDINGNOTRESPONDING

Repeat inhaledRepeat inhaled22 agonist everyagonist every2020--30 minutes30 minutes

Add soluble oralAdd soluble oralprednisoloneprednisolone

-- 20mg (220mg (2--5 years)5 years)

-- 3030--40mg (>5 years)40mg (>5 years)

IF LIFE THREATENING FEATURES PRESENTIF LIFE THREATENING FEATURES PRESENT

Discuss with senior clinician, PICU team orDiscuss with senior clinician, PICU team orpaediatrician. Consider:paediatrician. Consider:

Chest xChest x--ray and blood gasesray and blood gases Repeat nebulised Repeat nebulised 22 agonists plus ipratropiumagonists plus ipratropium

bromide 0.25mg nebulised every 20bromide 0.25mg nebulised every 20--30 minutes30 minutes

Bolus IV salbutamol 15Bolus IV salbutamol 15QQg/kg of 200g/kg of 200QQg/mlg/mlsolution over 10 minutessolution over 10 minutes

IV aminophyllineIV aminophylline


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Response to treatment of acute asthmaResponse to treatment of acute asthma

in children aged >2 years in A&Ein children aged >2 years in A&EModerateModerate

exacerbationexacerbationSevereSevere

exacerbationexacerbationLife threateningLife threatening

exacerbationexacerbation

RESPONDING TO TREATMENTRESPONDING TO TREATMENTNOTRESPONDING TONOTRESPONDING TO

TREATMENTTREATMENT

IF POORRESPONSE TOIF POORRESPONSE TO

TREATMENTTREATMENT

DISCHARGE PLANDISCHARGE PLANContinue Continue 22 agonistsagonists 11--44 hourlyhourly prnprnConsiderConsider prednisoloneprednisolone

2020mg (mg (22--55 years)years) 3030--4040mgmg

(>(>55 years) daily for up toyears) daily for up to 33 daysdays

Advise to contact if not controlledAdvise to contact if not controlledon above treatmenton above treatmentProvide a written asthma actionProvide a written asthma action

planplan

Review regular treatmentReview regular treatmentCheck inhaler techniqueCheck inhaler techniqueArrange follow upArrange follow up

ARRANGEADMISSIONARRANGEADMISSION

(lower threshold if concern over(lower threshold if concern over

social circumstances)social circumstances)

ARRANGE IMMEDIATEARRANGE IMMEDIATE

TRANSFER TO PICUTRANSFER TO PICU


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CASE 1

A 4 year old child was admitted to thepaediatric wards at 10 am with a 24 h history ofcough and wheeze. He had been seen previouslyas an outpatient by a colleague and diagnosed as

having asthma. He usually inhaled 200 g ofbudesonide twice a day using a large volumespacer and had excellent inhaler technique.Until the day before admission his symptomshad been well controlled. Despite bronchodilatortreatment for most of the day, he continued to

deteriorate and needed oxygen via a face maskat 5 l/min to maintain oxygen saturations above92%.


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Drug delivery: large-volumespacer versus nebuliser

There is good evidence to support the view thatpressurised metered dose inhalers (pMDI) incombination with large volume spacers are at least aseffective as nebulisers

In mild attacks two to four puffs of salbutamol (200400 g) may be sufficient,

But in moderate or severe attacks 10 puffs ofsalbutamol may be required.

During this time it is difficult to administersupplemental oxygen


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For children who do not initially requiresupplemental oxygen, 2 agonists given via apMDI+spacer are less likely to provoke hypoxia or

tachycardia than when the same drug is given by anebuliser.

Recent experience from Australia in the use oflarge volume spacers found that only 3% of children

admitted to hospital with an exacerbation ofasthma were unable to use a pMDI+spacer, although7.5% of 200 admissions eventually receivednebulisation.


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Intermittent versuscontinuous nebulisation

Salbutamol reaches its maximal bronchodilatingeffects at relatively low doses.

Increasing the dosage does not increase the

absolute bronchodilatation but does prolong thebronchodilator effect.

Continuous nebulisation in low dosages (0.15 mg/kgin 5 ml) is the most effective

sustained stimulation of the pulmonary 2receptors prevents the rebound bronchoconstriction that

may occur with intermittent therapy.


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om ne n a eanticholinergics and 2

agonists The evidence also supports the use of nebulised

ipratropium bromide (125250 g per dose) inaddition to 2 agonists for the first 2 h of asevere attack in children.

A systematic review and meta-analysisdemonstrated a reduction in hospital admissionsand a significant increase in spirometricparameters compared with those who did notreceive anticholinergics.


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Children who received more than twodoses did even better.

If symptoms are refractory to initial 2agonist treatment, then ipratropium

bromide mixed with the nebulised 2agonist solution should be given.

It is recommended that this is

repeated every 20 min for the firsthour and every 4 h thereafter.


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Steroids in acute asthma:route and dose

Children with an acute exacerbation of asthmashould receive steroid treatment as early aspossible.

This has been shown to reduce the risk of

admission to hospital and prevent a relapse . The available data suggest that intravenous

steroids are no more effective than oralsteroids and both begin to work within 34 h.

Intravenous hydrocortisone (4 mg/kg) shouldtherefore be reserved for children who areunable to tolerate oral fluids.


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. Doses of 12 mg/kg are currentlyrecommended for children with acute severe

asthma. The widely held practice of doubling theinhaled corticosteroid dosage in an acuteexacerbation has been tested in children andhas been found to be wanting.


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CASE 2 A 10 year old child is admitted at 8 pm followingan acute asthma attack triggered by a cold. He

had been well controlled until 2 weekspreviously, but his parents had noticed a gradualincrease in symptoms over the last fortnightand suspect that he had stopped taking hisinhalers.

He has not had any salbutamol prior toadmission as he is unable to generate a highenough inspiratory flow to activate his drypowder inhaler. His oxygen saturations are 90%in high flow oxygen and he is halfway throughhis second 5 mg salbutamol nebuliser andreceived oral steroids. He is pale with marked

respiratory distress and a respiratory rate of40/min.


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Intravenous salbutamol: bolusversus infusion

The exact role of intravenous treatment for themanagement of acute severe asthma in childhoodremains controversial.

In selected children it appears to be effective andoffers benefits above and beyond those seen withinhaled treatment alone.

Initial loading dose of salbutamol (15 g/kgover 5 min)

as without this it takes 1020 h for a plateauconcentration to be reached followed by a continuousinfusion (15 g/kg/min).


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If a child is ill enough for treatment withintravenous salbutamol, or intravenous

aminophylline as below, to be considered,this should be in a high-dependency unit orin a paediatric intensive care settingwherever possible.

Hypokalaemia is a common consequence ofsalbutamol administration


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n ravenous am nop y neversus salbutamol versus

nothing limited data to suggest an improvement in lung function indices

at 6 h following intravenous aminophylline,

There is no apparent reduction in symptoms, in the number ofnebuliser treatments required or in the length of hospital stay.

.

Aminophylline infusions are associated with unpleasant side-effects with a three-fold increase in the risk of vomiting.


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Magnesium

Bronchodilator: inhibits cellular Ca++ uptake/release

stabilizes most cell membranes

Intravenous magnesium sulphate is a safe andestablished treatment for acute asthma in adults. However, there is only limited experience of its

use in childhood. However, its place in the treatment of acute

severe asthma remains unclear . Doses of up to 50 mg/kg/day have been used forasthma in the emergency department.


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eukotriene receptorantagonists in acute asthma

Cysteinyl leukotrienes have been shown to be mediators ofinflammation in asthma and marked elevations occur duringacute asthma episodes.

In adults who were admitted to hospital with acute asthma.Intravenous montelukast in addition to standard treatment, gave

a more rapid recovery in FEV1 over a 2 h period .They alsoneeded less 2 agonist and fewer treatment failures occurredcompared to placebo.

Oral montelukast (4 mg) has been shown to be more effectivethan placebo in children between 2 and 5 years of age with mild

to moderate acute asthma, significantly reducing respiratorydistress during the first 4 h

However, its role in more severeasthma or in addition to oralsteroids remains unknown.


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evalbuterol versussalbutamol

Acute asthma is usually treated withsalbutamol. This is a racemic mixture

of (R)-salbutamol and (S)-salbutamol,but the bronchodilator effects ofsalbutamol are mediatedpredominantly by the (R)-salbutamolisomer, levalbuterol.


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A randomised controlled trial inchildren, however, comparing

levalbuterol to combined treatmentwith racemic mixture salbutamol andipratropium bromide showed nobenefit in terms of hospitaladmissions or respiratory distress


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Status AsthmaticusKetamine

Dissociativeanesthetic

Direct bronchodilator Potentiates catecholamines

Bronchorrhea

Other sideeffects: tachycardia

BP


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Status AsthmaticusInhaledAnesthetics

Halothane, enflurane, isoflurane

Mechanisms:

F2 agonist effect

vagolytic

direct airway relaxation

No randomized(levelI) trials


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Status AsthmaticusHelium - Oxygen(HELIOX)

Blend of 80:20 helium:oxygen

Biologicallyinert

Insolubleinhumantissue No deleterious effects

Low densitygas

Air: 1.29 g/l O2: 1.43 g/l

Helium: 0.17 g/l


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Status AsthmaticusHelium - Oxygen(HELIOX)

Most recent case reports and clinical studies

have found mixed results in the role of heliox

for use in asthma


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Status AsthmaticusMechanicalSupport

BiPAP

Intubation/MechanicalVentilation

ExtracorporealLifeSupport


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Status AsthmaticusNoninvasiveVentilation

Positive-pressureby nasalmask (BiPAP)

Potentialbenefits: airway stenting improveV/Q match

CPAP improved hypoxemia inasthmaticchildren


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Status AsthmaticusIntubation

Best done semi-electively earlier rather thanlater

Drugs of choice: Atropine

Ketamine/Midazolam

Succinylcholine


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Status AsthmaticusIntubation

Usually last resort

Potential M&M

Mortality rate in adults 0- 40%

in children 0 5%


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Status AsthmaticusMechanicalVentilation

GOALS: Rest inspiratory muscles

Protect airway

Provideadequategas exchangeNOTnormal exchange

Avoid barotrauma, catastrophe


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Status AsthmaticusMechanicalVentilationIndications

Coma

Respiratory or cardiac arrest

Cyanosis andhypoxemia onO2PaCO2 greater than50 andrising >

5mmHg/hrDeteriorating mentalstatus

Minimalchest movement/air exchange

Pneumothorax

Absolute:Absolute:

Relative:Relative:


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Status AsthmaticusMechanicalVentilation

Key approach: permissivehypercapnia

(controlled hypoventilation)

toleratepCO2 tokeep pH > 7.20- 7.25

prolonged expiratory time

rate, inspiratory time

tidalvolume

PEEP: auto-PEEP


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Therapies NOT Recommended

Antibiotics

Empiric, aggressive hydration Chest PT

Mucolytics

Sedation??


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SUMMARY


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Treatment of acute asthmaTreatment of acute asthma

in children aged >2 yearsin children aged >2 years

Children with life threatening asthma or SpOChildren with life threatening asthma or SpO22


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Steroid therapy for acuteSteroid therapy for acute

asthma in children aged >2 yearsasthma in children aged >2 years

Give prednisolone early in the treatment of acute asthma attacksGive prednisolone early in the treatment of acute asthma attacks

Use prednisolone 20mg (2Use prednisolone 20mg (2--5 years), 305 years), 30--40mg (>5 years)40mg (>5 years)

Those already receiving maintenance steroid tablets shouldThose already receiving maintenance steroid tablets shouldreceive 2 mg/kg oral prednisolone up to a maximum dose of 60receive 2 mg/kg oral prednisolone up to a maximum dose of 60mgmg

Repeat the dose of prednisolone in children who vomit andRepeat the dose of prednisolone in children who vomit andconsider IV steroidsconsider IV steroids

Treatment up to 3 days is usually sufficient, but tailor to theTreatment up to 3 days is usually sufficient, but tailor to thenumber of days for recoverynumber of days for recoveryDo not initiate inhaled steroids in preference to steroid tabletsDo not initiate inhaled steroids in preference to steroid tabletsto treat acute childhood asthmato treat acute childhood asthma


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Other therapies for acuteOther therapies for acute

asthma in children aged >2 yearsasthma in children aged >2 years

If poor response toIf poor response toFF22 agonist treatment, add nebulised ipratropiumagonist treatment, add nebulised ipratropiumbromide (250bromide (250mcgmcg/dose mixed with/dose mixed withFF22 agonist) *agonist) *

Aminophylline is not recommended in children with mild to moderateAminophylline is not recommended in children with mild to moderateacute asthmaacute asthma

Consider aminophylline for children in high dependency/intensive careConsider aminophylline for children in high dependency/intensive carewith severe or life threatening bronchospasm unresponsive to maximalwith severe or life threatening bronchospasm unresponsive to maximaldoses of bronchodilators and steroid tabletsdoses of bronchodilators and steroid tablets

Do not give antibiotics routinely in the management of acute childhoodDo not give antibiotics routinely in the management of acute childhood

asthmaasthma

ECG monitoring is mandatory for all intravenous treatmentsECG monitoring is mandatory for all intravenous treatments

* Dose can be repeated every 20-30 minutes


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Hospital admission for acuteHospital admission for acute

asthma in children aged >2 yearsasthma in children aged >2 yearsChildren with acute asthma failing to improve after 10 puffs ofChildren with acute asthma failing to improve after 10 puffs ofFF22 agonistagonistshould be referred to hospital. Further doses of bronchodilator should be givenshould be referred to hospital. Further doses of bronchodilator should be given

as necessary whilst awaiting transferas necessary whilst awaiting transfer

Treat with oxygen and nebulisedTreat with oxygen and nebulisedFF22 agonists during the journey to hospitalagonists during the journey to hospital

Transfer children with severe or life threatening asthma urgently to hospital toTransfer children with severe or life threatening asthma urgently to hospital to

receive frequent doses of nebulisedreceive frequent doses of nebulised FF22 agonists (2.5agonists (2.5--5mg salbutamol or 55mg salbutamol or 5--1010mg terbutaline)mg terbutaline)

Decisions about admission should be made by trained physicians after repeatedDecisions about admission should be made by trained physicians after repeatedassessment of the response to further bronchodilator treatmentassessment of the response to further bronchodilator treatment

Consider intensive inpatient treatment for children with SpOConsider intensive inpatient treatment for children with SpO22


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Treatment of acute asthmaTreatment of acute asthma

in children aged


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Report Card: StatusReport Card: StatusAsthmaticusAsthmaticus TherapyTherapy

OxygenOxygen AAFF AgonistsAgonists

InhaledInhaled A+A+IVIV BBIpratropiumIpratropium AA

CorticosteroidsCorticosteroids AAMagnesiumMagnesium B+B+


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Report Card: Status Report Card: Status AsthmaticusAsthmaticus TherapyTherapy

KetamineKetamine CC

HELIOXHELIOX BB--Inhaled AnesthesiaInhaled Anesthesia C+C+

BiPAPBiPAP CC++MethylxanthinesMethylxanthines DD


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QUESTIONS??

Acute Severe Asthma in Children 2

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