MANAGEMENT OF ACUTE SEVERE ASTHMA
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Transcript of MANAGEMENT OF ACUTE SEVERE ASTHMA
MANAGEMENT OF ACUTE SEVERE ASTHMA
Introduction
• A life-threatening exacerbation of asthma symptoms
• Findings:
PEF (peak expiratory flow) 33-50% predicted (< 200 l/min) Respiratory rate ≥ 25/min Heart rate ≥ 110/min Arterial blood gas analysis PaO2 (N: 75-105 mm Hg)and
. PaCO2 (N: 35-45 mm Hg)
Inability to complete sentences in 1 breath
Management
• Initial assessment
• Treatment
• Mechanical ventilation
• Monitoring
Initial assessmentImmediate assessment of
ability to speak
Vital signs
Measurement of PEF is mandatory unless the
patient is too ill to cooperate
Arterial blood gas analysis
Treatment
• Oxygen
• High doses of inhaled bronchodilators
• Systemic corticosteroids
• Intravenous fluids
• Subsequent management
Treatment contd…
• Oxygen
– High concentrations of oxygen (humidified if
possible)
– Goal: SaO2 > 92%
– Failure to achieve appropriate oxygenation
assisted ventilation.
Treatment contd…
• High doses of inhaled bronchodilators
– Short-acting β2-agonists (Salbutamol 5mg/hr)
• via nebuliser driven by oxygen or via a metered
dose inhaler through a spacer device
– An inhaled anticholinergics (Ipratropium bromide
500µg) may be added
Treatment contd…
• Systemic corticosteroids
– intravenous hydrocortisone 200 mg : in patients
who are unable to swallow or vomiting.
– Oral prednisolone 40 mg
Treatment contd…
• Intravenous fluids
– To correct dehydration and acidosis
– Normal saline + sodium bicarbonate/lactate
infusion
– Potassium supplements to treat hypokalemia
induced by Salbutamol
Treatment contd…• Subsequent management– If patients fail to improve• Intravenous magnesium sulphate(1.2–2 g over 20
min)• Intravenous β2 agonists(e.g. Salbutamol) • Intravenous aminophylline (5mg/kg loading dose
over 20 minutes followed by continuous infusion at 1mg/kg/hr )• Intravenous leukotriene receptor antagonists • Anaesthetics (e.g. halothane)
Mechanical Ventilation • Initial goals– To correct hypoxaemia
– To achieve adequate alveolar ventillation
– To minimize circulatory collapse
– To buy time for medical management to work• Indications– Coma – Respiratory arrest – Deterioration of arterial blood gas tensions despite
optimal therapy – Exhaustion, confusion, drowsiness
Monitoring of treatment• PEF should be recorded every 15-30 minutes • Pulse oximetry should ensure that SaO2 remains >
92% • If aminophylline is given, then monitor the serum
concentration (therapeutic range 10–20 µg /ml)• Repeat arterial blood gases if – initial PaCO2 measurement was raised
– PaO2 was < 8 kPa (60 mmHg) or – the patient deteriorates.