مقاربة نوبة الربو الحادة

1. ACUTE ASTHMA
MANAGEMENT
ANAS SAHLE , MD
DAMASCUSE HOSPITAL

2. Risk factors for death from asthma
1. Prior severe exacerbation(eg: ICU admit, intubation).
2. 2 or more asthma hospitalization in past year.
3. 3 or more ED visit for asthma in past year.
4. Hospitalization or ED visit for asthma in prior month.
5. Use of >2 SABA canisters per month.
6. Difficulty perceiving asthma symptoms or severity of
exacerbation.
7. Lack of written asthma action plan, sensitve to
ALTERNARIA(fungus).
8. Other social and comorbidity risks.
EPR-3 national heart lung and blood 2007

3. Risk factors for death from asthma
1. Sudden severe attacks
2. Recent systemic steroids.
3. >2 SABA canisters in prior month.
4. HospitalER in last month.
5. ≥ 2 ERhospitalization in last year.
6. Prior intubationICU stay.
7. Illicit drug use.
8. Heartpsychiartic disorder.
9. Low socioeconomic class.
curr Opin pulm med 2008

4. PEFR≥75% predicted Mild
exacerbation
Β2 Agonist(neb),(MDI)
Check 15-30 min
PEFR≥75% and PEFR<75% and
clinically stable clinically stable
Observe 2H and Treat as moderate
discharge if stable exacerbation

5. PEFR=50-75% predicted Moderate
exacerbation
5 mg SALBUTAMOL(NEB)
30-60 mg PREDNISOLONE
Check at 30 min
PEFR<50%
PEFR=50-75% clinically stable Or clinically
deteriorating
Repeat 5 mg SALBUTAMOL(NEB) Treat as severe
Check at 30 min
PEFR<50% or
clinically PEFR>50% ,clinically stable
deteriorating
Deteriorating : Observe for 2H
Treat as severe discharge if stable
treat as severe +PEF increasing

6. PEFR=33-50%predicted ,
Severe
cannot complete sentences , exacerbation
RR>25min , HR>110min
High flow O2,
5mg salbutamol(neb),
30-60mg prednisolone200mg hydrocortisone(IV)
CHECK at 15 min
If not improving
If improving: admit
repeat 5mg salbutamol(neb) every 15-30 min till improving
continue 4-6 hourly (neb)
500mcg ipratropium(neb)
continue prednisolone
consider magnesium(1,2-2)g over 20 min(IV)
40-50mg daily
check ABG
CHECK at 15 min
IF ABG: If improving: admit
If not improving
continue 2-4 hourly nebs
normalraised PCO2 start aminophylline(IV) daily
severe hypoxia<58 treat as life-threatening
low PH prednisolone or 6 hourly
discuss with ICU
hydrocortisone

7. PEFR<33%
O2 SAT<92%
Silent chest
Cyanosis Life-threatening
exacerbation
Bradycardia
Hypotension
Exhaustionconfusion
REFER
TO
High flow O2
ICU measure ABG
5mg salbutamol (neb)
500mcg ipratropium (neb)
hydrocortisone100mg (IV)
magnesium 2g(IV)
±250mg aminophylline (IV)

8. REFERRAL TO INTENSIVE CARE
• deteriorating PEF
• persisting or worsening hypoxia
• Hypercapnea
• arterial blood gas analysis showing fall in pH
• exhaustion, feeble respiration
• drowsiness, confusion, altered conscious state
• respiratory arrest

9. NON-INVASIVE VENTILATION
• It is unlikely that NIV would replace intubation
in these very unstable patients.
• but it has been suggested that this treatment
can be used safely and effectively.

10. Discharge
On dischargeplanning
, all patients should have:
1. Patients should be on home medication for 24
hours prior to discharge.
2. PEF>75% predicted , <25% variability.
3. Prednisolone 40mg for at least 5 days.
4. Oral antibiotics if confirmed evidence of
infection.
5. Supply of all inhalers and technique checked.
6. PEF meter.

12. Definition
 The peak expiratory
flow rate is an effort-
dependent
assessment of a
patients ability to
forcibly expel air
from their lungs
 Airways Obstruction

13. Peak Expiratory Flow Rate / PEFR
 Usually used in children over 5 years
 Assessment of Reversibility of Airways
limitation or Hyperresponsiveness
 Diurnal variation : Self -Monitoring in
asthma

14. Peak Expiratory Flow Rate / PEFR
 Usually used in children over 5 years
 Assessment of Reversibility of Airways
limitation or Hyperresponsiveness
 Diurnal variation : Self -Monitoring in
asthma

15. Peak Expiratory Flow Rate / PEFR
 Usually used in children over 5 years
 Assessment of Reversibility of Airways
limitation or Hyperresponsiveness
 Diurnal variation : Self -Monitoring in
asthma

16. Peak expiratory flow rate measurement

17. Peak expiratory flow rate measurement
Ask the patient to
stand up & hold the
peak flow in a
horizontal position

18. Peak expiratory flow rate measurement
Take care not to place
your fingers
over the scale

19. Peak expiratory flow rate measurement
Ask the patient now to
take a deep breath in
& make a tight seal
with their lips around
the mouth piece

20. Peak expiratory flow rate measurement
Now ask the patient
to blow out as hard
& as fast as they
can

21. Peak expiratory flow rate measurement
Remember fast
blast is better than
slow blow

22. Peak expiratory flow rate measurement
Note the number
where the sliding
pointer has
stopped on the
scale

23. Peak expiratory flow rate measurement
Reset the pointer to
'zero'

24. Peak Expiratory Flow

25.  Personal Best PEFR Value
 Baseline Predicated PEFR Value

26. Personal Best PEFR Value
 A baseline measure
 The baseline values should be obtained
when the patient is feeling well after a
period of maximal asthma therapy

27. Personal Best PEFR Value
 The patient should then record PEFR
measurements 2 to 4 times daily for
two weeks

28. Personal Best PEFR Value
 The personal best is generally the
highest PEFR measurement achieved
during this post-treatment monitoring
period

29. Personal Best PEFR Value
 The patient's normal PEFR range is
defined as 80 and 100 percent of the
patient's personal best.

30. Baseline Predicated PEFR Value
Tall – 80 X 5 = Prv PEFR
Example: 150 – 80 x 5 = 350 L/min

31. Predicated PEFR value vs Personal Best value
of PEFR
 The patient's normal value of PEFR:
 Self -Monitoring in asthma

32. Percentage PEFR Variability
Highest – Lowest
/ Highest x 100

33. Reversibility of PEF
Inhalation of 200-400 µg of
Salbutamol

34. Reversibility
A 20% improvement
in PEF from
baseline

35. L/min PEFR
PEFR
Reversibility
PEFR Ventoline
Reversibility

36. 250 – 150 / 250 = 40 %
Yes

37. Self -Monitoring in asthma
100 %
All clear
80 %
Caution
50 %
Medical Alert