Severe Asthmatic attack

1. PROF. M. S. ABDULLAH
AGA KHAN HOSPITAL – MOMBASA
MAY 2018

2. OBJECTIVES:
• Increase your knowledge of asthma epidemiology
• Increase your knowledge of asthma pathophysiology
• Improve your clinical and community care of people
with asthma
• Improve your clinical and community care of children
with asthma and their families

3. Definition of Asthma
• Episodic and/or chronic symptoms of airway obstruction.
• Bronchial hyper responsiveness to triggers.
• Evidence of at least partial reversibility of the airway obstruction.
• Alternative diagnoses are excluded.
A chronic inflammatory disease of the airways
with the following clinical features:

4. Relieve Symptoms
Prevent Symptoms
Prevent Attacks
Prevent Remodeling
Prevent Symptoms
Prevent Attacks
Evolution of Asthma Paradigms
Bronchial
Hyperreactivity
Fixed
Obstruction
Symptoms

5. Asthma pathophysiology
Key components: inflammation, bronchial hyper-reactivity,
airway remodeling
1970’s 1980’s 1990’s present
Bronchospasm Bronchospasm
+ Inflammation
Bronchospasm
+ Inflammation
+ Remodeling
T cell Eosinophil
Th-2
IL-5 / IL-13
Th17
Dendritic cells

6. Treatment of acute severe asthma
requiring hospitalization
Why do patients develop respiratory failure with severe
asthma attacks?
NHLBI Asthma web educ resources
Air trapping
Mucus plugging
Increased work of breathing

7. Epithelial
damage
Inflammatory
cell infiltration
Vascular
dilation
Mucous gland
hypertrophy
Edema
Mucus
Thickening
of basement
membrane
Guidelines for the Diagnosis and Management of Asthma.
Changes in Airway Morphology in
Asthma
Airway smooth
muscle

8. Four Components of
Asthma Management
Measures of Assessment and Monitoring
Control of Factors Contributing to Asthma Severity
Pharmacologic Therapy
Education for a Partnership in Asthma Care

9. Component 1:
Initial Assessment and Diagnosis of Asthma
 Determine that:
 Patient has history or presence of episodic symptoms of
airflow obstruction
 Airflow obstruction is at least partially reversible
 Alternative diagnoses are excluded
 Methods for establishing diagnosis:
 Detailed medical history
 Careful Physical exam
 Use Spirometry to demonstrate reversibility

10. Component 1:
Initial Assessment and
Diagnosis of Asthma(continued)
Does patient have history or presence of
episodic symptoms of airflow obstruction?
 Wheeze, shortness of breath, chest tightness, or
cough
 Asthma symptoms vary throughout the day
 Absence of symptoms at the time of the
examination does not exclude the diagnosis
of asthma

11. Initial Assessment and
Diagnosis of Asthma(continued)
Is airflow obstruction at least partially reversible?
 Use spirometry to establish airflow obstruction:
 FEV1 < 80% predicted;
 FEV1/FVC <65% or below the lower limit of normal
 Use spirometry to establish reversibility:
 FEV1 increases >12% and at least 200 mL after using
a short-acting inhaled beta2-agonist

12. Component 2:
Control of Factors
Contributing to Asthma Severity
 Assess exposure and sensitivity to:
Inhalant allergens
Occupational exposures
 Ask specifically about work-related triggers
Irritants:
Indoor air (including tobacco smoke)
Air pollution

13. Viruses and Asthma
 Viral infections in children frequently cause wheezing
 30-60% of children will wheeze in 1st 5 years
 Frequent cause of asthma exacerbation
 Unable to directly link viral infections with development
of asthma
 Proven risk factors include:
 Family history of asthma
 Environmental smoke exposure
 History of severe bronchiolitis in 1st 18 months

14. Benchmarks of Good Asthma Control
 Infrequent coughing or wheezing
 No shortness of breath or difficulty breathing
 No waking up at night due to asthma
 Normal physical activities
 No childcare or school absences due to asthma
 No missed time from work for parent or caregiver

15. Classification Of Asthma Severity:
Clinical Features Before Treatment
Days with
Symptoms
Nights with
Symptoms
PEV or FEV1
STEP 4
Severe
Persistent
Continual Frequent < 60
STEP 3
Moderate
Persistent
Daily > 5/month > 60% to
<80%
STEP 2
Mild Persistent
3-6/week 3-4/month > 80%
STEP 1
Mild
Intermittent
< 2/week < 2/month > 80%

16. Misclassification of Intermittent Asthma#ofPatients
400
600
800
1,000
Mild intermittent asthma
based on symptoms
and FEV1 alone
Mild
intermittent
60%
Mild
persistent
22%
Moderate
persistent
15% Severe
persistent
3%
200
400
600
200
Classification of the same group but now
based on symptoms, FEV1,
and medication use
n=4,362
953
patients
40%

17. Robertson et al. Pediatr Pulmonol. 1992;13:95-100.
0
5
10
15
20
25
30
35
40
Severe Moderate Mild
Patient AssessmentFindings from a cohort study reviewing all pediatric asthma-related deaths
(n=51) in the Australian state of Victoria from 1986 to 1989.
Pediatric Asthma Deaths:
Patients With Mild Asthma Are Also at Risk
Patient
Deaths
(%)
36%
31%
33%

18. Paradigm Shift in Asthma
Difficult
to control
Asthma
ControlledUncontrolled
Adjust
therapy

19. Functional
status?
Daytime
symptoms?
Missed work
and/or school?
Nighttime
awakenings?
Lung
function?
Asthma
Control
Use of “quick
relief” inhaler
and/or
nebulizer?
Utilization of
healthcare
resources?
Patient self-report
of control?
How Can Asthma Control Be Measured?
Inflammation?
Direct or indirect?
Satisfaction
with care?

20. In patients with moderate persistent asthma who are
on ICS, does the addition of another long-term control
agent improve outcomes?
 “Strong evidence” consistently indicates that the addition of a
long acting inhaled ß2 agonist leads to improvement in lung
function, symptoms & reduced additional ß2 agonist use
 Adding an LTM or theophylline to an ICS or doubling the ICS
dose improves outcomes “but the evidence is not as substantial”
 For children less than 5 the preferred treatment is low dose ICS
+ a long acting inhaled ß2 agonist or medium dose ICS
NIH Publication No. 02-5075, June 2002

21. What have we learned from all of the studies?
  Lung function
  Symptoms
  Albuterol use
  Exacerbations
 Reduces the need to increase ICS dose
low-dose ICS + LABA vs. “other therapy” results in:
Greening et al. Lancet. 1994;344:219-224.
Woolcock et al. Am J Respir Crit Care Med. 1996;153:1481-1488
Nelson et al J Allergy Clin Immunology 2000;106:1088-1095

22. Principles of Maintenance Therapy
Start high.
Step down once control is achieved.
Maintain at lowest dose of medication
that controls asthma.
Step up and down as indicated.

23. Step-down Therapy
Step down once control is achieved.
 After 2–3 mo.
 25% reduction over 2–3 months.
Follow-up monitoring
 Every 1–6 months.
 Assess symptoms and signs every time.
 Objective monitoring (PEFR or spirometery)
 Review medication

24. Step-up Therapy
Indications:
symptoms, need for quick-relief
medication, exercise intolerance,
decreased lung function.
May need short course of oral
steroids.
Continue to monitor.
Follow and reassess every 1–6 mo.
Step down when appropriate.

25. Acute Exacerbations
Principle: Gain control as quickly as possible.
Treat all asthma exacerbations promptly and
aggressively.
 Inhaled ß2-agonist inhalants for quick relief
 Access to quick relief medication
 Written action plan
 Indications
 Medications
 When to escalate to physician or emergency
medical services
 Short course of oral corticosteroids

26. Education for Partnership in Care
 Develop an asthma management plan for patients
 Agree on therapy goals
 Outline daily treatment and monitoring measures
 Prepare an action plan to handle worsening symptoms
 Provide routine education on patient self-management
 How and why to take medications
 Correct technique for devices
 Peak flow or symptom monitoring and documentation
 Factors that worsen asthma and actions to take

27. Objective:
 Teach to administer daily anti-inflammatory control
medications as needed and quick relief medicines
for patients with persistent asthma

28. Fears About Asthma Medicines
Many believe medicines are addictive
Majority believe medicines are not safe to take over a
long period of time
Many believe regular use will reduce effectiveness of
the medications

29. ASTHMA MEDICATIONS
 Beta 2 agonists - bronchodilators
 Albuterol (Proventil, Ventolin)
 Pirbuterol (Maxair)
 Levalbuterol (Xopenex)
 Terbutaline (Brethine)
 Metaproterenol (Alupent)

30. ASTHMA MEDICATIONS
 Long-acting beta 2 agonists
 Salmeterol (Serevent)
 Formoterol (Foradil)
 Combine with ICS (ADVAIR available)

31. Corticosteroids
 Inhaled (ICS)
Beclomethasone (Vanceril,
Beclovent, Q-VAR)
Budesonide (Pulmicort)
Flunisolide (Aerobid)
Fluticasone (Flovent,
ADVAIR)
Triamcinolone acetonide
(Azmacort)
 Systemic
Prednisone/Prednisolone
Methylprednisolone (Solu-
Medrol, Medrol)

32. ASTHMA MEDICATIONS
 Mast cell stabilizers
 Cromolyn sodium (Intal)
 Nedocromil (Tilade)
 Anticholinergic
 Ipratropium bromide
 (Atrovent)
 Methylxanthines
 Theophylline
 Aminophylline

33. ASTHMA MEDICATIONS
 Leukotriene inhibitors
 Oral, QD-BID
 Montelukast (Singulair)
 Zafirlukast (Accolate)
 Zileuton (Zyflo)
 Some evidence of effectiveness in preventing premenstrual asthma
exacerbations1
1. J Allergy Clin Immunol 1999;104:585-8.

34. Teaching Checklist
 Use of inhaler/spacer
 Use of nebulizer
 Use of Peak Flow Meter
 Give step by step directions
 Instruct how/where to get
spacers/nebs/PFM
 Instruct what to do if run out
of medicine or can’t get
devices
 Ask parent/child to
demonstrate technique at
each visit
 Reassure parent about using
alternative treatments with
medications

35. Spacers/Holding
Chambers

36. Spacers/Holding Chambers
 Recommended with all medium to high dose ICS
 Enhance delivery, especially with children
 Improves coordination and medication delivery
 some provide auditory feedback
 Minimize adverse effects from ICS
 decrease oral bioavailability
 reduce oral candidias (thrush)
 dysphonia, and bad taste

37. Dry Powder Inhalers (DPI)
 Spacers can not be used with DPI
 Turbuhaler®, Diskus®, Aerolizer™
 Must be able to do mouthpiece treatment
 Deep rapid inhalation

38. Peak
Flow
Meters

39. Acute Asthma
Management

40. Acute Asthma
Initial Assessment and Management
Assess
severity
Good
response
Incomplete
response
Poor
response
Inhaled
SABA
History
Physical Exam
Peak flow determination
Up to 2 treatments
20 minutes apart
• Normal peak flow
• Consider brief
trial of oral
corticosteroids
• Peak flow 50-80%
predicted
• Start oral
corticosteroids
• Contact primary
MD
• Peak flow <50%
predicted
• Start oral
corticosteroids
• Contact primary
MD
ER
Admit
Modified from NHLBI EPR3 2007

41. Acute Asthma Management
• Initial assessment of the patient
• Treatment Plan
• Mechanical ventilation if necessary
• Monitoring both acute, recovery
and stable state

42. Initial Assessment
• Immediate assessment of
- Ability to speak
- Vital signs
• Measurement of PEF is mandatory unless
the patient is too ill to cooperate
• Arterial blood gas analysis strongly
recommended

43. Acute Asthma Management
Clinical and Laboratory Assessment
 Assess clinically – accessory muscle use, tachypnea,
tachycardia, diaphoresis, pulsus paradoxus,
exhaustion.
 Assess airflow limitation – peak flow measurement.
 Assess oxygenation – pulse oximetry.
 Assess for hypercapnia – selected patients especially
if somnolent, fatigued, difficulty with speech, elderly,
concomitant use of sedatives.
 Imaging – chest X ray plus ECG
 Blood work – CBC, glucose.

44. Treatment of acute severe asthma
requiring hospitalization
Why do patients develop respiratory failure with severe asthma attacks?
NHLBI Asthma web educ resources
Air trapping
Mucus plugging
Increased work of breathing

45. Acute Severe Asthma Treatment
- Oxygen by mask or nasal prongs
- High doses of inhaled bronchodilators
- Systemic corticosteroids
- Intravenous fluids
- Additional management

46. Treatment of Acute Severe Asthma
Principles and Primary Goals of care
 Relieve airflow limitation: bronchodilator therapy
 Treat airway inflammation: steroids.
 Treat hypoxemia or hypercapnia if present.
 Non-invasive ventilation / mechanical ventilation
in severe cases (clinical judgment).
 Selected therapies: magnesium sulphate and
heliox.
 Limited or no role for antibiotics and
methylxanthines.

47. Treatment of Acute Asthma
Heliox
 For severe exacerbations unresponsive to the
salbutamol, albuterol and corticosteroid
therapy, adjunctive treatments may be used:
iv magnesium sulphate or heliox.
 Heliox is a mixture of helium and oxygen
(usually a 70:30 helium to oxygen ratio) that is
less viscous than ambient air.
 Heliox improves delivery and deposition of
nebulized albuterol.

48. Treatment of severe asthma
Anti-IgE Therapy
 Biologic antibody therapy (Omalizumab; Xolair) binds
IgE in the circulation and prevents it from activating
mast cells and basophils.
 In moderate to severe asthma, anti-IgE therapy
reduced exacerbation rate and reduced steroid dose
needed.
 Anti IgE therapy is recommended as an add-on to
optimized standard therapy in asthmatics 12 years and
older who need continuous or frequent treatment with
oral corticosteroids.
 Elevated serum IgE 1. Ann Intern Med. 2011 3;154(9):573-82
2. Lancet Respir Med. 2013;1(3):189-90.
3. Cochrane Database Syst Rev. 2014 13;1

49. Acute Asthma Management
Clinical and Laboratory Assessment
 Assess clinically – accessory muscle use, tachypnea,
tachycardia, diaphoresis, pulsus paradoxus,
exhaustion.
 Assess airflow limitation – peak flow measurement.
 Assess oxygenation – pulse oximetry.
 Assess for hypercapnia – selected patients especially
if somnolent, fatigued, difficulty with speech, elderly,
concomitant use of sedatives.
 Imaging – chest X ray plus ECG
 Blood work – CBC, glucose.

50. Treatment 2
Oxygen
• High concentration of oxygen (humidified
if possible)
Goal - SaO2 > 92%
• Failure to achieve appropriate oxygenation
Assisted ventilation

51. Treatment 3
High doses of inhaled bronchodilators
- Short acting ß2 agonists (salbutamol 5
mg/hr)
Via nebulizer driven by oxygen or via
metered dose inhaler through a spacer device
- An inhaled anticholinergic (ipratropium
bromide) may be added

52. Treatment 4
Intravenous Fluids
- To correct dehydration and acidosis
(Normal saline + sodium bicarbonate
infusion)
- Potassium supplements to treat
hypokalaemia induced by salbutamol

53. Treatment 5
• Systemic corticosteroids
Intravenous hydrocortisone 200 mg – in
patients who are unable to swallow or
persistently vomiting
• High dose Oral prednisolone

54. Treatment 6
Further management
• If patient fails to improve
• Intravenous magnesium sulphate (1.2 – 2 gm over 20
min)
• Intravenous β2 agonists (salbutamol)
• Intravenous aminophylline (5 mg/kg loading dose
over 20 min followed by continuous infusion at .
mg/kg/hr)
• Intravenous leukotriene receptor antagonists
• Anaesthetics (e.g. halothane)

55. Mechanical Ventilation
Initial goals
To correct hypoxaemia
To achieve adequate alveolar ventilation
To minimize circulatory collapse
To by time for medical management to work
Indications
Has lapsed into Coma
Gasping or Respiratory arrest
Deterioration of arterial blood gas tensions despite optimal
therapy
Patient Exhaustion, confusion, drowsiness

56. Monitoring of Treatment
• PEF should be recorded every 15 – 30 min
• Pulse oxymetry should ensure that SaO2 remains
>92%
• If aminophylline is given then monitor the serum
concentration (therapeutic range 10 – 20 ug / ml
• Repeat arterial blood gases if
If initial PaCO2 measurement was raised
If PaO2 was < 8 kPa (60 mmHg) or
The patient deteriorates despite good management