Asthma in Emergency room

.. . Ph.D

Contents
epidemiology pathophysiology of asthma management of asthma at ER prevention of asthma exacerbation

Asthma morbidity in the past year

25 20 15 10 5 0 admit ER visit loss work 14.8 23.6 21.7

Boonsawat et al.Survey of asthma control in Thailand 2001

Admission and ER visit due to asthma in the past year according to severity classification
60 45.2 40 35.7 28.4 20 17.1 24.5 18.4 admission ER visit

17.3 9.1

0
severe moderate mild intermittent

SEVERITY

Asthma admission in Thailand

(excluding Bangkok)

100000 80000 60000 40000 20000 0 2538 2539 2540 76202 66679 79769

90606

2543

Health Information Division, Bureau of Health Policy and Planing

ER visit at Srinagarind hospital (Teaching hospital)

500 400 300 200 100 0 162 49 1985 180 53 1986 176 50 1987 162 62 1988 124 84 1989 226 175 87 1990 122 1991 178 165 178 234 254 adult child

108 1992

1998

2001

ER visit at Nampong hospital (district hospital)

1500

1000 1370 500 1079

0 2543 2544

Mechanism of airway obstruction in severe asthma

Airway obstruction

Hyperinflation Work of breathing

Uneven ventilation

Wasted ventilation

VO2 ,VCO2

V/Q mismatching

Hypoxemia, hypercapnia

Respiratory acidosis Metabolic acidosis

Management of asthma at ER
Step1. Diagnosis Step 2. Assess the severity

Step 3. Treatment
Step 4. Assess the response

Step1. Diagnosis
Upper airway obstruction ?

Asthma ?
COPD exacerbate ?

Congestive heart failure ?

Step 2. Assess the severity

Assess the severity History

near fatal asthma requiring mechanical
ventilation long duration of current attack deterioration despite oral steroids

Assess the severity

Physical examination
inability to lie supine impaired sensorium inability to speak use of accessory muscle RR >30 PR >120

Assess the severity

Lab
PEFR < 100L/M. FEV1 < 700 cc ABG CXR

Predicitive Index

Fischls index
PR > 120 RR > 30 Pulsus paradox >= 18 PEFR < 120 Dyspnea accessory-muscle use Wheezing
N Engl J Med 1981;305:783-9

Step 3. Treatment
goal of treatment:
correction of hypoxemia rapid reversal of airflow obstruction with minimum side effect

Treatment
Oxygen Bronchodilators Corticosteroids

Rapid acting inhaled b2-agonists

Nebulization MDI with spacer

Classes of b2-agonists
Speed of onset

RESCUE MEDICATION
fast onset, long duration

fast onset, short duration

fast

inhaled terbutaline inhaled salbutamol

slow onset, short duration

inhaled formoterol

slow onset, long duration

slow

oral terbutaline oral salbutamol oral formoterol

inhaled salmeterol oral bambuterol

M A I N T E N A N C E

short

long

Duration of action

Nebulized versus intravenous albuterol in hypercapnic acute asthma

47 patients admitted with severe asthma PEF<150 L/m and PaCO2 > 40 nebulize 5 mgx2 vs IV 0.5 mg salbutamol in 1hr 86% of nebulize gr had been treat successfully (vs 48 % in IV gr) increase PEF, decrease PaCO2 greater in neulize gr nebulize route has a greater efficacy and fewer side effect than intravenous route

Salmeron S.Am J Respir Crit Care Med 1994;149:1466-70

 Nebulization MDI with spacer

Ipratropium bromide

The effect of adding Ipratropium bromide to salbutamol in the treatment of acute asthma

Chang in mean FEV1 at 45 min

200
Total 55 (2-107) N=977

100 IB+S better

0

S better
CA -100
SF Lanes. Chest 1988;114:365-372

NZ

US

TOTAL

risk of hospitalization
CA
IB+S
Patients hospitalized risk ratio 95%CI 171 16

NZ
S
171 23

US
S
167 42 IB+S 192 24 S 192 28

TOTAL
IB+S
534 75

IB+S
171 35

S
530 93

0.70 (0.38-1.27)

0.81 0.53-1.21

0.86 (0.52-1.42)

0.80 (0.61-1.06)

Effect of nebulized ipratropium on the hospitalization rates of children with asthma

60 52.6

patient hospitalized(%)

50 40 30 20 10.7 10.1 10 0 All patients moderate asthma severe asthma 36.5 27.4 37.5 control ipratropium

Qureshi et al.NEJM1988;339:1030-5

First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albutterol in the emergency department 180 patients, FEV1<50% albuterol MDI vs. albuterol and IB subjects who received IB had an overall 20.5% greater improvement in PEFR reduce the risk of hospital admission 49% (39% vs 20%) RR=0.51(95%CI 0.31-0.83) Five patients (95% CI 3-17) would need to be treated with IB to prevent a single admission
Rodrigo et al. Am J Respir Crit Care Med 2000;161:1862-8

A Meta-analysis of the effect of Ipratropium bromide in adult with acute asthma

10 studies including 1483 adults with acute asthma improve lung function

reduction in rate of hospital admission

Rodrigo et al. Am J Med1999; 107:363-370

Should inhaled anticholinergics should be added to b2 agonist for treating acute childhood and adolescent asthma? A systematic review reduce the risk of hospitalization by 30% (RR 0.72 95%CI 0.53-0.99) Eleven children would need to be treated to avoid one admission improve lung function no increase side effect

Plotnick LH.BMJ1998;317:971-977

Addition of Ipratropium bromide to b2-agonist

improve lung function reduce hospitalization no additional side effects


Magnesium Helium Oxygen therapy (Heliox ) general anesthesia Montelukast

Step 4. Assess the response

Dyspnea PE PR, RR, Accessory muscle use, PEFR

Predicitive Index
Poor Response

PEFR at 30 min after treatment<40% predicted Change in PEFR at 30 min after treatment <60 L/Min

Chest 1998; 114: 1016-1021

Acute Severe Asthma

B2-agonist (Neb or MDI) q 15-30 min + Corticosteroid

Improve B2-agonist q 1-2h

Not improve add anticholinergic

PEFR > 70 % Discharge

Admit

Acute Severe Asthma

PEF>50%
B2-agonist q 20 min + Corticosteroid

PEF<50%
B2-agonist +IB q 20 min + Corticosteroid

Not improve Improve B2-agonist q 1-2h add anticholinergic

PEFR > 70 % Discharge

Admit

NIH.NAEPP 1997

Prevent future relapses

Airway inflammation

Symptoms

Stimuli

Remodelling

Airway Hyperresponsiveness

Facilitated referral to asthma spectialist reduces relapses in asthma emergency room visits

50 % reduction in asthma ER relapses greater use of inhaled corticosteroids

J Allergy Clin Immunol 1991;87:1160-8

Results of a program to reduce admissions for adult asthma

104 asthmatic required multiple hospitalization

Intensive outpatient treatment inhaled corticosteroid peak flow monitor management plan Threefold reduction in readmission
Mayo PH.Ann Internal Med 1990;112:864-871

conclusions
asthma exacerbation is common in ER bronchospasm mucosal edema inflammation is the cause of obstruction coticosteroid,b2 agonist, anticholinergic is first line drugs asthma in ER indicate poor asthma control