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Acute asthma

  1. Acute Asthma Dr.Asif Ahmad Post Graduate Resident (PGR) Pediatrics Medicine Children ‘B’ Unit Pediatric Department MTI- LRH Peshawar, Pakistan.
  2. Contents My presentation consist of Two parts •Background knowledge of Asthma •Approach to Asthmatic patient
  3. Definition Asthma is a chronic inflammatory disease of the airways that is characterized by bronchial hyperactivity and variable airway obstruction which results in recurrent episodes of wheezing, breathlessness, chest tightness and/or coughing that can vary over time and in intensity.
  4. Pathophysiology • Bronchospasm • Airway inflammation
  5. Early-Phase Response •Peaks 30-60 minutes post exposure, subsides 30-90 minutes later • Characterized primarily by bronchospasm •Increased mucous secretion, edema formation, and increased amounts of tenacious sputum •Patient experiences wheezing, cough, chest tightness, and dyspnea
  6. Late-Phase Response •Characterized primarily by inflammation •Histamine and other mediators set up a self- sustaining cycle increasing airway reactivity causing hyper responsiveness to allergens and other stimuli •Increased airway resistance leads to air trapping in alveoli and hyperinflation of the lungs •If airway inflammation is not treated or does not resolve, may lead to irreversible lung damage
  7. Triggers • Allergens Outdoors: trees, shrubs, weeds, grasses, molds, pollens, air pollution, spores Indoors: dust, mites, mold, cockroach antigen • Irritants tobacco smoke, wood smoke, odors, sprays • Exposure to occupational chemicals • Exercise • Cold air • Changes in weather or temperature • Colds & infections
  8. • Environmental change: Moving to new home, starting new school, etc. • Animals: cats, dogs, rodents, horses • Medications: ASA, NSAID’s, Antibiotics, beta blockers • Strong emotions: fear, anger, laughing, crying • Conditions: GERD, TEF • Food additives: sulfite preservatives • Foods: nuts, milk/dairy products
  9. Clinical Features • Coughing and wheezing are the most common symptoms of childhood Asthma • Breathlessness, chest tightness or pressure, and chest pain also are reported • Poor school performance and fatigue may indicate sleep deprivation from nocturnal symptoms
  10. Cough •Nocturnal cough, recurring seasonal cough, or cough in response to specific exposures •Although wheezing hallmark of asthma, cough is often sole presenting complaint •Most common cause of chronic cough in children older than 3 years is asthma
  11. Wheeze •Wheezing is a high-pitched, expiratory sound produced when air forced through narrow airways •Asthma wheeze tends to be polyphonic (varied in pitch) •When airflow obstruction severe, can appreciate wheeze with inspiration and expiration.
  12. Other asthma symptoms in children can be subtle and nonspecific, including self-imposed limitation of physical activities, general fatigue (possibly resulting from sleep disturbance), and difficulty keeping up with peers in physical activities.
  13. Classifiaction
  14. Differential diagnosis
  15. Diagnostic Studies • Detailed history and physical exam • Chest X-ray • Peak flow monitoring • Pulmonary function tests (Age ≥ 6 years) • ABGs • Pulse Oximetry • Allergy testing • Blood levels of Eosinophils • Sputum culture and sensitivity
  16. Management Management of asthma should have the following components: (1)assessment and monitoring of disease activity (2) education to enhance patient and family knowledge and skills for self-management (3) Identification and management of precipitating factors and comorbid conditions that worsen asthma (4) appropriate selection of medications to address the patient’s needs.
  17. Medications
  18. Case Abdul hamid is a 7-year-old boy who presents to an Emergency Department with cough and trouble breathing typical of his usual asthma exacerbation. This episode began 2 days ago and has been accompanied by a runny nose and a low-grade fever without any other symptoms. Several family members are also ill with upper respiratory infections. His mother has been treating him with ventolin by a nebulizer every 4 hours, but he has become more short of breath this evening prior to coming to the ED.
  19. Past medical history is notable for asthma since infancy, with multiple prior hospitalizations. Other problems on review of systems include eczema and environmental allergies. Multiple family members also have asthma. On social history, his mother mentions that he is in 2nd class but has missed at least 10 days of school this year due to his asthma. His only current medication is salbutamol.
  20. On physical examination he appears in moderate respiratory distress with suprasternal and intercostal retractions. His vital signs are Temp 100°F Resp Rate 40 BrPM Heart rate 120 BPM Pulse oximetery 95% on room air. Lung exam is notable for diffuse symmetrical wheezes, a prolonged expiratory phase and diminished aeration. His nasal mucosa is erythematous with boggy turbinate and clear mucus. The remainder of the examination is unremarkable.
  21. Approach History The following areas should be covered unless previously recorded: Acute presenting history Triggers Treatment already given and response Past asthma history When diagnosed Previous admissions including to ICU Known triggers Interval symptoms Smoking exposure Current and past treatment including compliance and devices
  22. Other atopic conditions including food allergies Family history of atopic conditions If previously diagnosed Who currently manages the child’s asthma Dates of last review & next planned review Standard history as per any other patient Past medical history Family history Immunizations Medications and allergies Psychosocial history Developmental history
  23. Examination Key points to be noted include Degree of respiratory distress Respiratory rate Use of accessory muscles and recession Posture or position Oxygen saturation if available Ability to talk in phrases, sentences or words Ability to feed Any clinical signs of major atelectasis or pneumothorax Mental state (alertness and responsiveness) Heart rate
  24. Pulse oximetery should be performed if available. A small decrease in oxygen saturations commonly occurs after initial bronchodilator treatment and should be put into the context of the child’s clinical condition and response to treatment. Significant hypoxia is an indicator of more severe asthma. Peak flow has little use in acute asthma and clinical assessment is the best indicator of severity.
  25. Admission Criteria  Bronchodilator requirement more frequently than 3 hourly  Oxygen requirement  Other factors make discharge unsafe (e.g. social issues, lack of understanding, lack of ability to re- present if worsens).
  26. Consider admission to HDU/PICU Signs of critical asthma severity Requiring continuous nebulizers for >1 hour without improvement Requiring Salbutamol more frequently than every 30 minutes after 2 hours Hypoxia despite maximal oxygen or raised CO2.
  27. Investigations or Tests 1. Spirometery in Children Aged ≥ 6 years Forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 80% with a 12% improvement in FEV1 after SABA is specific for the diagnosis of Asthma. Performing spirometery is an important part of the diagnostic process to ensure an accurate diagnosis as 30% of patients with a diagnosis of asthma have been found not to have asthma when lung function testing was done. Spirometery is used as part of asthma control assessment, as patients with poor lung function are at risk for remodeling despite having well-controlled symptoms.
  28. 2. Peak flow monitoring •Not recommended for diagnosing asthma in children. •Can be used in patients with an asthma diagnosis who are poor perceivers of their asthma symptoms, as part of an asthma management plan. •Given the variability of normal values, determine a patient’s personal best peak flow when well to establish a baseline. 3. Chest x-ray 4. ABGs
  29. Assesment and Management
  30. Discharge criteria Patients may be discharged home if: •Tolerating 3 hours between bronchodilator doses •Normal saturations in room air •Sensible carers and easy access to medical care in the event of an acute deterioration.
  31. Discharge medications  Salbutamol initially 3-4 hourly with a weaning plan over the next 3-4 days. Continue oral Prednisolone to finish 3-5 days (no need for a weaning dose for courses less than 5 days).  Inhaler device and spacer technique should be checked before discharge.
  32. Inhaler and spacer technique
  33. Inhaler and spacer technique
  34. Medication Delivery Devices
  35. Patient Education All patients & families should have their level of asthma knowledge reviewed and appropriate education given. • Ensure that the patient device technique is correct. • If parents/carers smoke, ensure they are aware of the importance of a non-smoking environment and offer information on quitting if possible. • Patients and families should go home with written education material including an action and discharge plan.
  36. • How to take their medication properly (have patient demonstrate this, not just describe it). • The difference between a reliever and controller medication. • What triggers their asthma and how to avoid their triggers when appropriate. • Recommend annual influenza vaccination for the patient and their family. Asthma patients should also receive pneumococcal vaccines as appropriate for their age.
  37. Assessment of Asthma Control Assess asthma control and risk factors for asthma attacks at the time of diagnosis, when creating/ modifying a treatment plan and when monitoring treatment outcomes.
  38. The control based asthma management cycle