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Asthma and COPD exacerbation - Emergency

Asthma and COPD exacerbation - Emergency

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Asthma and COPD exacerbation - Emergency

  1. 1. Acute Severe Asthma & COPD Exacerbations Ni’ma Bader
  2. 2. Definition  An acute state where inflammation, airway edema, excessive mucus accumulation, and severe bronchospasm result in a profound airway narrowing that is poorly responsive to usual bronchodilator therapy
  3. 3. CLINICAL PRESENTATION  Symptoms ◦ Acute distress and severe dyspnea, shortness of breath, chest tightness, or burning. The patient is only able to say a few words with each breath.  Signs ◦ wheezing on auscultation, dry hacking cough, tachypnea, tachycardia, pale or cyanotic skin, hyper-inflated chest, and hypoxic seizures if very severe.
  4. 4. INITIAL HOME TREATMENT
  5. 5. 0
  6. 6. TREATMENT IN EMERGENCY DEPARTMENT OR URGENT CARE SETTING
  7. 7.  Initial assessment includes history, physical examination, and objective assessments.  The brief history will assess for: onset and causes of the exacerbation; severity of symptoms and if associated with anaphylaxis; medication use, adherence, and response to current therapy; and risk factors for asthma-related death.
  8. 8.  The asthma-related risk factors for death include:  a history of near-fatal asthma requiring intubation and mechanical ventilation  hospitalization or emergency care in the past year  current or recent use of oral corticosteroids  no current use of ICSs  over use of short-acting β2-agonist therapy (more than one canister per month)  history of psychiatric disease or psychosocial problems  poor medication adherence  lack of a written asthma action plan  food allergy.
  9. 9.  The physical exams: ◦ Vital signs ◦ Any complicating factors such as pneumonia or anaphylaxis as well as other comorbid conditions that could be causing acute shortness of breath such as inhaled foreign body, congestive heart failure, pulmonary infection, and pulmonary embolism.
  10. 10.  Objective assessments ◦ should be made before initiation of oxygen or drug treatment. ◦ Lung function testing by PEF or FEV1  should be measured before treatment if possible and thereafter at one hour after start of treatment and then periodically until response is achieved or no further improvement is evident. ◦ Oxygen saturation: preferably by pulse oximetry ◦ Arterial blood gases ◦ A chest X-ray ◦ Complete blood count
  11. 11.  Arterial blood gas measurements in acute asthma are indicated in the following settings:  Patients with persistent dyspnea whose PEF is below 25 percent of normal despite initial bronchodilator therapy  Selected patients with a PEF 25 to 50 percent of normal whose respiratory status is deteriorating despite intensive therapy  Patients who are too ill to perform a peak flow measurement  Patients who demonstrate signs or symptoms of hypercapnia, such as depressed consciousness, inappropriately slow respiratory rate, or myoclonus
  12. 12.  Features suggesting an alternate or comorbid condition ◦ Concomitant symptoms such as fever, purulent sputum production, urticaria, or pleuritic chest pain should raise the possibility of an alternative diagnosis such as pneumonia, flare of bronchiectasis, anaphylaxis, or pneumothorax.
  13. 13.  A chest radiograph should be obtained when:  A complicating cardiopulmonary process is suspected (eg, temperature >38.3ºC, unexplained chest pain, leukocytosis, or hypoxemia)  When a patient requires hospitalization,  When the diagnosis is uncertain
  14. 14. DETECTING AN EXACERBATION  Symptoms (R/O other causes)  Peak flow  Risk factors for fatal asthma
  15. 15. TREATMENT IN EMERGENCY DEPARTMENT OR URGENT CARE SETTING
  16. 16.  Oxygen  Inhaled beta agonists  Inhaled anticholinergics  Systemic glucocorticoids
  17. 17.  Oxygen therapy goals: ◦ Arterial oxygen saturation of  93% to 95% in adolescents and adults  94% to 98% in school-aged children and pregnant women or those with cardiac disease.
  18. 18.  Heliox vs. oxygen for nebulized β2- agonist
  19. 19.  Systemic glucocorticoids indication: ◦ A severe exacerbation with a peak expiratory flow ≤50 percent of baseline. Immediate administration is warranted. ◦ A moderate exacerbation with a peak expiratory flow >50 but <70 percent of baseline that does not reverse to normal after initial bronchodilator therapy. ◦ An asthma exacerbation that occurs despite ongoing daily or alternate-day oral glucocorticoid therapy. Such patients require supplemental glucocorticoids above their baseline dose.
  20. 20. Oral vs. IV corticosteroids
  21. 21.  Features that help with assessment of severity (may or may not be present): ◦ Impending respiratory failure:  Cyanosis, inability to maintain respiratory effort, depressed mental status, SpO2 <90%  PaCO2 >40 mmHg ◦ Severe exacerbation:  Speaks in single words  Sits hunched forward  Agitated, diaphoretic  Respiratory rate >30 breaths/minute  Heart rate >120 beats/minute  SpO2 (on air) <90%  PEF ≤50% predicted or personal best ◦ Mild to moderate exacerbation:  Talks in phrases or sentences  Prefers sitting to lying  Not agitated  Respiratory rate 16 to 30 breaths/minute  Heart rate 100 to 120 beats/minute  SpO2 >90%  PEF >50% but <80% predicted or personal best
  22. 22. Indications for hospitalization or discharge  Factors favoring continued observation in patients with a PEF of 40 to 60 percent of predicted are:  new onset asthma  multiple prior hospitalizations or emergency department visits for asthma  use of oral glucocorticoids at the time of presentation with the acute deterioration.
  23. 23.  Most patients with improving symptoms and a PEF >60 percent of predicted can be safely discharged, if they are knowledgeable about their asthma and have good availability of follow-up care.
  24. 24.  Magnesium sulfate ◦ MOA: bronchodilation due to inhibition of calcium influx into airway smooth muscle cells ◦ Dosage: single Intravenous dose 2 g infused over 20 min ◦ Suggested for patients who have a life- threatening exacerbation or whose exacerbation remains severe (PEF <40% of baseline) after one hour of intensive conventional therapy. ◦ Helpful in reducing hospital admissions
  25. 25. Nonstandard therapies  Anesthetic agents ◦ IV ketamine, inhaled halothane, isoflurane, and sevoflurane have bronchodilating effects, and have favorable responses in patients with refractory status asthmaticus ◦ Mechanism: inhibition of histamine and acetylcholine- induced bronchoconstriction and acting as a sympathomimetic agent. ◦ Ketamine has been recommended for rapid induction of anesthesia in patients with asthma who require intubation and mechanical ventilation. ◦ Hypotension is often the limiting factor in the administration of these agents
  26. 26.  Enoximone ◦ Phosphodiesterase inhibitors, associated with ventricular and atrial arrhythmias, hypotension, and hepatotoxicity. ◦ Further study is needed to evaluate the safety and efficacy of it  Parenteral beta-agonists — Intravenous and subcutaneous beta-agonists are generally avoided when treating asthma exacerbations in adults, because inhaled short-acting selective beta agonists have equal or greater efficacy and lower incidence of adverse effects (eg, tachycardia, arrhythmias, myocardial injury) compared with parenteral beta-agonists.
  27. 27.  Exceptions: ◦ patients suspected of having an anaphylactic reaction ◦ Those unable to use inhaled bronchodilators for a severe asthma exacerbation ◦ Epinephrine or terbutaline subcutaneously are an alternatives.
  28. 28.  High-dose inhaled glucocorticoids are not recommended as an alternative to oral glucocorticoids for patients with a discrete asthma exacerbation
  29. 29.  Leukotriene receptor antagonists ◦ do not administer leukotriene receptor antagonists as part of routine treatment of acute exacerbations, except in patients whose exacerbation was triggered by ingestion of aspirin or a nonsteroidal anti- inflammatory drug (NSAID), events associated with dramatic overproduction of leukotrienes.
  30. 30. Ineffective therapies  Methylxanthines  Empiric antibiotics  hydration (in the absence of evidence of dehydration)  Expectorants such as guaifenesin  Antihistamines  Chest physiotherapy.
  31. 31. MECHANICAL VENTILATION  Indication:  Slowing of the respiratory rate  depressed mental status  inability to maintain respiratory effort,  worsening hypercapnia and associated respiratory acidosis  inability to maintain an oxygen saturation >92 percent despite high-flow supplemental oxygen
  32. 32.  Virtually every patient who has suffered an asthma attack severe enough to require urgent care should receive an inhaled glucocorticoid as part of his or her discharge medication plan
  33. 33. Management of exacerbations of chronic obstructive pulmonary disease
  34. 34. Definition  acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day- to-day variations and leads to a change in medication
  35. 35.  Acute change in one or more of the following cardinal symptoms:  Cough increases in frequency and severity  Sputum production increases in volume and/or changes character  Dyspnea increases
  36. 36. Clinical features  Features of COPD exacerbation: Diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, smoking >20 pack years  Features of severe respiratory insufficiency: Use of accessory muscles; brief, fragmented speech; inability to lie supine; profound diaphoresis; agitation; asynchrony between chest and abdominal motion with respiration; failure to improve with initial emergency treatment  Features of impending respiratory arrest: Inability to maintain respiratory effort, cyanosis, hemodynamic instability, and depressed mental status
  37. 37.  Associated features that would suggest an alternate diagnosis or comorbidity include:  Constitutional symptoms (eg, fever, chills, night sweats)  Chest pain, chest pressure, or peripheral edema  Risk factors for thromboembolic disease or coronary disease  Upper respiratory symptoms that might suggest a viral respiratory infection
  38. 38.  RISK FACTORS FOR COPD EXACERBATION :  Advanced age  Duration of COPD  COPD-related hospitalization within the previous year  Theophylline therapy  Having one or more comorbidities (eg, ischemic heart disease, chronic heart failure, or diabetes mellitus)
  39. 39. Exacerbation risk  Low risk: Typically GOLD 1 or 2 (mild to moderate airflow limitation) and/or 0 to 1 exacerbation per year, no hospitalization due to an exacerbation  High risk: Typically GOLD 3 or 4 (severe or very severe airflow limitation) and/or ≥2 exacerbations per year or ≥1 hospitalization due to an exacerbation
  40. 40. Staging Acute Exacerbations of COPD Mild (type 1) One cardinal symptoma plus at least one of the following: URTIb within 5 days, fever without other explanation, increased wheezing, increased cough, increase in respiratory or heart rate >20% above baseline Moderate (type 2) Two cardinal symptomsa Severe (type 3) Three cardinal symptomsa
  41. 41. Factors Favoring Hospitalization for Treatment of COPD Exacerbation  Presence of high risk comorbidity (eg, pneumonia, arrhythmia, CHF, diabetes, renal or hepatic failure)  Suboptimal response to outpatient management  Marked worsening of dyspnea  Inability to eat or sleep due to symptoms  Worsening hypoxemia or hypercapnia  Mental status changes  Lack of home support for care  Uncertain diagnosis
  42. 42. Diagnostic testing Look at S/S Obtain ABG in all patients with severe COPD exacerbation Assess oxygen saturation with continuous pulse oximetry Do not assess peak expiratory flow or spirometry in acute severe COPD exacerbations as results are not accurate Obtain portable chest radiograph: Look for signs of pneumonia, acute heart failure, pneumothorax Obtain complete blood count, electrolytes (Na+, K+, Cl–, HCO3–), BUN, and creatinine; also obtain cardiac troponin, BNP, or NT-proBNP, if diagnosis is uncertain Test for influenza infection during influenza season Obtain ECG: Look for arrhythmia, ischemia, cor pulmonale
  43. 43. Criteria for ICU admission include: •Patients with high-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, liver failure) •Continued need for NPPV or invasive ventilation •Hemodynamic instability •Need for frequent nebulizer treatments or monitoring
  44. 44. Monitoring Perform continual monitoring of oxygen saturation, blood pressure, heart rate, respiratory rate Close monitoring of respiratory status Continuous ECG monitoring Monitor blood glucose
  45. 45. Management  Provide supplemental oxygen to target a pulse oxygen saturation of 88 to 92% or PaO2 of 60 to 70 mmHg.
  46. 46.  Provide combination of aggressive bronchodilator therapy and ventilatory support (NPPV or invasive ventilation)
  47. 47.  Noninvasive positive pressure ventilation (NPPV): ◦ Appropriate for the majority of patients with severe exacerbations of COPD unless immediate intubation is needed or NPPV is otherwise contraindicated ◦ Contraindications to NPPV include: Severely impaired consciousness, inability to clear secretions or protect airway, high aspiration risk
  48. 48.  Tracheal intubation and mechanical ventilation: ◦ Indicated for patients with acute respiratory failure, hemodynamic instability (eg, heart rate <50/minute, uncontrolled arrhythmia) and those in whom NPPV is contraindicated or who fail to improve with NPPV and aggressive pharmacotherapy
  49. 49. Therapy Comments Antibiotics Recommended if two or more of the following are present: •Increased dyspnea •Increased sputum production •Increased sputum purulence Corticosteroids Oral or IV therapy may be used. If IV is used, it should be changed to oral after improvement in pulmonary status. If continued longer than 14 days, then the dose should be tapered to avoid HPA Axis suppression. Bronchodilators MDIs and DPIs equal in efficacy to nebulization. β-Agonists also may increase mucociliary clearance. Long-acting β-agonists or long-acting antimuscarinics should not be used for quick relief of symptoms or on an as-needed basis. Controlled oxygen therapy Titrate oxygen to desired oxygen saturation (>90%). Monitor arterial blood gas for development of hypercapnia. Noninvasive mechanical ventilation Consider for patients with acute respiratory failure. Not appropriate for patients with altered mental status, severe acidosis, respiratory arrest, or cardiovascular instability.
  50. 50. Pharmacotherapy Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 4 to 8 inhalations from MDI every hour Inhaled anticholinergic agent: Ipratropium 500 micrograms via nebulizer or 4 to 8 inhalations from MDI every four hours Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours) Antibiotic therapy: Appropriate for majority of severe COPD exacerbations; select antibiotic based on likelihood of particular pathogens (eg, Pseudomonas risk factors, prior sputum cultures, local patterns of resistance) Antiviral therapy (influenza suspected)*: Oseltamivir 75 mg orally every 12 hours OR peramivir 600 mg IV once (for patients unable to take oral medication)
  51. 51. Patient Characteristics Likely Pathogens Recommended Therapy Uncomplicated exacerbations <4 exacerbations per year No comorbid illness FEV1 >50% of predicted S. pneumoniae H. influenzae M. catarrhalis H. parainfluenzae Resistance uncommon Macrolide (azithromycin, clarithromycin) Second- or third-generation cephalosporin Doxycycline Therapies not recommendeda: TMP/SMX, amoxicillin, first- generation cephalosporins, and erythromycin Complicated exacerbations: Age ≥65 and >4 exacerbations per year FEV1 <50% but >35% of predicted As above plus drug-resistant pneumococci, β-lactamase– producing H. influenzae and M. catarrhalis Amoxicillin/clavulanate Fluoroquinolone with enhanced pneumococcal activity (levofloxacin, gemifloxacin, and moxifloxacin) Complicated exacerbations with risk of P. aeruginosa Chronic bronchial sepsisb Need for chronic corticosteroid therapy Resident of nursing home with <4 exacerbations per year Some enteric gram-negatives As above plus P. aeruginosa Fluoroquinolone with enhanced pneumococcal and P. aeruginosa activity (levofloxacin) IV therapy if required: β- lactamase resistant penicillin with antipseudomonal activity 3rd- or 4th-generation cephalosporin with antipseudomonal activity
  52. 52.  Supportive care  Cigarette smoking cessation  Thromboprophylaxis  Nutritional support
  53. 53. Roflumilast  Is a phosphodiesterase 4 inhibitor indicated to reduce risk of exacerbations in patients with severe COPD  Roflumilast may be beneficial in patients with severe or very severe COPD who are at high risk of exacerbation (Group C and D) and are not controlled by inhaled bronchodilators. It may also be considered for patients who are intolerant or unable to use inhaled bronchodilators or corticosteroids. Roflumilast is not recommended for us with theophylline because the drugs share similar mechanisms.
  54. 54. Ultibro (indacaterol/glycopyrrolate)  MOA: ◦ Indacaterol: selective long beta 2 agonist ◦ Glycopyrrolate: anticholinergic agent  Indication: chronic COPD only

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