Transcript (Download) - Welcome to Saudi Initiative for Asthma

The Saudi Initiative for Asthma
On behalf of the SINA group
Mohamed S. Al-Moamary, FRCP (Edin) FCCP
King Abdulaziz Medical City-Riyadh
King Saud bin Abdulaziz Uinversity for Health Scinces
June 2010
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Asthma
Diagnosis & Management
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Enter the presenter’s institute
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What is SINA?
SINA is developed by a task force originated from the
Saudi Initiative for Asthma Group under the umbrella of
the Saudi Thoracic Society
SINA is a practical approach for a comprehensive
management of asthma in adults and children and when
to refer to a specialist.
International recommendations were customized to the
local setting for asthma diagnosis and management
Directed to HCW dealing with asthma who are not
specialists in the field.
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Purpose of SINA
To provide a document that is easy to
follow, simple to understand yet totally
updated and carefully prepared for use by
non-asthma specialist including primary
care doctors and general practice
physicians
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Where do you find SINA?
The SINA guideline was published in the
Annals of Thoracic Medicine:
Al-Moamary MS, Al-Hajjaj MS, Idrees MM,
Zeitouni MO, Alanezi MO, Al-Jahdali HH, Al
Dabbagh M. The Saudi Initiative for asthma. Ann
Thorac Med 2009;4:216-33
(www.thoracicmedicine.org):
The SINA guidelines booklet is available
at: www.sinagroup.org
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Saudi Thoracic Society commitment
The STS is committed to improve the care
of asthma by a long term plan:
Periodic scientific meetings
Annual asthma meeting (since 2001)
Frequent asthma courses
Educational brochures
Publishing new and updated asthma
guidelines
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SINA Task Force
Mohamed S. Al-Moamary (Head), College of Medicine, King
Saud bin Abdulaziz University for Health Sciences, Riyadh
Mohamed S. Al-Hajjaj, College of Medicine, King Saud
University, Riyadh
Majdy M. Idrees, Military Hospital, Riyadh
Mohamed O. Zeitouni, King Faisal Specialist Hospital and
Research Center, Riyadh
Mohammed O. Alanezi, College of Medicine, King Saud bin
Abdulaziz University for Health Sciences, Riyadh
Hamdan H. Al-Jahdali, College of Medicine, King Saud bin
Abdulaziz University for Health Sciences, Riyadh
Maha M. Al Dabbagh, King Fahd Armed Forces Hospital,
Jeddah
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Acknowledgment
The Saudi Initiative for Asthma group would like
to thank the following reviewers :
• Prof. Eric Bateman from the University of Cape
Town Lung Institute, Cape Town, South Africa
• Prof. J. Mark FitzGerald from the University of
British Columbia, Vancouver, BC, Canada
• Prof. Ronald Olivenstein from the MeakinsChristie Laboratories and the Montreal Chest
Research Institute, Royal Victoria Hospital,
McGill University, Montreal, Quebec, Canada.
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SINA Documents
Published manuscript
Booklet
Electronic version
Slides kit
Flyers
Website: www.sinagroup.org
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Sections of SINA
Epidemiology
Pathophysiology
Diagnosis
Medications
Approach to Management
Treatment Steps
Special Situations
Acute Asthma
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Prevalence
Prevalence of
asthma has
increased
between 1986 –
1995
Alfrayyah et al. Ann Allergy Asthma
Immunol 2001;86:292–296
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Burden of Asthma
Asthma is among the most common chronic
illnesses in Saudi Arabia
53% had missed school or work (AIRKSA-2007)
35% attempted Unconventional therapy (Al Moamary,
ATM 2008)
46% were controlled in Riyadh (AIRKSA-2007)
36% were controlled in 5 tertiary care centers in
Riyadh (Aljahdali SMJ-2008)
48% were controlled in one center (Al Moamary, ATM 2008)
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AIRKSA report (Ministry of Health)
78 % of adults & 84% of kids reported acute
asthma over 12 months (AIRKSA)
54 % of adults & 80% of kids reported ER over
12 months (AIRKSA)
45-68% of adults & 37-56% of kids reported
limitation of activity over 12 months (AIRKSA)
76 % of adults & 78% of kids never had
spirometry(AIRKSA)
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Pattern of asthma treatment
Ann Thorac Med 2006;1:20-5
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Pathology of Asthma
Inflammation
Airway Hyper-responsiveness
Airway Obstruction
Symptoms of Asthma
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Pathophysiology
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Inflammation  Remodeling
Inflammation
Airway Hypersecretion
Subepithelial fibrosis
Angiogenesis
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Diagnosis - History
Episodic attacks:
Cough
Breathlessness
Wheezing
Nocturnal symptoms
Patient could be asymptomatic between attacks
co-existent conditions: GERD, rhinosinusitis.
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Relevant Questions
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Physical Examination
Normal between attacks
Bilateral expiratory wheezing
Examination of the upper airways
Other allergic manifestations: e.g., atopic
dermatitis/eczema
Consider alternative Dx when there is
localized wheeze, crackles, stridor,
clubbing
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Investigations
Measurements of lung function:
Spirometry
Peak expiratory flow (PEF)
Normal Spirometry does not role out asthma
Spirometry is superior to PEF
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Bronchodilator response
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Clinical Assessment
Measurements of allergic status to identify
risk factors (if indicated)
Chest X-ray is not routinely recommended
Routine blood tests are not routinely
recommended
IgE measurement is indicated in severe
cases
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Level of Control:
• Control:
20-24
• Partial control: 16-19
• Uncontrolled: < 16
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Differential Diagnosis
Upper airway diseases
Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Heart disease
Other causes
Recurrent cough not due to asthma
Aspiration from swallowing mechanism dysfunction or GERD
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Differential Diagnosis
COPD (e.g., chronic bronchitis or emphysema)
Congestive heart failure
Pulmonary embolism
Mechanical obstruction of the airways (benign
and malignant tumors)
Pulmonary infiltration with eosinophilia
Cough secondary to drugs (e.g., angiotensinconverting enzyme (ACE) inhibitors)
Vocal cord dysfunction
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Asthma in children < 5 years
The diagnosis is challenging
Asthma must be distinguished from other
causes of persistent and recurrent
wheezing
The earlier the onset of a wheeze, the
better the prognosis
A family history of atopy and asthma and
maternal atopy are strongly associated
with persistent childhood asthma
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Asthma in children < 5 years
Three categories of wheezing:
Transient early wheezing:
It outgrown in the first three years
It associated with prematurity and parental smoking.
Persistent early-onset wheezing:
Symptoms continue beyond the age of six
Associated with acute viral respiratory infections
and have no evidence of atopy
Late-onset wheezing/asthma:
Symptoms persist into childhood and adult life.
Atopic background, often with eczema
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Asthma in children < 5 years
No tests can diagnose asthma with
certainty.
Lung function testing is not very helpful
CXR may help to exclude structural
abnormalities of the airway.
A trial of treatment with short-acting
bronchodilators and inhaled
corticosteroids (ICS) for at least 8 to 12
weeks may provide some guidance as to
the presence of asthma.
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Management
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Patient/Dr Partnership
Enhance the chance of disease control
Agreed goals of management
Guided self-management plan
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Asthma Education
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Non-Adherence
Drugs:
Poor technique of
inhaler devices.
Regimen with multiple
drugs.
Occurrence of Side
effects from the drugs.
Cost of medications.
Non-drugs
Lack of knowledge
about asthma.
Lack of partnership in
the management.
Inappropriate
expectations.
Underestimation of
severity.
Cultural issues.
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Precipitating Factors
Indoor Allergens and Air Pollutants
Outdoor Allergens
Occupational Exposure
Food and Drugs
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www.tnfos.com
‫‪Self-management plan‬‬
‫لكل مريض خطة عالجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالته‬
‫‪ -1‬الحالة المستقرة ‪:‬‬
‫‪ ‬ممارسة الحياة بشكل طبيعي (لعب ‪ ،‬نوم ‪ ،‬دراسة)‬
‫‪ ‬إختفاء أعراض الربو في الليل ‪.‬‬
‫‪ ‬ندرة إستخدام البخاخ في الموسع للشعب الهوائية (أقل من ‪ 3‬مرات أسبوعيا ً)‬
‫‪ ‬سرعة تدفق الهواء أكثر من ‪ %80‬من الحد الطبيعي‬
‫‪ - 2‬الحالة المتوسطة اإلستقرار (أزمة ربو على وشك الحدوث) ‪:‬‬
‫‪ 3‬مرات يوميا ً ‪.‬‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية أكثر من‬
‫‪ ‬اإلستيقاظ في الليل بسبب (كحة ‪ ،‬كتمة ‪ ،‬صفير في الصدر)‬
‫‪ ‬وجود أعراض نزلة برد فيروسية ‪.‬‬
‫‪ ‬القدرة على نفخ الهواء بين ‪ % 80 – 60‬من الحد الطبيعي ‪.‬‬
‫‪ - 3‬الحالة المتأزمة الحادة (سارع بطلب المساعدة الطبية)‬
‫إذا لم تحدث استجابة لما سبق أو حدث ‪:‬‬
‫‪ ‬زيادة أعراض أزمة الربو ‪.‬‬
‫‪ ‬عدم القدرة على إتمام كلمتين في نفس واحد ‪.‬‬
‫‪ ‬عودة أعراض الربو بعد أقل من نصف ساعة من إستخدام البخاخ الموسع‬
‫للشعب الهوائية ‪.‬‬
‫‪ ‬القدرة على نفخ الهواء أقل ‪ %50‬من الحد الطبيعي ‪.‬‬
‫(توجه للطوارئ أو أطلب اإلسعاف)‪ :‬إذا تدهورت أزمة الربو على الرغم من‬
‫اإلجراءات السابقة ‪ ،‬أو حدث إزرقاق فياألطراف أو تدهور في مستوى الوعى ‪ ،‬أو تدني‬
‫‪www.sinagroup.org‬‬
‫المعدل الطبيعي‬
‫في سرعة تدفق الهواء ألقل من ‪ % 50‬من‬
‫‪www.tnfos.com‬‬
‫اإلجراء الواجب إتباعه ‪ :‬اإلستمرار على األدوية المعطاة ‪:‬‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية _____بخة كل ____ ساعات عند الضرورة‬
‫وقبل التمارين ارياضية ب ‪ 30 – 15‬دقيقة ‪.‬‬
‫‪ ‬إستخدام البخاخ الواقي _____ بخة ______ مرة يوميا ً و بشكل منتظم لمدة (‬
‫أدوية أخرى ‪:‬‬
‫)‪.‬‬
‫اإلجراء الواجب إتخاذه ‪:‬‬
‫‪ ‬زيادة جرعة البخاخ الواقي______ إلى ______بخة _____مرة يوميا ً لمدة ‪10‬أيام‬
‫ثم الرجوع إلى الجرعة السابقة‬
‫(‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية‬
‫) بخة كل ____ساعات بإنتظام لمدة _____أيام أو حتى تتحسن الحالة‬
‫‪ ‬إستشارة الطبيب في أقرب وقت ممكن ‪.‬‬
‫)(‬
‫اإلجراء الواجب إتخاذه ‪:‬‬
‫‪ ‬إستخدام البخاخ الموسع للشعب الهوائية___ بخة كل ____ ساعات‬
‫‪‬طلب اإلستشارة الطبية بصفة عاجلة ‪.‬‬
‫‪ ‬زيادة جرعة البخاخ الواقي ____)إلى______ بخة ____)مرة يوميا ً لمدة‬
‫‪10‬أيام ثم الرجوع إلى الجرعة السابقة عمل ما يلي ‪:‬‬
‫‪‬البد من التوجه لقسم الطوارئ فوراً ‪.‬‬
Asthma Medications
Controllers are medications taken daily
on a long-term basis to keep asthma
under clinical control chiefly through their
anti-inflammatory effects.
Relievers are medications used on an asneeded basis that act quickly to reverse
bronchoconstriction and relieve
symptoms.
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Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled B2-agonists
Theophylline
Anti-IgE
Systemic glucocorticosteroids
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Inhaled Corticosteroids
The most effective antiinflammatory
medications for the treatment of asthma
Benefits of ICS:
Reduce symptoms:
improve quality of life
improve lung function
decrease airway hyperresponsiveness
control airway inflammation
reduce frequency and severity of
exacerbations, and reduce mortality.
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Inhaled Corticosteroids
When ICS discontinued, deterioration of
clinical control follows within weeks to
months in most patients
Most of the benefits from ICS are achieved
in adults at relatively low doses
Increasing to higher doses may provide
further benefits in terms of asthma control
but increases the risk of side effects
Tobacco smoking reduces the
responsiveness to ICS
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Inhaled Corticosteroids
To reach control, add-on therapy with
another class of controller is preferred to
increasing the dose of ICS
ICS are generally safe and well-tolerated
Though low-medium dose of ICS may
affect growth velocity, this effect is
clinically insignificant and may be
reversible.
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Inhaled Corticosteroids
Local adverse effects:
oropharyngeal candidiasis
Dysphonia – may be e reduced by using MDI
+ spacer devices and mouth washing
Systemic side effects are occasionally
reported with high doses and long-term
treatment
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Inhaled Corticosteroids
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Leukotriene modifiers (LTRA)
LTRA reduce airway inflammation and
improve asthma symptoms and lung
function but with a less consistent effect
on exacerbations, especially when
compared to ICS.
Alternative treatment to ICS for patients
with mild asthma, especially in those who
have clinical rhinitis
Some patients with aspirin-sensitive
asthma respond well to the LTRA
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Leukotriene modifiers (LTRA)
Available as Montelokast in Saudi Arabia
Their effects are generally less than that of
low dose ICS
When added to ICS, LTRA may reduce
the dose of ICS required by patients with
uncontrolled asthma, and may improve
asthma control
LTRA are generally well-tolerated. There
is no clinical data to support their use
under the age of six months.
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LABA
LABA: (formoterol and salmeterol)
Should not be used as monotherapy
Combination with ICS lead to:
improves symptoms
decreases nocturnal asthma
improves lung function
decreases the use rapid-onset inhaled B2-agonists
reduces the number of exacerbations
achieves clinical control of asthma in more patients,
more rapidly, and at a lower dose of ICS
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Combination devices
Sympicort turbohaler:
Budesonide/Formeterol: 160/4.5
Seretide:
Fluticasone/Salmeterol
Evohaler: 50/8
125/8
Diskus:
100/16
250/16
250/8
500/16
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Theophylline
Weak bronchodilator with modest antiinflammatory properties.
It may provide benefit as add-on therapy in
patients who do not achieve control on ICS
alone
Less effective than LABA and LTR.
Side effects:
gastrointestinal symptoms
cardiac arrhythmias
seizures, and even death
Drug interaction
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Anti-IgE
Omalizumab (Xolair) indication:
Uncontrolled severe allergic asthma on high
dose ICS and other controllers.
Needs specialist consultation.
Side effects:
Pain and bruising at injection site and very
rarely anaphylaxis (0.1%).
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Oral glucocorticosteroids
Long-term oral glucocorticosteroid therapy may
be required for uncontrolled asthma despite
maximum standard therapy.
It is limited by the risk of significant adverse
effects.
Side effects:
Osteoporosis, hypertension, diabetes, adrenal
insufficiency, obesity, cataracts, glaucoma, skin
thinning, and muscle weakness. Withdrawal can elicit
adrenal failure.
In patients prescribed long-term systemic
glucocorticosteroids, prophylactic treatment for
osteoporosis should be considered.
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Reliever Medications
Short-acting inhaled B2-agonists
Anticholinergics
Theophylline
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Short-acting B2-agonists
The medications of choice for symptoms relief
Pretreatment for exercise-induced
bronchoconstriction.
Formoterol is used for symptom relief because
of its rapid onset of action.
Increased use, especially daily use, is a
warning of deterioration of asthma control
Side effects: B2-agonists are associated with
adverse systemic effects such as tremor and
tachycardia.
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Anticholinergics
Less effective than SABA.
Used in combination in acute asthma.
An alternative bronchodilator for patients
with adverse effects from rapid acting
B2agonists.
Side effects: can cause a dryness of the
mouth and a bitter taste.
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Asthma control
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Principles of management
1. Initiation
2. Adjustment
3. Maintenance
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Initiation of treatment
Step 1  SABA on as needed bases
Step 2  For patients who are not
currently taking long-term controller
medications.
Step 3  If the initial symptoms are more
frequent.
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Initiation of treatment based on
Asthma Control Test
The consensus among SINA panel is to
simplify the approach to initiate asthma
therapy by using ACT
ACT Score ≥ 20
 Step 1
ACT Score 16–19  Step 2
ACT Score 16
 Step 3
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Adults Patients with Asthma
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Children with Asthma
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Assessment of Asthma Control
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Approach to Asthma Treatment
in Adults
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Approach to Asthma Treatment
in Children
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Principles of Asthma Treatment
Daily long-term controller medication is needed
ICS are considered as the most effective
controller
Relievers or rescue medications must be
available to all patients at any step
SABA or rapid onset LABA should be taken as
needed to relieve symptoms
Increasing use of reliever treatment is usually an
early sign of worsening asthma control
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Principles of Asthma Treatment
Treat patients who may have seasonal asthma
as having uncontrolled asthma during the
season at step 1 for the rest of the year
Patients who had two or more exacerbations
requiring oral corticosteroids or hospital
admissions in the past year should be treated as
patients with uncontrolled asthma, even if the
level of control seems good in between the
exacerbations
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Step 1 - Recommendations
The symptoms are usually mild and
infrequent
If patient may experience sudden, severe,
and life-threatening exacerbations, treat
these exacerbations accordingly
Consider rapid onset B2-agonist to be
taken “as needed” to treat symptoms
If B2-agonist use increases to more than
two days a week, treate as partially
controlled asthma
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Step 2 - Recommendations
The preferred recommendation is daily
ICS at a low dose (< 500 μg of
beclomethasone equivalent/day
Alternative treatments include LTRA
(montelukast)
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Step 3 – Recommendations
Add a LABA to a low-medium dose ICS for
patients whose asthma is not controlled on
a low dose ICS alone, such as:
Fluticasone/Salmeterol (Seretide)
Budesonide/Formoterol (Symbicort)
Use a maintenance dose of the
combination drugs twice daily
Use the rapid onset B2-agonist as a
reliever treatment (Evidence A).[129]
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Step 3 - S.M.A.R.T® approach
S.M.A.R.T® approach: Use of
Formoterol/Budesonide for both rescue
and maintenance
Maintenance dose single inhaler (1–2 puff
160/4.5 BID) is selected plus extra puffs from
the same inhaler up to a total of 12 puffs per
day.
Those patients who require such high dose
should seek medical advice to step up
therapy that may include use of short course
of oral prednisone.
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Step 3 - GOAL study
GOAL study has shown that an escalating
dose of combination of Fluticasone/
Salmeterol (Seretide) achieves
Well controlled asthma in 85% of patients
Totally controlled asthma in 30% of patients
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Step 3 – Alternative therapy
Increasing the dose ICS to the medium to
high dose range as a monotherapy
Adding LTRA to a low-medium dose ICS,
especially with concomitant rhinitis
Adding sustained release theophylline to a
low-medium dose ICS
Consultation with a specialist is
recommended for patients whenever there
is a difficulty in achieving control
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Step 4 – Recommendations
Maximizing treatment is recommended by
combining high-dose ICS with LABA
Adding LTRA or theophylline to high-dose
ICS and LABA should be considered
Omalizumab may be considered:
Allergic asthma (as determined by skin test or
RAST study) and still uncontrolled.
Special knowledge about the drug
Consultation is recommended
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Step 5 - Recommendations
Omalizumab to be considered for patients
who have allergic asthma and persistent
symptoms despite the maximum therapy
mentioned above
lowest possible dose of long-term oral
corticosteroids for patient who:
Does not have allergic asthma
Omalizumab is not available or not
adequately controlling the disease
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Step 5 – long term steroids
Long-term systemic corticosteroids:
lowest possible dose to maintain control
Monitor for the development of side effects
Continue attempts to reduce the dose
Maintaining high-dose of ICS therapy
Strongly consider concurrent treatments with
calcium supplements and vitamin D
Consultation is mandatory
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Asthma Control for Children
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Children younger than 5 years
The most effective bronchodilator
available is SABA
If control is not achieved and controller
treatment commenced, the lowest dose of
ICS delivered by MDI and a spacer
LTRA is considered as an alternative
therapy especially when there is
concomitant rhino-sinusitis.
Doubling the dose of ICS If asthma control
is not achieved on low dose ICS
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Children younger than 5 years
If asthma is not controlled, increase ICS
dose to the maximum, and/or adding a
LTRA or theophylline
Low dose of oral corticosteroids for a few
weeks should be limited to severe
uncontrolled cases
Seasonal symptoms: discontinue daily
controller therapy after the season
Frequent episodes by severe viral
infection may justify a trial of ICS
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Maintaining Control
Regular follow-up is essential
Follow-up at 1- to 6- month intervals is
recommended, depending on the level of
control
Consider 3- month intervals, if a step down
in therapy is anticipated.
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Allergen Immunotherapy (AIT)
gradual immunization by increasing doses
of standardized allergen responsible for
causing allergic symptoms either
subcutaneously or sublingually
This will induce increased tolerance to the
allergen that may provide long-term relief
of symptoms during subsequent exposure
to the same allergen
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Allergen Immunotherapy (AIT)
AIT is more effective in seasonal asthma
than in perennial asthma particularly when
used against a single allergen
AIT may be considered if strict
environmental avoidance and
pharmacologic intervention have failed to
control asthma
Side effects include systemic allergic
reactions, occasional anaphylaxis and,
even, rare fatalities
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Special Situations
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Asthma and pregnancy
Present in up to 8% of pregnant women.
Unpredictable course: one third will have
worsening of their of asthma control
Maintaining adequate control of asthma
during pregnancy is essential for the
health and well-being of both the mother
and her baby.
Identifying and avoiding triggering factors
should be the first step of therapy for
asthma during pregnancy
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Asthma and pregnancy
Same stepwise approach as in the
nonpregnant patient.
Salbutamol is the preferred SABA
ICSs are the preferred controllers
Use of ICS, theophylline, antihistamines,
B2-agonists, and LTRA is generally safe
Acute exacerbations of asthma during
pregnancy should be treated on the same
outlines as in nonpregnant patients
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Cough-variant asthma
Cough is the main symptom
It is common in children, and is often more
problematic at night
Other diagnoses to be considered are:
Drug-induced cough caused by angiotensinconverting-enzyme inhibitors
GERD
Postnasal drip and chronic sinusitis
Treatment is similar to long-term
management of asthma
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Exercise-induced Asthma
Bronchoconstriction peaks within 10 to 15
minutes after completing the exercise and
resolves within 60 minutes.
Prevention:
SABA before exercise
Warm-up period before exercise
Some patients may need maintenance
therapy
Regular use of LTRA may help in this
condition especially in children
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Aspirin/NSAID induced Asthma
Occurs in 10–20% of adults with asthma
The majority experience first symptoms
during the third to fourth decade.
Once aspirin or NSAID hypersensitivity
develops, it is present for life.
Within 1-2 hours following ingestion of
aspirin, an acute, severe attack develops,
and is usually accompanied by rhinorrhea,
nasal obstruction, conjunctival irritation,
and scarlet flush of the head and neck
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Aspirin/NSAID induced Asthma
Prevention by avoidance of aspirin/NSAID
Patients for whom aspirin is considered
essential, they should be referred to an
allergy specialist for aspirin desensitization
Aspirin and NSAID can be used in
asthmatic patients who do not have aspirin
induced asthma
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GERD triggered asthma
GERD is more prevalent in asthmatics
Mechanisms of GERD triggered asthma:
vagal mediated reflex
reflux of micro-aspiration of gastric contents
into the upper airways
If GERD symptoms presents, a trial of
GERD therapy for 6–12 weeks and lifestyle
modifications may be considered
Asymptomatic patients with uncontrolled
asthma may not benefit from GERD therapy
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Management of Acute Asthma
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Management of Acute Asthma
Mortality reported in patients who have
received inadequate treatment or poor
education
The following should be carefully checked:
Previous history of near fatal asthma
Patient on three or more medications
Heavy use of SABA
Repeated visits to emergency department
Brittle asthma
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Severity of acute asthma
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Initial Management of Acute Asthma
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Oxygen
High concentration of inspired oxygen
should be used to correct hypoxemia
Pulse oximetry should be used to tailor
oxygen therapy
Failure to achieve oxygen saturations
of more than 92% is a good predictor of
the need for hospitalization
Normal or high PaCO2 is an indication
of a severe attack, and the need for
specialist consultation
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Bronchodilators
Inhaled salbutamol is the preferred
choice
Repeated doses should be given at 15–
30 minute intervals.
Alternatively, continuous nebulization
(Salbutamol at 5–10 mg/hour) may be
used for one hour if there is an
inadequate response to initial
treatment.
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Bronchodilators
In patients who are able to use the
inhaler devices, 6–12 puffs of MDI with
a spacer are equivalent to 2.5 mg of
Salbutamol by nebulizer
In moderate to severe acute asthma,
combining ipratropium bromide with
Salbutamol has some additional
bronchodilation effects, in reducing
hospitalizations and greater
improvement in PEF or FEV1
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Steroid therapy
Systemic steroids: reduce relapses and
subsequent hospital admission
Oral steroid = injected steroids
Oral prednisolone: 40–60 mg daily
Parenteral steroids:
Hydrocortisone: 300–400 mg/day
Methylprednisolone: 60–80 mg/day
Systemic steroids should be given for
seven days for adults and three to five
days for
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Magnesium sulphate
A single dose of IV magnesium
sulphate (1.2–2 gm IV infusion over 20
mins) is safe and effective
Routine use of IV magnesium sulphate
in patients with acute asthma
presenting to emergency department is
not recommended.
Its use should be limited to those with
sever exacerbation who fail to respond
to treatment after an hour
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Intravenous aminophylline
In acute asthma, the use of intravenous
aminophylline did not result in any
additional bronchodilation compared to
standard care with B2-agonists
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Antibiotics
Viral infection is the usual cause of
asthma exacerbation
The role of bacterial infection has been
probably overestimated, and routine
use of antibiotics is strongly
discouraged
They should be used when there is
associated pneumonia or bacterial
bronchitis
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Referral to a specialist center
Status asthmatics
Deteriorating PEF
Persisting or worsening hypoxia
Hypercapnea, respiratory acidosis (pH <7.3)
Severe exhaustion
Increase work of breathing
Drowsiness
Confusion
Coma
Respiratory arrest
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Criteria for admission
Patients whose peak flow is ≥ 60% best or
predicted one hour after initial treatment can be
discharged from the emergency department
Criteria for admission:
Any feature of a life threatening, near fatal attack
Any feature of a severe attack that persists after initial
treatment.
unless any of the following is present:
still suffering from significant symptoms
previous history of near fatal or brittle asthma
concerns about compliance and pregnancy
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Acute asthma in children < 5 years
Early symptoms of an acute exacerbation
would usually follow an upper respiratory
infection.
Ssymptoms: shortness of breath, wheeze,
nocturnal cough, exercise intolerance .
Initiation of treatment: two puffs (200 μg(
of salbutamol via spacer is recommended
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Acute asthma in children < 5 years
Immediate medical attention should be
taken in case of children less than two
year who had a history of poor response to
three doses of SABA within 1–2 hours,
saturation less than 92%, or the child is
acutely distressed.
In this age group, the risk of fatigue,
respiratory compromise and dehydration is
considerable
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