Acute Asthma Exacerbation

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Acute Asthma Exacerbation
Clinical Presentation
Minimal no signs or symptoms
No cough
No wheezing
No chest tightness
No shortness of breath at day or night
Able to do all normal activities
Worse signs and symptoms
Cough
Wheezing
Chest tightness
Shortness of Breath
Waking at night with symptoms
Able to do some normal activities
Life threatening signs and symptoms
Very short of breath
Difficult to walk or talk
Blue lips or fingernails
Medications not working
Unable to do activities
Diagnosis
Confirmed by a worsening of symptoms: like wheezing, frequent cough, shortness of breath or chest tightness.
Low Expiratory Flow Rates (i.e. Peak Flow)
Identification of underlying triggers or infection
Respiratory alkalosis and hypoxemia
Respiratory Acidosis is a late diagnosis sign showing impending respiratory failure in acute asthma exacerbations.
Pulsus Paradoxus - a consequence of lung hyperinflation
Tachypnea & Tachycardia
Hypercapnia
Epidemiology
Pros
The death rate from Asthma has been on a steady decline sine 1995.
Asthma is controllable in combination with preventative care and proper treatment.
New pharmacologic treatments provides the ability to better control Asthma.
Cons
Asthma effects as many as one third adolescents in some countries.
Prevalence rate in American is around 4-8%.
Boys are more frequently effected that girls.
Around 26 million people and 7 million children are effected by Asthma in America.
Pathophysiology
Bronchoconstriction in the trachea, bronchi, and bronchioles.
Airway walls dilate and leak secretions, oedema, adding to the overall narrowing and hyper-responsiveness of the airway.
Unmyelinated afferent fibers in combination with peptide neurotransmitters can induce smooth muscle or bronchospasm.
Mast cell degranulation leads to vasoactive mediators increasing vasodilation and capillary permeability while chemotactic mediators increase cellular infiltration with the over-production of neutrophils, eosinophils, and lymphocytes.
An abnormal narrowing and hypersensitive, congested airway.
Outpatient Treatment
Green Zone: Doing Well
•No cough, wheeze, chest tightness, or shortness of breath during the day or night •Continue normal activities
+Continue long-term control medications daily and any medications needed before activities.
---> What is your best peak flow reading?
Yellow Zone: Asthma Is Getting Worse
•Cough, wheeze, chest tightness, or shortness of breath, or
•Waking at night due to asthma; You can do some but not all normal activities.
--->Is Peak Flow between 50-79% of best peak flow?
Continue to take all Green Zone medication and add quick relief medication: Short-acting beta2-agonist -->every 20 minutes up to an 1 hour/ two-four puffs. Use Nebulizer if available.
If symptoms resolve, return to Green Zone. If they do not continue in Yellow Zone and call MD for possible use of oral steroid in addition to nebulizer and short-acting beta2-agonist.
Red Zone: Medical Alert!
•Very short of breath and Quick-relief medicines are not helping.
•Cannot do normal activities. •Shortness of breath making it difficult to walk or talk.
•Blue lips or fingernails.
•In the Yellow Zone for over 24 hours with similar or worse symptoms.
---> Is peak flow less than 50% of your best?
**Continue taking medications in Yellow Zone and CALL MD. ***Take 4-6 puffs of quick-acting medications
****Call 911 or go straight to the hospital if symptoms continue past 15 minutes and/or you have not reached your doctor.
Inpatient Treatment
Oxygen
Inhaled short-acting beta 2-agonist intermittently or continuously
Corticosteroids - oral or intravenously
Consider other therapies
Monitor patient closely: SpO2,FEV1, PEF, and vitals.
In extreme cases consider intubation
References
American Lung Association, (2016). Asthma Action Plan. Lung Health & Diseases. Retrieved from http://www.lung.org/assets/documents/asthma/asthma-action-plan.pdf.
American Lung Association, (2016). How is Asthma Diagnosed? Lung Health & Diseases. Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease lookup/asthma/diagnosing-treating-asthma/how-is-asthma-diagnosed.html
American Lung Association, (2016). Learn about Asthma. Lung Health & Diseases. Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/learn-about-asthma/
Pollart, S. (2011). Management of Acute Asthma Exacerbations. American Family Physician. 84(1):40-47. Retrieved from http://www.aafp.org/afp/2011/0701/p40.html
Huether, S.E. & McCance, K. L. (2012). Understanding pathophysiology (Laureate custom ed.). St. Louis, MO: Mosby.
McPhee, S. J., & Hammer, G. D. (2010). Pathophysiology of disease: An introduction to clinical medicine (Laureate Education, Inc., custom ed.). New York, NY: McGraw-Hill Medical.
Zimbron, J. (2008). Mind maps—Dementia, endocarditis, and gastro-oesophageal reflux disease (GERD) [PDF]. Retrieved from http://MedMaps.co.uk
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