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epidemiology pathophysiology of asthma management of asthma at ER prevention of asthma exacerbation
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
100000 80000 60000 40000 20000 0 2538 2539 2540 76202 66679 79769
90606
2543
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
1500
0 2543 2544
Airway obstruction
Uneven ventilation
Wasted ventilation
VO2 ,VCO2
V/Q mismatching
Hypoxemia, hypercapnia
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 ?
Physical examination
inability to lie supine impaired sensorium inability to speak use of accessory muscle RR >30 PR >120
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
Classes of b2-agonists
Speed of onset
RESCUE MEDICATION
fast onset, long duration
fast
inhaled formoterol
slow
M A I N T E N A N C E
short
long
Duration of action
Ipratropium bromide
The effect of adding Ipratropium bromide to salbutamol in the treatment of acute asthma
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)
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
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
Magnesium Helium Oxygen therapy (Heliox ) general anesthesia Montelukast
Predicitive Index
Poor Response
PEFR at 30 min after treatment<40% predicted Change in PEFR at 30 min after treatment <60 L/Min
Admit
PEF>50%
B2-agonist q 20 min + Corticosteroid
PEF<50%
B2-agonist +IB q 20 min + Corticosteroid
Admit
NIH.NAEPP 1997
Airway inflammation
Symptoms
Stimuli
Remodelling
Airway Hyperresponsiveness
Facilitated referral to asthma spectialist reduces relapses in asthma emergency room visits
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