la crisi asmatica angelo corsico clinica di malattie dell’apparato respiratorio fondazione irccs...
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LA CRISI ASMATICA
Angelo Corsico
Clinica di Malattie dell’Apparato Respiratorio
Fondazione IRCCS Policlinico S.Matteo
Università di Pavia
le urgenze pneumologiche in pronto soccorsoPavia, 24 novembre 2006
le urgenze pneumologiche in pronto soccorsoPavia, 24 novembre 2006
PremessaGestione delle crisi asmaticheLa gestione in Pronto SoccorsoAltri trattamenti
Six-part Asthma Management Program
Part 5: Managing Severe Asthma Exacerbations
Six-part Asthma Management Program
Part 5: Managing Severe Asthma Exacerbations
Severe exacerbations are life-threatening medical emergencies
Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department
Severe exacerbations are life-threatening medical emergencies
Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department
Adult and child asthma emergency department rates, United States: 1992–2001
Source: National Hospital Ambulatory Care Survey; National Center for Health Statistics
0
20
40
60
80
100
120
140
92 94 96 98 2000
Rate
per
10,0
00
ChildrenChildren
AdultsAdults
During exacerbations: a linear decline of PEF over a period of a few days, a sharp point of inflection, then a linear increase.
During poor asthma control: wide diurnal variability and bronchodilator reversibility.
Reddel, Lancet 1999
Severe asthma
7%
Clinical respiratory infections
15%
Acute exposure to allergens or other
triggers
14%
Poor asthma control (inadequate treatment)
64%
% OF SUBJECTS WITH ED ADMISSIONS % OF SUBJECTS WITH ED ADMISSIONS BY CAUSES OF ASTHMA ATTACKBY CAUSES OF ASTHMA ATTACK
EMERGENCY VISITS FOR ASTHMAEMERGENCY VISITS FOR ASTHMAPoliclinico San Matteo, Pavia 2002 Policlinico San Matteo, Pavia 2002
Cerveri et al. ATS 2004
Rapid exacerbation characterized by one or more of the following features:
Accessory muscle activity Paradoxical pulse exceeding 25 mmHg Heart rate > 100 beats/min Respiratory rate > 25-30 breaths/min Limited ability to speak PEF rate or FEV1 < 50% pred.
Arterial oxygen saturation < 91-92%
CONSENSUS DEFINITION OF ACUTE SEVERE ASTHMA
McFadden, AJRCCM 2003
Deaths Due to Asthma, United States, 1979-2001
Source: Compressed Mortality Files
0
1000
2000
3000
4000
5000
6000
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
Year
age group0 to 4 5 to 14 15 to 34 35 to 64 65 +
Krishnan, AJRCCM 2006
Our study indicates that 1,499 deaths (33% of all 4,487 deaths from asthma in the United States in 2000) occurred in patients hospitalized for asthma exacerbations.
Improvements in the management of asthma exacerbations before hospitalization (e.g., at home, during transportation to the emergency department) will have the greatest benefit in further reducing the overall risk of death.
Becker, JACI 2004
263 potential asthma-related athletic deaths between July 1993 and December 2000.
The subjects were usually white male aged 10 to 20 years.
Mild intermittent or persistent asthma by history was commonly identified.
Sudden fatal asthma exacerbations occur in both competitive and recreational athletes and can be precipitated by sporting activity.
The positive benefits to an active lifestyle cannot be negated by the risks outlined here.
le urgenze pneumologiche in pronto soccorsoPavia, 24 novembre 2006
PremessaGestione delle crisi asmaticheLa gestione in Pronto SoccorsoAltri trattamenti
Key PointsKey Points
Early treatment is best. Early treatment is best. Important elements:Important elements:– A written action planA written action plan
Guides patient self-management at homeGuides patient self-management at homeEspecially important for patients with moderate-to-severe persistent asthma and Especially important for patients with moderate-to-severe persistent asthma and
any patient with a history of severe exacerbationsany patient with a history of severe exacerbations– Recognition of early signs of worsening asthmaRecognition of early signs of worsening asthma– Prompt communication between patient and clinician about:Prompt communication between patient and clinician about:
Serious deterioration in symptoms or peak flow, orSerious deterioration in symptoms or peak flow, or
Decreased responsiveness to inhaledDecreased responsiveness to inhaledbetabeta22-agonists, or-agonists, or
Decreased duration of betaDecreased duration of beta22-agonist effect-agonist effect
Risk Factors for Risk Factors for Death From AsthmaDeath From Asthma
Past Past historyhistory of sudden severe exacerbations of sudden severe exacerbations Prior Prior intubationintubation or admission to ICU for asthma or admission to ICU for asthma ≥≥2 2 hospitalizationshospitalizations for asthma in the past year for asthma in the past year ≥≥3 3 ED visitsED visits for asthma in the past year for asthma in the past year Hospitalization or an ED visit for asthmaHospitalization or an ED visit for asthma
in the past monthin the past month
Use of Use of >2 canisters per month>2 canisters per month of inhaled short-acting of inhaled short-acting betabeta22-agonist-agonist
Risk Factors for Risk Factors for Death From Asthma Death From Asthma (continued)(continued)
Current use of Current use of systemic corticosteroids systemic corticosteroids or recent or recent withdrawal from systemic corticosteroidswithdrawal from systemic corticosteroids
Difficulty perceivingDifficulty perceiving airflow obstruction airflow obstructionor its severityor its severity
ComorbidityComorbidity, as from cardiovascular diseases or , as from cardiovascular diseases or chronic obstructive pulmonary diseasechronic obstructive pulmonary disease
Serious Serious psychiatric diseasepsychiatric disease or psychosocial or psychosocial problemsproblems
Risk Factors for Risk Factors for Death From Asthma Death From Asthma (continued)(continued)
Low Low socioeconomic statussocioeconomic status and andurban residenceurban residence
Illicit Illicit drug usedrug use
Sensitivity to Sensitivity to AlternariaAlternaria
Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Primary therapies for exacerbations: Repetitive administration of rapid-acting
inhaled β2-agonist Early introduction of systemic
glucocorticosteroids Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function
Primary therapies for exacerbations: Repetitive administration of rapid-acting
inhaled β2-agonist Early introduction of systemic
glucocorticosteroids Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function
Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the
particular patient Availability of medications Emergency facilities
Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the
particular patient Availability of medications Emergency facilities
le urgenze pneumologiche in pronto soccorsoPavia, 24 novembre 2006
PremessaGestione delle crisi asmaticheLa gestione in Pronto SoccorsoAltri trattamenti
Brief Physical ExamBrief Physical Exam
Assess severity: Assess severity: Alertness, distress, accessory Alertness, distress, accessory muscle use, tachycardia, tachypnea, pulsus muscle use, tachycardia, tachypnea, pulsus paradoxus, cyanosisparadoxus, cyanosis
Identify complications Identify complications (e.g., pneumonia, (e.g., pneumonia, pneumothorax, pneumomediastinum)pneumothorax, pneumomediastinum)
Identify diseases that affect asthmaIdentify diseases that affect asthma(otitis, rhinitis, sinusitis)(otitis, rhinitis, sinusitis)
Rule out upper-airway obstructionRule out upper-airway obstruction
Functional AssessmentFunctional Assessment
Measure FEVMeasure FEV11 or PEF: or PEF: Upon presentation (begin treatment as soon as Upon presentation (begin treatment as soon as
asthma exacerbation is recognized)asthma exacerbation is recognized) At intervals depending on response to therapyAt intervals depending on response to therapy Before dischargeBefore discharge
Monitor SaOMonitor SaO22 in patients with severe distress in patients with severe distress
or with FEVor with FEV11 or PEF <50% predicted or PEF <50% predicted
Brief HistoryBrief History(after treatment is initiated)(after treatment is initiated)
Time of onset and Time of onset and cause of exacerbationcause of exacerbation
Severity of symptomsSeverity of symptoms, especially compared to previous attacks, especially compared to previous attacks
All current medicationsAll current medications and time of last dose and time of last dose
Prior Prior hospitalizations and ED visitshospitalizations and ED visits, especially in past year, especially in past year
Prior episodes of Prior episodes of respiratory failurerespiratory failure or loss of consciousness or loss of consciousness due to asthmadue to asthma
Existence of Existence of comorbiditiescomorbidities
Laboratory AssessmentLaboratory Assessment
Consider Consider ABGABG in patients with suspected in patients with suspected hypoventilation, severe distress, or with FEVhypoventilation, severe distress, or with FEV11 or PEF or PEF
<30% predicted after initial treatment<30% predicted after initial treatment CBCCBC may be appropriate in patients with fever or may be appropriate in patients with fever or
purulent sputumpurulent sputum Serum Serum theophylline concentrationtheophylline concentration Serum Serum electrolytes, chest x-ray, ECGelectrolytes, chest x-ray, ECG in in
special circumstancesspecial circumstances
Emergency Department and Emergency Department and Hospital Management:Hospital Management: Goals Goals
Correction of significant hypoxemiaCorrection of significant hypoxemia
Rapid reversal of airflow obstructionRapid reversal of airflow obstruction
Reduction of likelihood of recurrenceReduction of likelihood of recurrence
Initial TreatmentInitial Treatment OxygenOxygen to achieve O to achieve O22 saturation saturation >>90%90%
FEV1 or PEF >50%:FEV1 or PEF >50%: Inhaled Inhaled betabeta22-agonist by metered-dose-agonist by metered-dose inhaler or inhaler or
nebulizer, up to three treatments in first hournebulizer, up to three treatments in first hour
FEV1 or PEF <50%:FEV1 or PEF <50%: Inhaled Inhaled high-dose beta2-agonist and anticholinergic high-dose beta2-agonist and anticholinergic by nebulizationby nebulization every 20 minutes or continuously for 1 hour every 20 minutes or continuously for 1 hour
Oral corticosteroidsOral corticosteroids
Repeat assessmentRepeat assessment (symptoms, physical exam, PEF, O (symptoms, physical exam, PEF, O2 2 saturation, other saturation, other
tests as needed)tests as needed)
Initial Treatment Initial Treatment (continued)(continued)
Impending or Actual Respiratory ArrestImpending or Actual Respiratory Arrest
Intubation and Intubation and mechanical ventilationmechanical ventilation with 100% O with 100% O2 2
Nebulized betaNebulized beta22-agonist and anticholinergic-agonist and anticholinergic
Intravenous corticosteroidIntravenous corticosteroid Admit to hospital intensive careAdmit to hospital intensive care
Treatment After Repeat AssessmentTreatment After Repeat Assessment
• Physical exam:Physical exam: moderate moderate symptomssymptoms
• FEVFEV11 or PEF > 50% or PEF > 50%
predicted or personal best predicted or personal best
• Inhaled Inhaled short-acting betashort-acting beta22--
agonist every 60 minutesagonist every 60 minutes• Systemic corticosteroidSystemic corticosteroid• Continue treatmentContinue treatment 1 to 3 1 to 3
hourshours, provided there is , provided there is improvementimprovement
• Physical exam: Physical exam: severe severe symptomssymptoms at rest, accessory at rest, accessory muscle use, chest retractionmuscle use, chest retraction
• History: History: high-risk patienthigh-risk patient• FEVFEV11 or PEF <50% or PEF <50% predicted predicted
or personal bestor personal best• No improvementNo improvement after initial after initial
treatmenttreatment
• OxygenOxygen• Inhaled short-acting betaInhaled short-acting beta22--
agonist hourly or agonist hourly or continuouslycontinuously + inhaled anticholinergic+ inhaled anticholinergic
• Systemic corticosteroidSystemic corticosteroid
Emergency Department and Emergency Department and Hospital ManagementHospital Management
Not generally recommended:Not generally recommended: MethylxanthinesMethylxanthines Antibiotics (except for patients with pneumonia, Antibiotics (except for patients with pneumonia,
bacterial sinusitis)bacterial sinusitis) ““Aggressive” hydrationAggressive” hydration Chest physical therapyChest physical therapy
Not recommended:Not recommended: MucolyticsMucolytics SedationSedation
Good Good ResponseResponse
Incomplete Incomplete ResponseResponse
• Mild-to-Mild-to-moderate moderate symptomssymptoms
• FEVFEV11 or PEF or PEF
50% to 70%50% to 70%
• Individualized Individualized decision:decision: hospitalizationhospitalization
• No distressNo distress• Physical exam: Physical exam:
normalnormal• FEVFEV11 or PEF or PEF >>70%70%• Sustained responseSustained response
@ @ 60 min after last 60 min after last treatmenttreatment
• Discharge HomeDischarge Home
Poor Poor ResponseResponse
• Physical exam:Physical exam: symptoms severesymptoms severe, , drowsiness, drowsiness, confusionconfusion
• PCOPCO22 >>42 mm Hg42 mm Hg
• FEVFEV11 or PEF <50% or PEF <50%
• Admit to hospital Admit to hospital or intensive careor intensive care
HospitalizationHospitalization
Consider:Consider: Duration and severity ofDuration and severity of airflow obstruction airflow obstruction Course and severity of priorCourse and severity of prior attacks attacks Medication Medication useuse Access to careAccess to care Home conditions andHome conditions and support support ComorbiditiesComorbidities
Admit to Hospital Intensive CareAdmit to Hospital Intensive Care
• Inhaled betaInhaled beta22-agonist hourly or -agonist hourly or
continuously + inhaled anticholinergiccontinuously + inhaled anticholinergic• IV corticosteroidIV corticosteroid• OxygenOxygen• Possible intubation and mechanical Possible intubation and mechanical
ventilationventilation
• Admit to hospital wardAdmit to hospital ward
Emergency Department Emergency Department Discharge CriteriaDischarge Criteria
If If FEVFEV11 or PEF or PEF 70%70% predicted and symptoms predicted and symptoms
are minimal, are minimal, dischargedischarge
If FEVIf FEV11 or PEF or PEF >>50% but 50% but 70%70% predicted and predicted and
symptoms are mild, decision is symptoms are mild, decision is individualizedindividualized
If response is prompt, observe for If response is prompt, observe for 30 to 60 minutes before discharging30 to 60 minutes before discharging
Emergency Department and Emergency Department and Hospital Discharge ActionsHospital Discharge Actions
Prescribe sufficient medication and instructionsPrescribe sufficient medication and instructionsfor usefor use
Schedule follow-up or referral visit within 3 to 5 daysSchedule follow-up or referral visit within 3 to 5 days– Consider referral to specialist if patient has history ofConsider referral to specialist if patient has history of
life-threatening exacerbations or multiple hospitalizationslife-threatening exacerbations or multiple hospitalizations
Teach correct inhaler use and trigger avoidanceTeach correct inhaler use and trigger avoidance
Hospital Discharge Hospital Discharge Actions Actions (continued)(continued)
Discharge medications should include:Discharge medications should include:
– Short-acting betaShort-acting beta22-agonist-agonist
– Sufficient oral corticosteroid to complete course Sufficient oral corticosteroid to complete course of therapy (3 to 10 days) or to continue therapy of therapy (3 to 10 days) or to continue therapy until followup appointmentuntil followup appointment
– If inhaled corticosteroids are prescribed,If inhaled corticosteroids are prescribed,start before course of oral corticosteroidsstart before course of oral corticosteroidsis completedis completed
le urgenze pneumologiche in pronto soccorsoPavia, 24 novembre 2006
PremessaGestione delle crisi asmaticheLa gestione in Pronto SoccorsoAltri trattamenti
Intravenous magnesium Intravenous magnesium (MgSO(MgSO44))
Is effective at improving airflow and reducing admissions in very severe asthma exacerbations (eg, 40% of predicted PEF).
Has few adverse effects, is inexpensive, and is easy to administer.
Rapid adoption of this therapy in North American EDs.
Intravenous leukotriene modifiersIntravenous leukotriene modifiers
Data on intravenous montelukast suggest that leukotriene modifiers have important bronchodilating effects and that this adjunct therapy may prove useful.
The relatively slow onset of action of oral agents will limit their usefulness in the management of truly severe exacerbations.
Intravenous epinephrineIntravenous epinephrine In some Australian EDs is commonly used to treat the
acute bronchospasm, initiate adequate antiinflammatory treatment, and avoid the risks and complications associated with intubation.
Theoretically it may control airway edema but its use needs to reflect a balance between clinical efficacy and safety.
Evidence on therapeutic safety is difficult to collect and research.
Epinephrine should not be the first step in treating these patients.
PEF ~ 70%
PEF ~ 50%
With frequent admission
With one
previous admission
40%
EMERGENCY VISITS FOR ASTHMAEMERGENCY VISITS FOR ASTHMA
Policlinico San Matteo, Pavia 2002 Policlinico San Matteo, Pavia 2002
Cerveri et al. ATS 2004
Without
previous admission
60%