MAYA RAMAGOPAL M.D. DIVISION OF PULMONOLOGY & CYSTIC FIBROSIS CENTER

Transcription

1 MAYA RAMAGOPAL M.D. DIVISION OF PULMONOLOGY & CYSTIC FIBROSIS CENTER

2 16 year old female with h/o moderate persistent asthma presents to the ED after 6 hours of difficulty breathing, cough, and wheezing despite Q2 hr Albuterol treatments at home. Had been at a warehouse the previous day stacking girl scout cookie boxes

3 ROS: Afebrile, nasal congestion and sneezing PMHx: Asthma: usual triggers include dust exposure, & cold weather;2 previous ED visits; no floor or PICU admissions

4 T 97, RR 24/minute, PR 96/minute, room air saturation 91% Difficulty speaking in sentences HEENT-pale turbinates, allergic shiners Post nasal drip RS- no nasal flaring,subcostal retractions Decreased air entry at bases, wheeze posterior bilaterally CVS- tachcardic. No murmurs Abdomen-soft,non distended, non tender No clubbing,well perfused Skin-no rashes

5 Oxygen Combivent x 3 Prednisone 60mg PO CXR Albuterol Q2 hrs

6 PICU V. FLOOR

7 Albuterol Q2 hrs Methylprednisolone 4mg/kg/day Famotidine Labs: CBC, Daily BMP, Mg, Phos Pulse oximetry Q 4 hrs

8 Chronic inflammatory disorder of the airways Characterized by variable and recurring symptoms, airflow obstruction, bronchial hyper responsiveness and underlying inflammation NHLBI, EPR

9 20 million adults and children in the US have received an asthma diagnosis sometime in their lifetime 6.2 million were under the age of million individuals have experienced an asthmatic episode in the previous year 4.1 million were children Hospitalization rates increased 16.7% between 1980 and 2005 Estimated direct and indirect costs in 2007 totaled $19.7 billion 2007 Chart book on Cardiovascular, Lung and Blood Diseases. NIH, NHLBI

10 Prevalence of self-reported asthma 67.8/1,000 persons Increase in prevalence in 5-14 age group: 42.8/1,000(1980) to 84.5/1,000 (2007) Highest increase in minorities: 10-12% of AA children have asthma at some time Chart book on Cardiovascular, Lung and Blood Diseases. NIH,NHLBI

11 >14.5 million outpatient visits >696,900 hospitalizations 1.8 million emergency room visits 10 million missed school days 30.5 million prescriptions >5,500 deaths 2007 Chart book of Cardiovascular, Lung and Blood Diseases NIH, NHLBI

12 Innate immunity Genetics Environmental factors

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17 Respiratory infections: viral, bacterial, fungal, parasitic Allergens: Pollen, grass, weeds, dust mites, cockroaches, mice, pet dander, mold, food Irritants: ETS, cold air, chemicals, perfumes, hairspray Weather change Exercise Co morbid conditions: Stress/depression, GERD, OSA, allergic rhinitis, sinusitis, obesity, ABPA

18 NORMAL AND ASTHMATIC MEDIUM SIZED AIRWAY

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20 Beta 2 agonist therapy more than every 2-3 hours No improvement after systemic steroids Supplemental oxygen required h/o rapid progression in past exacerbations h/o non compliance Poor social support

21 Inhaled β2 agonists- continous or every 2 hours Sytemic glucocorticoids Supplemental oxygen to maintain oxygen saturations >92% Asthma education Initiation /change of controller Plan discharge

22 Systemic corticosteroids are used routinely in the management of children with severe acute asthma Lack of consensus regarding the agent, dose, and route of corticosteroid administration

23 Reduce production inflammatory mediators Inhibit macrophages, monocytes, T lymphocytes, eosinophils, basophils, and airway epithelial cells Decrease microvascular leakage and mucus secretion in irritated airway Improve effectiveness of B2 agonist

24 Management of asthma exacerbations requiring urgent medical care (urgent care or emergency department) includes: Systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations or for patients who fail to respond promptly and completely to a SABA (Evidence A).

25 In the hospital: Give systemic corticosteroids to patients who are admitted to the hospital (Evidence A), because oral systemic corticosteroids speed the resolution of asthma exacerbations

26 Hypersensitivity reaction Varicella,herpes simplex Doses1-2mg/kg/day in 2 divided doses- we go upto 4mkd Max doses 60mg-120mg /day

27 Children: Unable to perform FEV1 or PEF, severe distress or FEV1 or PEF < 40%of predicted (Evidence C) Serial pulse oximetry to assess severity of the exacerbation and improvement with treatment (Evidence B)

28 Need for continuous versus intermittent not addressed Pulse oximetry should be documented prior to and after SABA treatment during hospitalization

29 In the ED: recommended (Evidence A) Adding multiple high doses of ipratropium bromide to a selective SABA produces additional bronchodilation Results in fewer hospital admissions, particularly in patients who have severe airflow obstruction

30 In the hospital: not recommended (Evidence A) Two controlled clinical trials failed to detect a significant benefit from the addition of ipratropium to treatment after hospitalization for severe acute asthma

31 Not recommended for routine assessment Consider for patients suspected of a complicating cardiopulmonary process ie: congestive heart failure, pneumothorax, pneumomediastinum, pneumonia, or lobar atelectasis

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37 Theoretical benefits Various manual therapies increase movement in rib cage and spine to improve lung function and circulation Mobilize cough and phlegm Risk Stress and worsening of brochospasms Recommendations: No evidence to support use Exception: atelectasis More research needed

38 Peak expiratory flow rate On admission During hospitalization: minutes post SABA treatment After discharge: daily

39 Upper airway diseases -Allergic rhinitis and sinusitis Large airway obstructions -Foreign body in trachea or bronchus -Vocal cord dysfunction -Vascular ring/laryngeal webs - Laryngotracheomalacia, tracheal stenosis, bronchostenosis - lymph node enlargement/tumor Small airway obstructions -Viral bronchiolitis/obliterative bronchiolitis -BPD -Heart disease -Cystic fibrosis Miscellaneous causes -Chronic aspiration - Bronchiectasis

40 Address the trigger that resulted in this admission Step up therapy according to EPR-3 New action plan Continue asthma education- use of spacer and MDI

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