Recurrent wheezing illnesses 24.9% Similar to Australia Above global averages

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1 Prof Mike South Department of General Medicine Royal Children s Hospital Melbourne Australia Asthma is very common in Australia Approx 25% children have recurrent wheezing illnesses 6000 asthma ED attendances at RCH / year 2000 asthma admission at RCH / year Asthma in Vietnam? Recurrent wheezing illnesses 24.9% Similar to Australia Above global averages 1

2 Asthma Pathophysiology Smooth Muscle Contraction (bronchospasm) Airway wall inflammation & thickening Normal Acute asthma Excess mucus production Predominately small / medium airways Airway obstruction Increased work of breathing Respiratory Muscle Fatigue V:Q mismatch CO2 retention Hypoxaemia Respiratory Failure Ventilation defects in acute asthma Hyperpolarized helium (He 3) MRI Normal 2

3 Asthma exacerbations Minor Mild Moderate Severe Critical Moderate exacerbations Inhaled β2 Agonist (salbutamol - MDI spacer) Systemic Corticosteroids (oral prednisolone) 3

4 Severe exacerbations Oxygen Inhaled β2 Agonist Inhaled anticholinergic Corticosteroids Nebulised Salbutamol* Continuous 0.5% solution Nebulised ipratropium 250 mcg 3 times in 1st hr only Added to salbutamol IV methyl prednisolone 1mg/kg 6 hourly * Beware toxicity Hypokalaemia Lactic Acidosis Critical exacerbations Oxygen Inhaled β2 Agonist (salbutamol - nebulised) Inhaled anticholinergic (ipratropium - nebulised) Systemic Corticosteroids (IV methyl prednisolone) Next choice of drugs?? Aminophylline Magnesium IV β2 Agonist (salbutamol) 4

5 Critical exacerbations - Aminophylline An old drug Previously very popular Out of fashion in 1980s-90s Critical exacerbations - Aminophylline 2? A perfect drug in asthma Bronchodilator Mast cell stabiliser Respiratory stimulant Improves respiratory muscle contractility Cardiac inotrope Improves Mucocilliary transport The drug with the best documented efficacy in severe acute asthma in children 5

6 Critical exacerbations - Aminophylline 3 Large Study (confirmed by 2 since) vs placebo: Improved symptom scores Improved spirometry Improved SaO2 Less IV salbutamol Less need for IPPV Reduced duration of IPPV Nausea & vomiting. Critical exacerbations - Aminophylline 4 Dosing Load: 10mg/kg (max 500mg) IV over 1hr. Maintenance: See appendix Monitor theophylline level: μmol/L 6

7 Critical exacerbations - Salbutamol IV Conclusions There is no evidence to support the use of IV beta2-agonists in patients with severe acute asthma. These drugs should be given by inhalation. No subgroups were identified in which the IV route should be considered. Probably overly harsh review Critical exacerbations - Magnesium Five trials 182 patients Reduced hospitalisation Small improvement in lung function Nothing on ICU outcomes Probably safe 7

8 Drug therpay: severe critical exacerbations Oxygen Salbutamol (nebulised) Ipratropium (nebulised) Methyl prednisolone (IV) Increasing severity Add: IV aminophylline IV Magnesium IV salbutamol The forgotten treatment Time Often bronchospasm is reversed but signs persist due to airway inflammation, oedema, & mucus. Natural recovery plus anti-inflammatory effects of steroids take time. Tempting to continue escalating bronchodilators (toxicity) Do not rush to do so if patient is coping. Reassurance of patient / family / staff very important. 8

9 Non-invasive Mechanical ventilatory support Case series evidence One small trial No ICU outcomes We have been using - looks promising Invasive Mechanical ventilatory support Rarely needed now. Thiopentone / Suxamethonium Ketamine Tube size / cuff Pressure-controlled 16 breaths/minute Permissive hypercapnoea - 70mmHg PEEP 5-10 cm PIP - chest movement SaO2 - accept 85-90% in 70% O2 IT 0.8 Beware hypovolaemia Beware failure to ventilate Manual lateral chest compression 9

10 Other therapies - case series evidence only Heliox Nebulised DNase Deoxyribonuclease Ketamine Volatile anaesthetics eg Halothane? sevoflurane - reduced gas viscosity - mucolysis - bronchodilator - bronchodilator Remember Have a structured approach to drug therapy Be patient - effects of steroids take time Be vigilant - drug side effects (especially salbutamol) Negative circulatory effects of asthma Do not rush to intubate Accept high PaCo2 & slightly low SaO2 10

11 Cám ón Thank You Appendix - Aminophylline dosing Load: 10mg/kg (max 500mg) IV over 1hr. Maintenance: 1-9yr 1.1mg/kg/hr (55mg/kg in 50ml at 1ml/hr) or 6mg/kg/dose IV over 1hr 6H; 10-16yr 0.7mg/kg/hr (<35kg 35mg/kg in 50ml at 1ml/hr; >35kg 25mg/ml at 0.028ml/kg/hr); or 4mg/kg/dose IV over 1hr 6H; 11

12 Appendix - IV Salbutamol dosing Load: 5-10mcg/kg/min for 1hr Maintenance: 1-2mcg/kg/min (1mcg/kg/min using 1mg/ml soltn = 0.06 x Wt ml/hr). Appendix - IV Magnesium dosing Load: 50% 0.1ml/kg (50mg/kg) IV over 20min Maintenance: 0.06 ml/kg/hr (30mg/kg/hr); Keep serum Mg mmol/l 12

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