Nguyen Tien Dung A/Prof. PhD. MD Head of Pediatric Department - Bach Mai Hospital
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1 Nguyen Tien Dung A/Prof. PhD. MD Head of Pediatric Department - Bach Mai Hospital
2 A girl patient 11 years old admitted to Bach mai Hospital at 4h15, 12nd November because of difficult breathing She has been asthmatic for 3 years. At night, 11st Nov she felt tired, fever, sneezing, running nose, so went to bed early. At 1:00 AM, 12nd Nov, wake up because of breathless, so took 2 puffs of Ventolin pmdi 100 mcg. After 30 minutes, still felt uncomfortable, and taking 2 more puffs then went back to bed. However, She had to wake up because of breathless. She took 2 more puffs then going to Bach Mai hospital. 4/23/2014 2
3 Physical examination Wheeze, Breathless and has to sit. Severe intercostal, supraclavical and suprasternal retractions and cyanosis. Could not talk in sentence, only in words, and chest tightness. Heart rate 130/min. Blood pressure 110/85 mmhg. Respiratory rate 38/min. Temperature 370C. Her lung exam revealed rhonchi Lab Normal X-ray of lung Arterial blood gas ph 7,35. PaCO2 37 mmhg, HCO3-19mmol/L. PaO2 62 mmhg. SpO2 87% 4/23/2014
4 A. B. C. D. E. 4/23/2014 Acute Respiratory Distress Mild acute asthma Moderate acute asthma Severe acute asthma Other
5 A. B. C. D. E. 4/23/2014 Acute Respiratory Distress Mild acute asthma Moderate acute asthma Severe acute asthma Other
6 DEFINITION OF AN ACUTE ASTHMA EXACERBATION An exacerbations of asthma (asthma attacks or acute asthma) are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms. GINA 2011
7 Intensity An Acute Attack Time MODELING AN ACUTE ASTHMA Uncontrolled
8
9 Symptoms Mild Moderate Severe Breathless Walking Talking Infant: softer shorter cry; difficult feeding Prefers sitting At rest Infant: stops feeding Can lie down Respiratory Arrest imminent Hunched forward Talks in Sentences Phrases Words Alertness May be agitated Usually agitated Usually agitated Respiratory rate Increase Increase Often>30/min Drowsy or confused Normal rate of breathing in awake children: <2 months:<60/min; 2-12 months: <50/min; 1-5 y: <40; 6-8y: <30 Accessory muscles and suprasternal retractions Usually not Usually Usually Paradoxical thoracoabdominal movement Wheeze Moderate, often only end respiratory Loud Usually loud Absence of wheeze Heart Rate < >120 Bradycardia Limitation of normal pulse rate in children: 2-12 months: < 160/min; 1-2 years: < 120/min; 2-8 years : < 110/min
10 Symptoms Mild Moderate Severe Respiratory Arrest imminent Pulsus paradoxus Absent <10 mm Hg May be present mm Hg Adult > 25mmHg Child mmhg Absence suggests PEF after initial bronchodilator % predicted or % personal best Over 80% 60-80% <60% predicted or personal best (<100L/min adults or response lasts < 2 hours) PaO2 (on air) >60mmHg <60mmHg Possible cyanosis And/or PaCO2 Normal Test not usually necessary <45 mm Hg <45mmHg >45mmHg/ Possible respiratory failure SaO2 (on air) >95% 91-95% <90% Hypercapnea develops more rapidly in young children than in adults and adolescents A few parameters* *GINA Updated 2010* Having 4 or more symptoms** **Asthma Guideline of MoH 2010;Page.30
11 2. Patient has been diagnosed severe acute asthma. What are the treatment approach that you prefer and Why? A. Oxygen delivered by nasal canulae B. pmdi Ventolin C. Nebulizer of Ventolin D. Prednisolone (oral) or IV Methylprednisolon or Budezonide (Nebulizer) E. Oral Seduxen or IV Phenobacbital 4/23/2014
12 2. Patient has been diagnosed severe acute asthma. What are the treatment approach that you prefer and Why? A. Oxygen delivered by nasal canulae B. pmdi Ventolin C. Nebulizer of Ventolin D. Prednisolone (oral) or IV Methylprednisolon or Budezonide (Nebulizer) E. Oral Seduxen or IV Phenobacbital 4/23/2014
13 Oxygen 1 Should 2 is administered as the first-line treatment be administered if SaO2 91% in room air To achieve SaO2 95%2;3 Should be administered by mask or nasal 2;3et al. The treatment of critical status 1. DeNicola LK cannulae asthmaticus in children. Pediatr. Clin. North Am. 41, (1994) 2. Geelhoed GC, Landau LI, LeSoef PN. Predictive value of oxygen saturation in emergency evaluation of asthmatic children. Br. Med. J. 297(6645), (1988) 3. GINA 2011
14 Cochrane review including 2295 children and 614 adults from 27 trials indicated that MDIs used with spacer yielded outcome at least as good as nebuliser1 In older children, if the attack in not severe enough to warrant treatment with oxygen, inhalers and spacer may be equally effective as nebulizer2 In very young or severe children (SaO2 <92%) nebulizer with oxygen is preferred method of administration, because of the uncertainty of delivery of MDIs3 1. Cates CJ et al. Holding chambers (spacers) versus nebulizers for betaagonist treatment of acute asthma. Cochrane 2009, Issue 1 2. Beniamin Volovitz. Expert Rev. Resp. Med 2(5), (2008) 3. BTS. Guidelines on the management of asthma. Thorax 48(S1-S24) (1993)
15 Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids. Children appear to respond well to oral steroids. Rowe BH, et all. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;(1):CD
16 Hospital admission rates are similar in children with moderate to severe asthma exacerbation given oral methylprednisolone and those given i.v. methylprednisolone1 IM methylprednisolone (4 mg/kg) treatment combined with an adrenergic agent, given early during an acute asthmatic episode, significantly reduces the hospital admission rate of infants and toddlers2 1. Barnett PL, et al. Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med Feb;29(2): Tal A, et al. Pediatrics Sep;86(3):350-6.
17 Mild Moderate Severe Oxygen No Yes Yes Salbutamol Puff Puff/Nebulizer Nebulizer/Injectio n Ipratropium No Puff/Nebulizer Nebulizer Steroids Consider Oral/Nebulizer/Injec Nebulizer/IV tion Aminophylline No No IV Hospitalization No Consider Yes Observation/Eval uation After 20 minute 20 min/time in 1 hour 20 min/time in 2 hours or longer X-ray No Consider Yes No Yes Arterial blood gas No
18 A. B. C. D. E. Methylprednisolon 40 mg x 4 times/day Methyprednisolon 500mg x 2 times/day Prednisolon oral 10mg x 4 times/day Budesonide 0,5mg nebulizer x 4-6 times/day Budesonide 0,5mg nebulizer x 2 times/day
19 A. B. C. D. E. Methylprednisolon 40 mg x 4 times/day Methyprednisolon 500mg x 2 times/day Prednisolon oral 10mg x 4 times/day Budesonide 0,5mg nebulizer x 4-6 times/day Budesonide 0,5mg nebulizer x 2 times/day
20 Administration of a 500-mg dose of methylprednisolone offers no advantages over a 100-mg dose in the emergency department treatment of acute asthma1 Use a dose of 20mg prednisolone for children 2-5 years and mg for children >5 years and maximum dose of 60mg2 1. Emerman CL, Cydulka RK. A randomized comparison of 100-mg vs 500mg dose of methylprednisolone in the treatment of acute asthma. Chest Jun;107(6): BTS. British Guideline on the Management of Asthma. Revised May 2011
21 For moderate acute asthma Prednisolone 1-2mg/kg/day (maximum 60mg) or Dexamethasone mg/kg/day (maximum 10mg) For severe acute asthma Methylprednisolon 1-2mg/kg/dose (maximum 60mg q.6h) Hydrocortisone 5-7mg/kg (maximum 400mg q.6h) The Canadian Paediatric Society. Guideline of Managing the paediatric patient with acute asthma exacerbation. 2012
22 17 clinical studies qualified (470 adults and 663 children) Reduce hospitalization rate, especially in compared with placebo (OR= 0.30; 95% CI, ). Improve clinical symptoms significantly faster than placebo and Systematic Corticosteroids. Increase significantly discharge from Hospital rate (OR, 4.70; 95% CI, 2.97 to 7.42; p = ) Conclusion: Multi-doses of Nebulizer Corticosteroids 30min/time in 1 hour will be effectiveness significantly in acute asthma Rodrigo GJ. Rapid effects of inhaled corticosteroids in acute asthma: an evidence-based evaluation. Chest Nov;130(5):
23 ICS in acute asthma exacerbation Recommendation of GINA 2011 High dose ICS + Salbutamol in acute asthma provided greater bronchodilation than sabutamol alone (Evidence B) High dose ICS conferred greater benefit than addition CS across all parameters, including hospitalizations, especially for patients with more severe attacks. ICS can be as effective as Oral Corticosteroids at preventing relapses. Inhaled Budesonide + Oral Prednisolon have lower rate of relapse than using prednisolon alone (Evidence B). High does ICS (2.4mg Budesonide/day) achieves a relapse rate similar to 40mg oral Prednisolon daily (Evidence A). Cost-effectiveness
24 Indication of ICS in acute asthma exacerbation High dose Budesonide (2,4mg/day) in the following situations: Contraindications with Systematic Corticosteroids such as: - Gastritis - Gastric hemorrhage - High blood pressure - Diabetes Unable to use injection Corticosteroids N.T. Dung. Acute asthma treatment in children. Tạp chí Nghiên cứu dược thông tin thuốc; Tập1, Số 2/2010: 57-62
25 B. Patient was diagnosed a severe acute asthma and treated with oxygen via nasal canullae. Nebulizer Ventolin continuously 20min/time, IV Solumedron, and monitoring carefully At 5:30 AM: Patient had improved a little bit but breathless again and cannot sleep. Heart rate 155 /min. Blood pressure 115/82 mmhg. Respiratory rate 34/min. SpO2 90%. Arterial blood gas: ph 7,32 PaCO2 42mmHg; PaO2 70 mmhg; HCO3-24 mmol/l 4/23/2014
26 A. IV Sabutamol 15mcg/kg/10 minutes B. Nebulized Ipratropine 250mcg/dose C. Infusion of Natribicarbonat 1,4% D. Digoxin E. Other 4/23/2014
27 A. IV Sabutamol 15mcg/kg/10 minutes B. Nebulized Ipratropine 250mcg/dose C. Infusion of Natribicarbonat 1,4% D. Digoxin E. Other 4/23/2014
28 C. Continue nebulized Ipratropine and IV Salbutamol but patient was not improved 9:15 AM: Patient breathless and worsen cyanosis, cannot cough and very tired. Blood pressure 130/90 mmhg. Heart rate 185/min. Respiratory rate 13/min. Breath sounds decreased and absent of wheeze, SpO2 79%. Arterial blood gas ph 7,27. PaCO2 57 mmhg, HCO3-24 mmol/l, PaO2 51mmHg 4/23/
29 A. Continuing IV Salbutamol B. IV Solumedron one more dose C. Test of electrolyte in the blood D. Infusion of Ringerlactat E. Intubation and ventilation 4/23/2014
30 A. Continuing IV Salbutamol B. IV Solumedron one more dose C. Test of electrolyte in the blood D. Infusion of Ringerlactat E. Intubation and ventilation 4/23/2014
31 Doctor decided to give intubation and ventilation for patient and Give one more dose of IV Solumedron. Test electrolyte in the blood is normal Next day: patient was improved and taken out intubation and stop ventilation Patient was discharged after 7 days treatment in Bach Mai Hospital. 4/23/
32 Oxygen for moderate and severe acute asthma Salbutamol pressures/puff or nebulizer Corticosteroids oral/injection or nebulizer Ipratropium puff or nebulizer Infusion of Aminophylline IV Salbutamol Intubation and Ventilation
33 Cannot under-evaluate the severity of an acute asthma Attention to asthma triggers - Historical severe asthmatic, intubation or ventilation - Hospitalize or emergency in the previous year - Taking or just stopped using Oral Corticosteroids - Not taking Inhaled Corticosteroids recent days - Dependent on SABA - Mental illness or have to take sedative - Low compliance with asthmatic pharmacology treatments 4/23/2014 GINA 2011
34 DeNicola LK et al. The treatment of critical status asthmaticus in children. Pediatr. Clin. North Am. 41, (1994) Geelhoed GC, et al. Predictive value of oxygen saturation in emergency evaluation of asthmatic children. Br. Med. J. 297(6645), (1988) GINA 2011 Cates CJ et al. Holding chambers (spacers) versus nebulizers for betaagonist treatment of acute asthma. Cochrane 2009, Issue 1 Beniamin Volovitz. Expert Rev. Resp. Med 2(5), (2008) Rowe BH, et all. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;(1):CD Barnett PL, et al. Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med Feb;29(2): Tal A, et al. Pediatrics Sep;86(3): Emerman CL, Cydulka RK. A randomized comparison of 100-mg vs 500mg dose of methylprednisolone in the treatment of acute asthma. Chest Jun;107(6): BTS. British Guideline on the Management of Asthma. Revised May 2011 The Canadian Paediatric Society. Guideline of Managing the paediatric patient with acute asthma exacerbation Rodrigo GJ. Rapid effects of inhaled corticosteroids in acute asthma: an evidence-based evaluation. Chest Nov;130(5):
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