Asthme aigu grave. Dr Olivier GOLINVAL Pneumologue CHR Verviers Respiliege.be ABEFORCAL 21/10/2017
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1 Asthme aigu grave (AAGr ) Dr Olivier GOLINVAL Pneumologue CHR Verviers Respiliege.be ABEFORCAL 21/10/2017
2 Qu est-ce qu il est nécessaire d avoir? A. Solumédrol 125 mg B. Adrénaline C. Set d intubation D. Ventolin HFA + Spacer E. Téléphone F. PFM (Peak Flow Meter)
3 Qu est-ce qu il est nécessaire d avoir? A. Solumédrol 125 mg B. Adrénaline C. Set d intubation D. Ventolin HFA + Spacer E. Téléphone F. PFM (Peak Flow Meter)
4 GINA Ce n est pas une bonne copine un peu vulgaire Global INitiative for Asthma GINA teaching slide What else!
5 Managing exacerbations in primary care PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation ASSESS the PATIENT Is it asthma? Risk factors for asthma-related death? Severity of exacerbation? MILD or MODERATE Talks in phrases, prefers sitting to lying, not agitated Respiratory rate increased Accessory muscles not used Pulse rate bpm O2 saturation (on air) 90 95% PEF >50% predicted or best SEVERE Talks in words, sits hunched forwards, agitated Respiratory rate >30/min Accessory muscles in use Pulse rate >120 bpm O2 saturation (on air) <90% PEF 50% predicted or best LIFE-THREATENING Drowsy, confused or silent chest URGENT START TREATMENT SABA 4 10 puffs by pmdi + spacer, repeat every 20 minutes for 1 hour Prednisolone: adults 1 mg/kg, max. 50 mg, children 1 2 mg/kg, max. 40 mg Controlled oxygen (if available): target saturation 93 95% (children: 94-98%) TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid CONTINUE TREATMENT with SABA as needed ASSESS RESPONSE AT 1 HOUR (or earlier) IMPROVING ASSESS FOR DISCHARGE Symptoms improved, not needing SABA PEF improving, and >60-80% of personal best or predicted Oxygen saturation >94% room air Resources at home adequate ARRANGE at DISCHARGE Reliever: continue as needed Controller: start, or step up. Check inhaler technique, adherence Prednisolone: continue, usually for 5 7 days (3-5 days for children) Follow up: within 2 7 days FOLLOW UP Reliever: reduce to as-needed Controller: continue higher dose for short term (1 2 weeks) or long term (3 months), depending on background to exacerbation Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherence Action plan: Is it understood? Was it used appropriately? Does it need modification?
6 PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation ASSESS the PATIENT Is it asthma? Risk factors for asthma-related death? Severity of exacerbation? LIFE-THREATENING Drowsy, confused or silent chest URGENT TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid GINA 2017, Box 4-3 (2/7) Global Initiative for Asthma
7 Quelle est la méthode la plus efficace pour évaluer l importance de la crise? A. Examen clinique (stéthoscope) B. Mesure du débit de pointe C. Observation du patient D. Appel au Mage du quartié (résultat garanti par telefone, retour de l etre aimé. Première consultation gratuite, paiement après résultat. Grande réputation internationale dans le quartié) E. Oxymètre de pouls
8 Quelle est la méthode la plus efficace pour évaluer l importance de la crise? A. Examen clinique (stéthoscope) B. Mesure du débit de pointe C. Observation du patient D. Appel au Mage du quartié (résultat garanti par telefone, retour de l etre aimé. Première consultation gratuite, paiement après résultat. Grande réputation internationale dans le quartié) E. Oxymètre de pouls
9 PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation ASSESS the PATIENT Is it asthma? Risk factors for asthma-related death? Severity of exacerbation? MILD or MODERATE Talks in phrases, prefers sitting to lying, not agitated Respiratory rate increased Accessory muscles not used Pulse rate bpm O 2 saturation (on air) 90 95% PEF >50% predicted or best SEVERE Talks in words, sits hunched forwards, agitated Respiratory rate >30/min Accessory muscles in use Pulse rate >120 bpm O 2 saturation (on air) <90% PEF 50% predicted or best LIFE-THREATENING Drowsy, confused or silent chest URGENT TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid GINA 2017, Box 4-3 (3/7) Global Initiative for Asthma
10 PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation ASSESS the PATIENT Is it asthma? Risk factors for asthma-related death? Severity of exacerbation? MILD or MODERATE Talks in phrases, prefers sitting to lying, not agitated Respiratory rate increased Accessory muscles not used Pulse rate bpm O 2 saturation (on air) 90 95% PEF >50% predicted or best SEVERE Talks in words, sits hunched forwards, agitated Respiratory rate >30/min Accessory muscles in use Pulse rate >120 bpm O 2 saturation (on air) <90% PEF 50% predicted or best LIFE-THREATENING Drowsy, confused or silent chest URGENT START TREATMENT SABA 4 10 puffs by pmdi + spacer, repeat every 20 minutes for 1 hour Prednisolone: adults 1 mg/kg, max. 50 mg, children 1 2 mg/kg, max. 40 mg Controlled oxygen (if available): target saturation 93 95% (children: 94-98%) TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid GINA 2017, Box 4-3 (4/7) Global Initiative for Asthma
11 START TREATMENT SABA 4 10 puffs by pmdi + spacer, repeat every 20 minutes for 1 hour Prednisolone: adults 1 mg/kg, max. 50 mg, children 1 2 mg/kg, max. 40 mg Controlled oxygen (if available): target saturation 93 95% (children: 94-98%) TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid CONTINUE TREATMENT with SABA as needed ASSESS RESPONSE AT 1 HOUR (or earlier) IMPROVING ASSESS FOR DISCHARGE Symptoms improved, not needing SABA PEF improving, and >60-80% of personal best or predicted Oxygen saturation >94% room air Resources at home adequate GINA 2017, Box 4-3 (5/7) Global Initiative for Asthma
12 START TREATMENT SABA 4 10 puffs by pmdi + spacer, repeat every 20 minutes for 1 hour Prednisolone: adults 1 mg/kg, max. 50 mg, children 1 2 mg/kg, max. 40 mg Controlled oxygen (if available): target saturation 93 95% (children: 94-98%) TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid CONTINUE TREATMENT with SABA as needed ASSESS RESPONSE AT 1 HOUR (or earlier) IMPROVING ASSESS FOR DISCHARGE Symptoms improved, not needing SABA PEF improving, and >60-80% of personal best or predicted Oxygen saturation >94% room air Resources at home adequate ARRANGE at DISCHARGE Reliever: continue as needed Controller: start, or step up. Check inhaler technique, adherence Prednisolone: continue, usually for 5 7 days (3-5 days for children) Follow up: within 2 7 days GINA 2017, Box 4-3 (6/7) Global Initiative for Asthma
13 START TREATMENT SABA 4 10 puffs by pmdi + spacer, repeat every 20 minutes for 1 hour Prednisolone: adults 1 mg/kg, max. 50 mg, children 1 2 mg/kg, max. 40 mg Controlled oxygen (if available): target saturation 93 95% (children: 94-98%) TRANSFER TO ACUTE CARE FACILITY While waiting: give inhaled SABA and ipratropium bromide, O 2, systemic corticosteroid CONTINUE TREATMENT with SABA as needed ASSESS RESPONSE AT 1 HOUR (or earlier) IMPROVING ASSESS FOR DISCHARGE Symptoms improved, not needing SABA PEF improving, and >60-80% of personal best or predicted Oxygen saturation >94% room air Resources at home adequate ARRANGE at DISCHARGE Reliever: continue as needed Controller: start, or step up. Check inhaler technique, adherence Prednisolone: continue, usually for 5 7 days (3-5 days for children) Follow up: within 2 7 days FOLLOW UP Reliever: reduce to as-needed Controller: continue higher dose for short term (1 2 weeks) or long term (3 months), depending on background to exacerbation Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherence Action plan: Is it understood? Was it used appropriately? Does it need modification? GINA 2017, Box 4-3 (7/7) Global Initiative for Asthma
14 Merci pour votre attention!
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