Approach patient with asthma :--to asses severity of asthma by :-- a- scoring of asthma
b- classification of severity of asthma
A- scoring of asthma :- depend on many factors
including mental state , cyanosis , accessory muscle ,
air exchange , pulsus parodoxus , Pao2 , Paco2
Scoring :-- 1-0-4 no needs admission
impending resp failure – 5-6—2
more than 7 – resp failure – needs -3
I.C.Uwith intubation
-1 -
:-Scoring of asthma
zero
mental state
normal
cynosis
non
accessory muscle none
air entery
good
pulus paradoxus < 10
PaO2
70-100
PaCO2
<40%
1
2
agitated or depressed
in room air
moderate
fair
10-40
< 70% in room air
40-65
coma- 1
in 40% o2-2
marked-3
poor-4
> 40- 5
< 70% in 40% o2-6
> 65-7
:-Scoring
no immediate danger ---------- home discharge :- 0-4 -1
impending respiratory failure ------ hospital admission :- 5-6 -2
respiratory failure --------- intensive care unit :- 7- > 3
-2 -
B-classification :- can asses severity of acute exacerbation in children :
S&S
Mild
Moderate
severe
1-altertness
normal&may be agitated N or usual agitated
usually agitated
color
normal
pale
cyanosis- 2 •
resp rate
normal to 30% 30-50%above normal 3-more than-3
•
above normal
50%
dyspnea
mild dyspnea on walking moderate sever at rest-4
speak in normal
speak in phrases in single word
sentences
or partial sentences
partial phra
accessory
no to mild
moderate retraction
sever with-5
muscle
retraction
intercostal, sternal
nazal flaring
•
used
hyperinflation of chest
auscultation expiratory
expiratory + inspiratory
silent chest-6
PEFR
70-90% above normal 40-70%
less than 40%-7
Pco2
less than 42%
less than 42%
more than 42%-8
O2 saturation more than 95% 90-95%
less than 90%
-3
•
•
•
•
•
•
•
•
•
-9
Aims of therapy :-1-to reverse asthmatic symptoms .
2-prevent or diminished the frequency of recurrence of symptoms
3-maintain normal or close to normal pulmon. Function test
•
.maintain normal activity level including exercise-4
:---Treatment of acute asthma •
•
)depend on severity & location ( home , emergency ward ,hospital
:--Home management •
•
PEFR :- done every 2-3 times per day ( if PEFR is decreased -1
•
needs medical intervention & if decreased between 50-80%
•
needs change in medical therapy & if below 50% needs
acute
•
intervention
•
inhalation therapy by ventolin inhalor-2
•
incomplete response needs short course of cortico steriod-3
•
1-2mglkg lday
•
medical attention for sever exacerbation & persistent resp- 4
•
---distress .
--4
In emergency ward :-1-O2 therapy :-to improve oxygenation .
2-ventolin or albuterol nebulizer:-0.15mglkg every 20 minutes for
one hour.
Inhaled iprotropium bromide ( given every 6 hr
in adose o.25 mg for 6
•
may need systemic C.S either orally or I.V-3
) years of age and o.5 mg for those 12 years of age
•
in sever case , used S.C adrenalin o,o1ml/kg given once or -4
•
twice at interval 20 minutes to obtain optimum relief ( 0.5 ml
•
)is often effectively
•
:-after one hr ---re-asses
•
if sustained improvement of symptoms , normal physical finding -1
•
O2 saturation of more than 92% , PEF of more than 70% for
&
•
.hr ----home discharge 3
•
if discharge , on 1-ventolin inhalor for above 5 years or oral
butadine
2-.3-7 day course of C.S
•
if no response ( persistent symptoms ) ---asses & hospital -2
admission :---a- if moderate distress needs ward admission
•
b- if sever distress needs I.C.U
•
--5--
Indication of hospital admission :-1-moderate to sever exacerbation that not improved within 1-2hr
.from intensive therapy in emergency ward
•
has risk factors for morbidity & mortality ( risk factors for sever-2
•
) :---asthma
•
A- biological – 1-previous sever asthma exacerbation
•
sever air way obstruction-2
•
rapid attack 4- sever air way hyper- -3
responsiveness
•
poor response to systemic C.S-5
•
repeated visit to emergency ward in last 48 hrs-6
•
.or more hospital admission of the past year 7-2
•
:--B-economic & psycho-social
•
poverty
2- crowding 3-mother less than 20 -1
years
•
poor education 5-family dysfunction -4
•
psychopath in parent & children -6
•
C-environment :- 1- allergen exposure 2-smoking
•
air pollution
4-urban environment-3
•
---6---
Status asthmatics :-defined by increasing sever asthma that is not respond to treatment
that are usually effective .
:--- When diagnose , is made
A-admission to I.C.U & doing chart for observation for PR,RR, BP
send for CBP, S.electrolyte , cardiac monitor & blood gas
,
)analysis ( PO2, PCO2, PH
:-B-start therapy
O2 therapy
2- correction of dehydration- 1
bronch-dilator by a-continuous or frequent Nebulizer with O2- 3
b- aminophylin( 5mglkg ) or continuous in a
dose 0.75-1.25 mglkg lhr
c- anti muscurine like atropin sulfate ( o.o5- o.1mglkg
atropin sulfate in adose of not > o.25mg ( S.E like mental confusion ,
)tachycardia
iprotropium bromide has fewer S.E than atropin
C.S ( methyl prednisolone in adose of 1-2 mg /kg /every 6 hr
5-- 4
mechanical ventilation for sever hypoxia o2 saturation of < 90%
6
.– sedation is Contra indication
chest x-ray should be done in all patients & repeated as indicated -7
, to detect complication . 8-other therapy like Mg sulfate
Chronic asthma :--classify into :-( mild , moderate , severe ) depend on history , physical
.examination & pulmonary function test
severity of asthma
Day with symptom night sym
FEV1
1-mild intermittent
<2episode per wk
<2 per month >80%
•
mild persistent
3-6 episode per wk 3-4 per moth >80%-2
moderate persistent daily symptoms >5night per month 60-80%-3
Sever persistent Continuous Sym. Frequent
<60%-4 •
• Prevention :-•
•
Mild intermittent :-- 1-no daily medication needed
2-used short acting inhaled B2 agonist
( salbutamol , albuterol ) as needed ( 1-3 puff every 4 hr )
• Mild persistent :- one daily medication like ( low dose inhaled
•
C.S 40micro-gram 1-4 puff per day ), intal ( cromolyn) ,nedocromil
• & leukotrin antagonist like montolukast , zafirlukast
• Lipo-oxygenase inhibition like zileuton which given above 12 years
-8--
•
•
Moderate persistent:--either:-A-one daily medication by medium
dose inhaled C.S ( 80micro-gram 2-4 puff / twice a day Or
B-two daily medication like low to medium dose inhaled c.s + long
)acting bronch-dilator especially for night time symptoms ( salmetrol
•
sustained released theophylin or long acting B2 agonist,
:-Sever persistent :--3 daily medication •
•
+high dose inhaled c.s 80 micro gram puff l twice a day -1
•
+long acting brncho-dilator( salmetrol )or B2 agonist-2
oral c.s in a dose 1 mg lkg l day of not exceed 60 mg l day then -3
gradually reduce dose to lowest dose which control symptoms
•
.correction comborbid condition & emotional disturbances -4
:--Exercise induced asthma :--prevented by •
•
inhalation adrenerhic drug immediately before exercise like -1
inhaled albuterol which give protection for 4 hr . OR inhaled
.salmetrol given halve hr before exercise
•
inhaled cromolyn or nedocromil shortly before exercise -2
•
---thank you
---9
•
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•