Whats New in Asthma? Kirsty Short ECI and St Vincents Hospital - PowerPoint PPT Presentation

What’s New in Asthma? Kirsty Short ECI and St Vincent’s Hospital Advanced Trainee

But Asthma’s Easy!? • New Australian guidelines released March 2014 • Lack of consensus between international guidelines • No guidance on management of the crashing asthmatic beyond calling for help • Lack of engagement of critical care specialties in Australian guideline development • ECI involvement in Difficult Airway Society (DAS) guidelines

Comparison of Guidelines

Asthma in ED • 2.3 million Australians in 2012 • 378 deaths in 2011, mainly in the elderly • National Bureau of Statistics ‘Snapshots’

-~.:,._.-_.-~ .... NationaiAsthma • .. .a Counci !Australia I AUSTRALIAN ASTHMA HiANDBOOK QUICK REFERENCE GUIDE asthmahandbook.org. au VERS I ON 1. 0

National Asthma Council Guidelines: 2014 Changes • Emphasis on primary and secondary assessment • Allocation of asthma severity – Mild/mod grouped together – Severe – Life ‐ threatening

25 10 ~ Secondary Asthma Assessment Mild / Moderate (all of): Severe (any of): Life-threatening (any of): Speech Can finish a sentence in one Can only speak a few words in Can't speak one breath breath Unable to lie fl at due to dyspnoea Collapsed or exhausted Posture Can walk Sitt ing hunched forward Breathing Respi ratory distress is not severe Paradoxical chest wall Severe respi ratory distress movement: inward movement or on inspi ration and outward Poor respiratory effort movement on expir ation (chest sucks in when person breathes in) or Use of accessory muscles of neck or inte r co stal muscles or 'tracheal tug' du ri ng inspi rat i on or Subcostal recess ion t abdominal breath ing') Consciousness Alert t Drowsy or unconscious Skin colour No rmal t Cyanosis Respiratory rate < 25 breaths/ min breaths/min Bradypnoea (indicates respiratory exhaustion) Adults :< 110 beats/ min Adu lts: ~ beats/min Cardi ac arrhythmia Heart rate Children: normal range Ch il dren: tachycardia or Bradyca rd ia (may occur just before respi ratory arrest) t Chest auscultation Wheeze Silent chest or or No rmal lung sou nd s Reduced air entry Oxygen saturation > 94 % 90-94 % <90% (pulse oximetry) or Clinical cyanosis Blood gas analysis Not indic ated Not indicated PaO, < 60 mmHg (adults. PaC0 7 >50 mmHg§ performed) t if PaC0 7 within normal range despite low Pa0 2 pH <7. 35#

Guideline Changes • More prescriptive O 2 saturation targets • Inhaled route of bronchodilation preferred • Steroids for all in first hour • Out: Aminophylline • Revised IV salbutamol dosing regime • NPPV advocated, more studies required

What the Guidelines Don’t Cover • Use of HFNP • Approach to NPPV • Intubating the asthmatic • Adrenaline in the asthmatic without anaphylaxis • What to do if there’s no ICU

~ ~ -. ASSESS SEVERITY AND START BRONCHODILATOR Table U. Rapid pr imary assessment of acute asthma in adults and children Life-threatening Can walk and speak Any of : unable to speak in Any of: drowsy , collapsed, whole sentences in sentences, visibly breathless, exhausted, cyanotic, poo r one breath increased work of breathing, respiratory effort , oxygen oxygen saturation 90-94% saturation less than 90% Give 4-12 ruffs Give 12 puffs salbutam ol (100 meg per actuat ion) Give 2 x 5 mg nebules salbutamol salbutamo (1 00 meg via pMDI plus spacer via cont inuous nebulisation per actuation ) via OR Start oxygen (if oxygen saturation pMDI plus spacer less than 95%) rPrrnrttPnt nebulisation if pati ent spacer. Give 5 mg nebuliser with air u REASSESS SEVERITY adults and children aged 6 years and over Table V. Secondary severity assessment of acute asthma in CONTINUE CONTINUE CONTINUE BRONCHODILATOR BRONCHODILATOR BRONCHODILATOR Continuous nebulisati on until dyspnoea improves. Repeat dose every 20-30 mins Repeat dose every 20 minutes for f i rst hour if needed (or for first hour (3 doses) or Th en consid er changing to pMD I plus sooner as needed) sooner as needed spacer or inte rmi ttent nebulis er (doses as for Severe) IF POOR RESPONSE, Give 8 puff s (160 meg) via pM DI (21 meg/actuation) every 20 mi nute s for first hour ADD IPRATROPIUM BROMIDE OR Repeat every 4-6 hours as needed Give 500 meg nebule via nebu li s er added to nebu li sed sa lb ut amol every 20 minutes for first h our

Persistin~ life-threatenin~ Persistin~ CONSIDER OTHER ADD-ON TREATMENT OPTIONS Table X. Add - on treatment options for acute asthma START Oral prednisolone 37. 5-50 mg then continue 5-10 days SYSTEMIC OR, IF ORAL ROUTE NOT POSSIBLE CORTICOSTEROIDS Hydrocortisone 100 mg IV every 6 hours 1 REASSESS RESPONSE TO Pertormspirometry(itpatientcapable) TREATMENT (1 HOUR AFTER Repeat pulse oximetry STARTING BRONCHODILATOR) Check tor dyspnoea while supine HOUR * * Dyspnoea resolved Dyspnoea persists • i OBSERVE or for more than 1 hour after acute asthma dyspnoea resolves acute asthma l PROVIDE POST-ACUTE CARE Transfer to ICU or discuss transfer/retrieval Ensure person (or carer) is able to monitor with senior medical staff and manage asthma at home Provide oral prednisolone for 5-10 days Ensure person ha s regul ar inhaled preventer Check and coach in correct inhaler technique Provide spacer if needed Provide inter im asthma action plan Advise/arrange follow -up review

tar~et ASSESS SEVERITY AND START BRONCHODILATOR Tabl e U. Rapid primary asses sm e nt of acute as thma in adult s and childr en • life-threatening Can walk and SJ?eak Any of: unable to speak in Any of: drowsy , collapsed , whole sentences in one sentences , visibly breathless , exllausted, cyanotic . , poor breath (Young children : increased work of breathing , respiratory effort , oxygen oxygen saturation 90-94% saturation less than 90% can move about and speak in phrases) Give salbutamol (100 meg Give salbutamol via continuous per Give salbutamol (100 meg per nebullsatlon driven by oxygen actuation) via pMDI plus actuation) via pMDI plus spacer (plus spacer (plus mask for younger mask for younger children) 6 yea r s a nd over: use 2 x 5 mg children) nebules 6 years and ove r: 12 puffs 6 y ears a nd over: 4-12 puffs 0 - 5 years : use 2 x 25 mg nebu l es 0-5 years: 6 puffs 0 -5 y ea rs: 2-6 puffs Start oxygen If oxygen saturation OR less than 95 % T itrate to oxygen saturation of at l east 95% REASSESS SEVERITY T abl e V. Seco ndary se ve rity assessm e nt of acut e as thma in adul ts and childr en 6 yea rs and ov er ac ut e as thma in c hildr en 0 -5 ye ars Tabl e W . S ec ondary se ve rity assessm e nt of • ----- CONTINUE CONTINUE CONTINUE BRONCHODILATOR BRONCHODILATOR BRONCHODILATOR Continuous nebullsatlon until breath i ng difficulty Improves . Repeat dose every 20 - 30 Repeat dose every 20 minutes mlns for first hour If needed fo r first hour (3 doses) or Th en co nsi d er ch ang in g to pMDI plu s (or sooner as needed) sooner as needed sp ace r or i nt erm itt en t n ebu li ser • • (d o ses as fo r Severe ) IF POOR RESPONSE , 6 y ears and over: 8 puffs (160 meg) via pMD I (21 meg/actuation) every 20 mrnutes fo r first hour ADD IPRATROPIUM BROMIDE 0 -5 years : 4 puffs (80 meg) via pMDI (21 m eg/actuation) every 20 minutes Repeat every 4-6 hours as needed for first hour. OR Gi ve v ia n eb uli ser a dded to ne buli s ed s albut amo l 6 y ears and over: 500 meg nebule 0 -5 yea rs: 250 meg nebule

• CONSIDER OTHER ADD-ON TREATMENT OPTIONS Tab le. Add - on treatment options for acute asthma Oral predniso l one 2 mglkg oral (maximum 50 mg) then 1 mglkg on days 2 and 3 START OR , if or al rou te not po ssi ble SYSTEMIC Hydrocortisone IV initial dose 8 - 10 mg./kg ( max 300 mg). then 4 - 5 rngl\<g/dose CORTICOSTEROIDS every 6 hours on day 1. then every 12 hours on day 2. then once on day 3 OR Methylprednisolone IV initial dose 2 mg/kg (max 60 mg). then 1 mg/kg every 6 hours on day 1, then every 12 hours on day 2, then once on day 3 .& For children 0 - 5 years, a110id system ic corticostero i ds if mild/moderate wheezing responds to initial bronchodilator treatment 1 REASSESS RESPONSE TO TREATMENT (1 HOUR AFTER STARTING BRONCHODILATOR) Pcrtormspiromctrv(itchildcapablcl HOUR • • No breathing difficulty Breath i ng difficulty persists I OBSERVE Breathing REASSESS for more than 1 hour after difficulty pers i sts dyspnoea resolves 1 L PROVIDE POST-ACUTE CARE Persisting Ensure parents are able to monitor and manage or asthma at home life-threatening Provide oral prednisolone for 3-5 days No breathing acute asthma Ensure child has regular Inhaled preventer ••••• difficu l ty If for more Indicated than one hour Check and coach In correct Inhaler technique Provide spacer If needed Transfer to ICU or discuss transfer/retrieval Provide Interim asttlma :><:lion plan with senior medical staff Advise/a r range follow-up review