LA CRISI ASMATICA Angelo Corsico Clinica di Malattie dell’Apparato Respiratorio Fondazione IRCCS...

LA CRISI ASMATICA

Angelo Corsico

Clinica di Malattie dell’Apparato Respiratorio

Fondazione IRCCS Policlinico S.Matteo

Università di Pavia

le urgenze pneumologiche in pronto soccorsoPavia, 24 novembre 2006


PremessaGestione delle crisi asmaticheLa gestione in Pronto SoccorsoAltri trattamenti

Six-part Asthma Management Program

Part 5: Managing Severe Asthma Exacerbations


Part 5: Managing Severe Asthma Exacerbations

Severe exacerbations are life-threatening medical emergencies

Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department

Severe exacerbations are life-threatening medical emergencies

Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department

Adult and child asthma emergency department rates, United States: 1992–2001

Source: National Hospital Ambulatory Care Survey; National Center for Health Statistics

0

20

40

60

80

100

120

140

92 94 96 98 2000

Rate

per

10,0

00

ChildrenChildren

AdultsAdults

During exacerbations: a linear decline of PEF over a period of a few days, a sharp point of inflection, then a linear increase.

During poor asthma control: wide diurnal variability and bronchodilator reversibility.

Reddel, Lancet 1999

Severe asthma

7%

Clinical respiratory infections

15%

Acute exposure to allergens or other

triggers

14%

Poor asthma control (inadequate treatment)

64%

% OF SUBJECTS WITH ED ADMISSIONS % OF SUBJECTS WITH ED ADMISSIONS BY CAUSES OF ASTHMA ATTACKBY CAUSES OF ASTHMA ATTACK

EMERGENCY VISITS FOR ASTHMAEMERGENCY VISITS FOR ASTHMAPoliclinico San Matteo, Pavia 2002 Policlinico San Matteo, Pavia 2002

Cerveri et al. ATS 2004

Rapid exacerbation characterized by one or more of the following features:

Accessory muscle activity Paradoxical pulse exceeding 25 mmHg Heart rate > 100 beats/min Respiratory rate > 25-30 breaths/min Limited ability to speak PEF rate or FEV1 < 50% pred.

Arterial oxygen saturation < 91-92%

CONSENSUS DEFINITION OF ACUTE SEVERE ASTHMA

McFadden, AJRCCM 2003

Deaths Due to Asthma, United States, 1979-2001

Source: Compressed Mortality Files

0

1000

2000

3000

4000

5000

6000

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

Year

age group0 to 4 5 to 14 15 to 34 35 to 64 65 +

Krishnan, AJRCCM 2006

Our study indicates that 1,499 deaths (33% of all 4,487 deaths from asthma in the United States in 2000) occurred in patients hospitalized for asthma exacerbations.

Improvements in the management of asthma exacerbations before hospitalization (e.g., at home, during transportation to the emergency department) will have the greatest benefit in further reducing the overall risk of death.

Becker, JACI 2004

263 potential asthma-related athletic deaths between July 1993 and December 2000.

The subjects were usually white male aged 10 to 20 years.

Mild intermittent or persistent asthma by history was commonly identified.

Sudden fatal asthma exacerbations occur in both competitive and recreational athletes and can be precipitated by sporting activity.

The positive benefits to an active lifestyle cannot be negated by the risks outlined here.

Key PointsKey Points

Early treatment is best. Early treatment is best. Important elements:Important elements:– A written action planA written action plan

Guides patient self-management at homeGuides patient self-management at homeEspecially important for patients with moderate-to-severe persistent asthma and Especially important for patients with moderate-to-severe persistent asthma and

any patient with a history of severe exacerbationsany patient with a history of severe exacerbations– Recognition of early signs of worsening asthmaRecognition of early signs of worsening asthma– Prompt communication between patient and clinician about:Prompt communication between patient and clinician about:

Serious deterioration in symptoms or peak flow, orSerious deterioration in symptoms or peak flow, or

Decreased responsiveness to inhaledDecreased responsiveness to inhaledbetabeta22-agonists, or-agonists, or

Decreased duration of betaDecreased duration of beta22-agonist effect-agonist effect

Risk Factors for Risk Factors for Death From AsthmaDeath From Asthma

Past Past historyhistory of sudden severe exacerbations of sudden severe exacerbations Prior Prior intubationintubation or admission to ICU for asthma or admission to ICU for asthma ≥≥2 2 hospitalizationshospitalizations for asthma in the past year for asthma in the past year ≥≥3 3 ED visitsED visits for asthma in the past year for asthma in the past year Hospitalization or an ED visit for asthmaHospitalization or an ED visit for asthma

in the past monthin the past month

Use of Use of >2 canisters per month>2 canisters per month of inhaled short-acting of inhaled short-acting betabeta22-agonist-agonist

Risk Factors for Risk Factors for Death From Asthma Death From Asthma (continued)(continued)

Current use of Current use of systemic corticosteroids systemic corticosteroids or recent or recent withdrawal from systemic corticosteroidswithdrawal from systemic corticosteroids

Difficulty perceivingDifficulty perceiving airflow obstruction airflow obstructionor its severityor its severity

ComorbidityComorbidity, as from cardiovascular diseases or , as from cardiovascular diseases or chronic obstructive pulmonary diseasechronic obstructive pulmonary disease

Serious Serious psychiatric diseasepsychiatric disease or psychosocial or psychosocial problemsproblems

Risk Factors for Risk Factors for Death From Asthma Death From Asthma (continued)(continued)

Low Low socioeconomic statussocioeconomic status and andurban residenceurban residence

Illicit Illicit drug usedrug use

Sensitivity to Sensitivity to AlternariaAlternaria


Part 5: Establish Plans for Managing Exacerbations



Primary therapies for exacerbations: Repetitive administration of rapid-acting

inhaled β2-agonist Early introduction of systemic

glucocorticosteroids Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function

Primary therapies for exacerbations: Repetitive administration of rapid-acting

inhaled β2-agonist Early introduction of systemic

glucocorticosteroids Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function





Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the

particular patient Availability of medications Emergency facilities

Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the

particular patient Availability of medications Emergency facilities

Brief Physical ExamBrief Physical Exam

Assess severity: Assess severity: Alertness, distress, accessory Alertness, distress, accessory muscle use, tachycardia, tachypnea, pulsus muscle use, tachycardia, tachypnea, pulsus paradoxus, cyanosisparadoxus, cyanosis

Identify complications Identify complications (e.g., pneumonia, (e.g., pneumonia, pneumothorax, pneumomediastinum)pneumothorax, pneumomediastinum)

Identify diseases that affect asthmaIdentify diseases that affect asthma(otitis, rhinitis, sinusitis)(otitis, rhinitis, sinusitis)

Rule out upper-airway obstructionRule out upper-airway obstruction

Functional AssessmentFunctional Assessment

Measure FEVMeasure FEV11 or PEF: or PEF: Upon presentation (begin treatment as soon as Upon presentation (begin treatment as soon as

asthma exacerbation is recognized)asthma exacerbation is recognized) At intervals depending on response to therapyAt intervals depending on response to therapy Before dischargeBefore discharge

Monitor SaOMonitor SaO22 in patients with severe distress in patients with severe distress

or with FEVor with FEV11 or PEF <50% predicted or PEF <50% predicted

Brief HistoryBrief History(after treatment is initiated)(after treatment is initiated)

Time of onset and Time of onset and cause of exacerbationcause of exacerbation

Severity of symptomsSeverity of symptoms, especially compared to previous attacks, especially compared to previous attacks

All current medicationsAll current medications and time of last dose and time of last dose

Prior Prior hospitalizations and ED visitshospitalizations and ED visits, especially in past year, especially in past year

Prior episodes of Prior episodes of respiratory failurerespiratory failure or loss of consciousness or loss of consciousness due to asthmadue to asthma

Existence of Existence of comorbiditiescomorbidities

Laboratory AssessmentLaboratory Assessment

Consider Consider ABGABG in patients with suspected in patients with suspected hypoventilation, severe distress, or with FEVhypoventilation, severe distress, or with FEV11 or PEF or PEF

<30% predicted after initial treatment<30% predicted after initial treatment CBCCBC may be appropriate in patients with fever or may be appropriate in patients with fever or

purulent sputumpurulent sputum Serum Serum theophylline concentrationtheophylline concentration Serum Serum electrolytes, chest x-ray, ECGelectrolytes, chest x-ray, ECG in in

special circumstancesspecial circumstances

Emergency Department and Emergency Department and Hospital Management:Hospital Management: Goals Goals

Correction of significant hypoxemiaCorrection of significant hypoxemia

Rapid reversal of airflow obstructionRapid reversal of airflow obstruction

Reduction of likelihood of recurrenceReduction of likelihood of recurrence

Initial TreatmentInitial Treatment OxygenOxygen to achieve O to achieve O22 saturation saturation >>90%90%

FEV1 or PEF >50%:FEV1 or PEF >50%: Inhaled Inhaled betabeta22-agonist by metered-dose-agonist by metered-dose inhaler or inhaler or

nebulizer, up to three treatments in first hournebulizer, up to three treatments in first hour

FEV1 or PEF <50%:FEV1 or PEF <50%: Inhaled Inhaled high-dose beta2-agonist and anticholinergic high-dose beta2-agonist and anticholinergic by nebulizationby nebulization every 20 minutes or continuously for 1 hour every 20 minutes or continuously for 1 hour

Oral corticosteroidsOral corticosteroids

Repeat assessmentRepeat assessment (symptoms, physical exam, PEF, O (symptoms, physical exam, PEF, O2 2 saturation, other saturation, other

tests as needed)tests as needed)

Initial Treatment Initial Treatment (continued)(continued)

Impending or Actual Respiratory ArrestImpending or Actual Respiratory Arrest

Intubation and Intubation and mechanical ventilationmechanical ventilation with 100% O with 100% O2 2

Nebulized betaNebulized beta22-agonist and anticholinergic-agonist and anticholinergic

Intravenous corticosteroidIntravenous corticosteroid Admit to hospital intensive careAdmit to hospital intensive care

Treatment After Repeat AssessmentTreatment After Repeat Assessment

• Physical exam:Physical exam: moderate moderate symptomssymptoms

• FEVFEV11 or PEF > 50% or PEF > 50%

predicted or personal best predicted or personal best

• Inhaled Inhaled short-acting betashort-acting beta22--

agonist every 60 minutesagonist every 60 minutes• Systemic corticosteroidSystemic corticosteroid• Continue treatmentContinue treatment 1 to 3 1 to 3

hourshours, provided there is , provided there is improvementimprovement

• Physical exam: Physical exam: severe severe symptomssymptoms at rest, accessory at rest, accessory muscle use, chest retractionmuscle use, chest retraction

• History: History: high-risk patienthigh-risk patient• FEVFEV11 or PEF <50% or PEF <50% predicted predicted

or personal bestor personal best• No improvementNo improvement after initial after initial

treatmenttreatment

• OxygenOxygen• Inhaled short-acting betaInhaled short-acting beta22--

agonist hourly or agonist hourly or continuouslycontinuously + inhaled anticholinergic+ inhaled anticholinergic

• Systemic corticosteroidSystemic corticosteroid

Emergency Department and Emergency Department and Hospital ManagementHospital Management

Not generally recommended:Not generally recommended: MethylxanthinesMethylxanthines Antibiotics (except for patients with pneumonia, Antibiotics (except for patients with pneumonia,

bacterial sinusitis)bacterial sinusitis) ““Aggressive” hydrationAggressive” hydration Chest physical therapyChest physical therapy

Not recommended:Not recommended: MucolyticsMucolytics SedationSedation

Good Good ResponseResponse

Incomplete Incomplete ResponseResponse

• Mild-to-Mild-to-moderate moderate symptomssymptoms

• FEVFEV11 or PEF or PEF

50% to 70%50% to 70%

• Individualized Individualized decision:decision: hospitalizationhospitalization

• No distressNo distress• Physical exam: Physical exam:

normalnormal• FEVFEV11 or PEF or PEF >>70%70%• Sustained responseSustained response

@ @ 60 min after last 60 min after last treatmenttreatment

• Discharge HomeDischarge Home

Poor Poor ResponseResponse

• Physical exam:Physical exam: symptoms severesymptoms severe, , drowsiness, drowsiness, confusionconfusion

• PCOPCO22 >>42 mm Hg42 mm Hg

• FEVFEV11 or PEF <50% or PEF <50%

• Admit to hospital Admit to hospital or intensive careor intensive care

HospitalizationHospitalization

Consider:Consider: Duration and severity ofDuration and severity of airflow obstruction airflow obstruction Course and severity of priorCourse and severity of prior attacks attacks Medication Medication useuse Access to careAccess to care Home conditions andHome conditions and support support ComorbiditiesComorbidities

Admit to Hospital Intensive CareAdmit to Hospital Intensive Care

• Inhaled betaInhaled beta22-agonist hourly or -agonist hourly or

continuously + inhaled anticholinergiccontinuously + inhaled anticholinergic• IV corticosteroidIV corticosteroid• OxygenOxygen• Possible intubation and mechanical Possible intubation and mechanical

ventilationventilation

• Admit to hospital wardAdmit to hospital ward

Emergency Department Emergency Department Discharge CriteriaDischarge Criteria

If If FEVFEV11 or PEF or PEF 70%70% predicted and symptoms predicted and symptoms

are minimal, are minimal, dischargedischarge

If FEVIf FEV11 or PEF or PEF >>50% but 50% but 70%70% predicted and predicted and

symptoms are mild, decision is symptoms are mild, decision is individualizedindividualized

If response is prompt, observe for If response is prompt, observe for 30 to 60 minutes before discharging30 to 60 minutes before discharging

Emergency Department and Emergency Department and Hospital Discharge ActionsHospital Discharge Actions

Prescribe sufficient medication and instructionsPrescribe sufficient medication and instructionsfor usefor use

Schedule follow-up or referral visit within 3 to 5 daysSchedule follow-up or referral visit within 3 to 5 days– Consider referral to specialist if patient has history ofConsider referral to specialist if patient has history of

life-threatening exacerbations or multiple hospitalizationslife-threatening exacerbations or multiple hospitalizations

Teach correct inhaler use and trigger avoidanceTeach correct inhaler use and trigger avoidance

Hospital Discharge Hospital Discharge Actions Actions (continued)(continued)

Discharge medications should include:Discharge medications should include:

– Short-acting betaShort-acting beta22-agonist-agonist

– Sufficient oral corticosteroid to complete course Sufficient oral corticosteroid to complete course of therapy (3 to 10 days) or to continue therapy of therapy (3 to 10 days) or to continue therapy until followup appointmentuntil followup appointment

– If inhaled corticosteroids are prescribed,If inhaled corticosteroids are prescribed,start before course of oral corticosteroidsstart before course of oral corticosteroidsis completedis completed

Intravenous magnesium Intravenous magnesium (MgSO(MgSO44))

Is effective at improving airflow and reducing admissions in very severe asthma exacerbations (eg, 40% of predicted PEF).

Has few adverse effects, is inexpensive, and is easy to administer.

Rapid adoption of this therapy in North American EDs.

Intravenous leukotriene modifiersIntravenous leukotriene modifiers

Data on intravenous montelukast suggest that leukotriene modifiers have important bronchodilating effects and that this adjunct therapy may prove useful.

The relatively slow onset of action of oral agents will limit their usefulness in the management of truly severe exacerbations.

Intravenous epinephrineIntravenous epinephrine In some Australian EDs is commonly used to treat the

acute bronchospasm, initiate adequate antiinflammatory treatment, and avoid the risks and complications associated with intubation.

Theoretically it may control airway edema but its use needs to reflect a balance between clinical efficacy and safety.

Evidence on therapeutic safety is difficult to collect and research.

Epinephrine should not be the first step in treating these patients.

PEF ~ 70%

PEF ~ 50%

With frequent admission

With one

previous admission

40%

EMERGENCY VISITS FOR ASTHMAEMERGENCY VISITS FOR ASTHMA

Policlinico San Matteo, Pavia 2002 Policlinico San Matteo, Pavia 2002

Cerveri et al. ATS 2004

Without

previous admission

60%

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