Medical Documentation Avni Bhalakia, M.D. St. Barnabas Hospital July 29, 2009.
HEATHER LEMON-MULÉ, MD DIRECTOR, PEDIATRIC ALLERGY & IMMUNOLOGY ST. BARNABAS HOSPITAL JULY 28, 2009...
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Transcript of HEATHER LEMON-MULÉ, MD DIRECTOR, PEDIATRIC ALLERGY & IMMUNOLOGY ST. BARNABAS HOSPITAL JULY 28, 2009...
HEATHER LEMON-MULÉ, MDDIRECTOR, PEDIATRIC ALLERGY &
IMMUNOLOGYST. BARNABAS HOSPITAL
JULY 28 , 2009
Acute Asthma:2009 Update
Definition of Asthma
A chronic inflammatory disease of the lungs characterized by reversible airway obstruction and airway hyper-reactivity
Acute asthma exacerbations are paroxysmal episodes of wheeze, cough, tachypnea, dyspnea, hypoxia, respiratory failure
Etiology of Acute Exacerbations
Viral agents identified in >80% of pediatric asthma exacerbations and >50% of adult asthma exacerbations
Rhinovirus is identified in>65% of wheezing episodes caused by URIs
Peaks in hospital admissions for asthma correlate with RV seasons (spring and fall)
Acute Asthma Etiology
Etiology of Acute Asthma Exacerbations
Allergen exposure (aeroallergen)ExerciseAtypical bacteriaGERDSinusitisASA/NSAID ingestion (AERD)
Pathophysiology
Pathophysiology: Virus-Induced Wheezing
Pathophysiology of Acute Asthma
Pathophysiology: Virus-Induced Wheezing
RV in Asthma: Innate Immune Defect?
Interferons are anti-viral proteins produced in the innate immune response to viral infections
IFN-β induces apoptosis in infected cells; decreased production of IFN-β in asthmatics allows increased viral replication
Asthmatics also have decreased production of IFN-α and IFN-λ
Allergy and Viral Infections: Synergy?
Murray et al (Thorax 2006) showed allergen-exposed, atopic asthmatic children at greater risk for hospital admission with LRT viral infections
Similar findings in adult asthmatic patients (BMJ 2002)
Allergen Sensitization and Exposure
Exposure to seasonal allergens implicated in sudden asthma-related deaths
Alternaria sp exposure is associated with exacerbations and a 200-fold increased risk for respiratory arrest
HDM, cat and CR sensitization are RF for emergency treatment
Grass pollen sensitization (“thunderstorm asthma”) is associated with asthma exacerbation epidemics
Role of Atypical Bacteria?
Cunningham et al (Eur Respir J 1998) showed strong correlation between C. pneumoniae-specific IgA in NLF and asthma exacerbation frequency in children
Wark et al (Eur Respir J 2002) found 38% of adults treated in ED for asthma exacerbations had serologic evidence of C. pneumoniae reactivation and greater lower airway inflammation
Both studies had high viral detection rates (85% and 76%)
Role of Atypical Bacteria?
Johnston et al (NEJM 2006) performed RDBPCT with telithromycin in adult asthmatics experiencing acute exacerbations
>50% of patients had serologic evidence of infection but only 3 by PCR assay (C. pneumoniae)
Telithromycin treated patients had improved symptom scores, but not lung function compared with placebo
Differential Diagnosis of Acute Asthma
Bronchiolitis (and other viral PNAs)CroupBacterial Pneumonia (typical or atypical)Foreign BodyVocal Cord DysfunctionAllergic ReactionPanic AttackCongestive Heart FailurePertussisCF exacerbation
Determining Exacerbation Severity
Clinical signs and symptoms
Objective measurements (functional assessment)
Implications for management
Signs and Symptoms of Acute Asthma
Symptoms Mild Moderate Severe Impending Respiratory Arrest
Breathlessness While walking At rest (Infants – softer, shorter cry, difficulty feeding)
At rest (Infants – stops feeding)
Can lie down Prefers sitting Sits uprightTalks in Sentences Phrases Words Unable to speakAlertness May be agitated Often agitated Usually agitated Drowsy or
confusedSignsRespiratory Rate Often increased Usually increased Increased May be decreasedUse of Accessory Muscles
Usually not Commonly Usually Paradoxical thoracoabdominal movement
Wheeze Often only end expiratory
Throughout expiration
Throughout inhalation/expiration
Absence of wheeze
Heart Rate Usually normal Usually increased Increased Often BradycardicPulsus paradoxus Absent (<10 mm
Hg)May be present (10-25 mm Hg)
Often Present (20-40 mm Hg) (>25 mm Hg adult)
Absence suggests respiratory muscle fatigue
Modified from NAEPP Guidelines 2007
Determining Severity: PEF
Symptoms & Signs Initial PEF (or FEV1) Clinical Course
Mild Dyspnea only with activity (infants: tachypnea only and does not interfere with feeding)
PEF ≥70% predicted or personal best
Prompt relief with SABA;Usually cared for at home;Oral steroids usually not required
Moderate Dyspnea interferes with or limits activity (may interfere with infant feeding)
PEF 40-69% predicted or personal best
Requires office/ED visit; Relief from frequent inhaled SABA; Oral steroids often required; sx last 1-2 days after Rx initiated
Severe Dyspnea at rest; interferes with conversation (and infant feeding)
PEF <40% predicted or personal best
Usually requires ED visit and hospitalization; partial relief from SABA; oral steroids required; sx last >3 days after Rx initiated; adjunctive therapies helpful
Life Threatening Too dyspneic to speak; perspiring
PEF < 25% predicted or personal best
Requires ED/hospitalization and probable ICU; poor response to SABA; IV steroids required; adjunctive therapies helpful
Determining Severity: Functional Assessment
Functional Assessment
Mild Moderate Severe Subset: Life-Threatening
PEF (% predicted or personal best)
≥70 40-69 or response lasts < 2 ours
<40 <25 (may not be needed or pt may not be capable)
PaO2 (on RA)
and/or
PaCO2
Normal (test usually not required)
<42 mm Hg (test usually not required)
≥ 60 mm Hg (test usually not required)
<42 mm Hg (test usually not required)
<60 mm Hg: possible cyanosis
≥ 42 mm Hg: possible respiratory failure
SaO2 (on RA) at sea level
>95% 90-95% <90%
RF for Asthma-Related Death: Asthma History
Previous severe exacerbations (especially history of ETI or ICU admission)
≥2 admissions for asthma within previous 12 months
≥3 ED visits for asthma within previous 12 months
Hospitalization or ED visit within past monthUse of >2 canisters of SABA/monthDifficulty perceiving asthma symptoms or
severity of exacerbations
Other RF for Asthma-Related Death
Social: low SES or inner city residence, illicit drug use or other major psychosocial problems
Comorbidities: cardiovascular disease, other chronic lung disease, chronic psychiatric disease
Special Consideration: Infants
Infants high-risk group for respiratory failure Greater peripheral airway resistanceFewer collateral channels of ventilationFurther extension of airway smooth muscle
into the peripheral airwaysLess elastic recoilMechanical disadvantage of the diaphragmVentilation/perfusion characteristics promote
hypoxemia more readily than older children/adults
Special Consideration: Infants
Use of accessory muscles, inspiratory/expiratory wheezing, paradoxical breathing, cyanosis and RR>60 suggest serious distress
SaO2<90% also sign of serious distress; SaO2<92% after 1 hour of treatment good indicator of need for hospitalization
Initial Assessment: Brief History
Time of onset and any potential causes of current exacerbation
Severity of symptoms, especially compared with previous exacerbations, and response to any already given treatments
All current medications and time of last dose, especially of asthma medications
Any prior episodes of respiratory insufficiency due to asthma
Other potentially complicating illness
Initial Assessment: Physical Examination
Assess the severity of the exacerbation: overall patient status, including level of alertness, fluid status, and presence of cyanosis, respiratory distress, and wheezing
Identify possible complications Rule out upper airway obstructionClues to the presence of alternative reasons for
dyspnea include dysphonia, inspiratory stridor, monophonic wheezing loudest over the central airway, normal values for PaO2, and unexpectedly complete resolution of airflow obstruction with intubation.
Laboratory Studies: Indications
CXR: obtain if complicating process suspectedCBC: consider for patients with suspected
serious bacterial infectionsABG: indicated in patients suspected of
hypoventilation, severe distress or FEV1 or PEF ≤25% predicted or personal best after initial treatment
VBG: PCO2>45 mmHg may serve as a screening test but cannot substitute for an ABG
Serum electrolytes generally not indicated unless patient at risk for electrolyte disturbances
Treatment Goals
Correction of hypoxemia
Rapid reversal of airflow obstruction
Reduction of likelihood of relapse or recurrence of exacerbation
Assess SeverityPatients at high risk for a fatal attack require immediate medical attention after initial treatment.Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness should result in initial treatment while immediately consulting with a clinician.
Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps as listed below.
If available, measure PEF—values of 50–79% predicted or personal best indicate the need forquick-relief mediation. Depending on the response to treatment, contact with a clinician may also be indicated. Values below 50% indicate the need for immediate medical care.
Assess SeverityPatients at high risk for a fatal attack require immediate medical attention after initial treatment.Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness should result in initial treatment while immediately consulting with a clinician.
Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps as listed below.
If available, measure PEF—values of 50–79% predicted or personal best indicate the need forquick-relief mediation. Depending on the response to treatment, contact with a clinician may also be indicated. Values below 50% indicate the need for immediate medical care.
Initial TreatmentInhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs by MDI+ VHC or nebulizer treatments.
Initial TreatmentInhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs by MDI+ VHC or nebulizer treatments.
Good Response: No wheezing or dyspnea (assess tachypnea in young children). PEF ≥80% predicted or personal best.Contact clinician forfollow-up instructions/management
May continue inhaled SABA every 3–4 hours for 24–48 hours.
Consider short course of oral systemic corticosteroids for high-risk patients
Good Response: No wheezing or dyspnea (assess tachypnea in young children). PEF ≥80% predicted or personal best.Contact clinician forfollow-up instructions/management
May continue inhaled SABA every 3–4 hours for 24–48 hours.
Consider short course of oral systemic corticosteroids for high-risk patients
Incomplete Response: Persistent wheezing and dyspnea (tachypnea). PEF 50–79% predicted or personal best.Add oral systemic corticosteroid.
Continue inhaled SABA.
Contact clinician urgently (this day) for further instruction.
Incomplete Response: Persistent wheezing and dyspnea (tachypnea). PEF 50–79% predicted or personal best.Add oral systemic corticosteroid.
Continue inhaled SABA.
Contact clinician urgently (this day) for further instruction.
Poor Response: Marked wheezing and dyspnea. PEF <50% predicted or personal best. Add oral systemic corticosteroid. Repeat inhaled SABA immediately. If distress is severe and nonresponsive to initial treatment:—Call your doctor AND—PROCEED TO ED;—Consider calling 9–1–1 (ambulance transport).
Poor Response: Marked wheezing and dyspnea. PEF <50% predicted or personal best. Add oral systemic corticosteroid. Repeat inhaled SABA immediately. If distress is severe and nonresponsive to initial treatment:—Call your doctor AND—PROCEED TO ED;—Consider calling 9–1–1 (ambulance transport).
To EDTo EDModified from NAEPP Guidelines 2007
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Individualized decision re: hospitalization
Individualized decision re: hospitalization
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
ImproveImproveImproveImprove
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Admit to Hospital Intensive CareAdmit to Hospital Intensive Care
Modified from NAEPP Guidelines 2007
Inhaled SABA
Onset of action within 5 minutesPeak effect in 30-60 minutesDuration of action 4-6 hours
Promote bronchodilation by smooth muscle relaxation
May be given intermittently or continuously (nebulized)
Inhaled SABAs
Medication Children ≤ 12 years old Children > 12 years old CommentsAlbuterol nebulizer solution (0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/3 ml, 5 mg/ml)
0.15 mg/kg (min of 2.5 mg) q20mins for 3 doses then 0.15-0.3 mg/kg (max 10 mg) q1-4h prn OR 0.5 mg/kg/hr continuous nebulization
2.5-5 mg q20mins for 3 doses then 2.5-10 mg q1-4h prn OR 10-15 mg/hr continuously
Dilute aerosols to minimum of 3 ml; gas flow at 6-8 L/min.
Albuterol MDI (90 mcg/puff)
4-8 puffs q20min for 3 doses then q1-4h prn; use VHC; add mask in children <4 years old
4-8 puffs q20min up to 4 doses then q1-4h prn
MDI plus VHC equally efficacious as nebulized therapy in mild-moderate exacerbations
Levalbuterol nebulizer solution (0.63 mg/3 ml, 1.25 mg/0.5 mL, 1.25 mg/3 mL)
0.075 mg/kg (min dose 1.25 mg) q20min for 3 doses then 0.075-0.15 mg/kg up to 5 mg q1-4h prn
1.25-2.5 mg q20min for 3 doses then 1.25-5 mg q1-4h prn
Comparable efficacy to albuterol; not evaluated by continuous nebulization
Levalbuterol MDI (45 mcg/puff)
Same as albuterol MDI dosing
Same as albuterol MDI dosing
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Individualized decision re: hospitalization
Individualized decision re: hospitalization
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
ImproveImproveImproveImprove
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Admit to Hospital Intensive CareAdmit to Hospital Intensive Care
Modified from NAEPP Guidelines 2007
Inhaled Anticholinergics
Medication Children ≤12 yo Children >12 yo CommentsIpratropium bromideNebulized solution (0.25 mg/ml)
0.25-0.5 mg q20min for 3 doses, then prn
0.5 mg q20min for 3 doses then prn
Added to SABA during severe exacerbations; no proven benefit for mild/moderate exacerbations; no proven benefit once patient hospitalized
Ipratropium bromideMDI (18 mcg/puff)
4-8 puffs q20min prn up to 3 hours
8 puffs q20min prn up to 3 hours
Children should use VHC; studies have examined MDI up to 3 hours only
Ipratropium bromide with albuterolNebulized solution (each vial contains 0.5 mg ipratropium and 2.5 mg albuterol)
1.5-3 ml q20min for 3 doses then prn
3 ml q20min for up to 3 doses then prn
Reserved for first 3 hours of treatment of severe exacerbations; no proven benefit once patient hospitalized
Ipratropium bromide with albuterol MDI (18 mcg ipratropium and 90 mcg albuterol per puff)
4-8 puffs q20min prn up to 3 hours
8 puffs q20min prn up to 3 hours
Children should use VHC; indications as above
Systemic Corticosteroids
Prednisone/Methylprednisolone/Prednisolone
Children ≤ 12 yo: 1-2 mg/kg/day (max 60 mg/day) for 3-10 days until PEF is 70% predicted or personal best
Children >12 yo: 40-80 mg/day for 3-10 days until PEF is 70% predicted or personal best
Preschool Wheezers: The Great CS Debate
Panickar et al (NEJM 2009) performed RDBPCT comparing oral prednisolone to placebo in 687 children between ages of 10 and 60 months
Majority of children experienced mild-moderate wheezing
Primary outcome was length of hospitalization; secondary outcomes were PRAM score, albuterol use and 7-day symptom scores
Preschool Wheezers: The Great CS Debate
Prednisolone no better than placebo for any outcome
Study strengths: RDBPCT, large number of patients, use of standardized scoring (PRAM), majority of patients with viral wheezer phenotype
Limitations: possibly under-dosing of prednisolone for a significant number of patients, lack of data on subjects refusing participation, no provision of age of patients at high-risk for persistent asthma, no viral studies
Preschool Wheezers: The Great CS Debate
Several other studies have found contradictory results, particularly in patients at high-risk for the development of atopic asthma (positive API)
Recent study found reduced rate of relapse in subjects infected with RV when treated with prednisolone as compared to placebo
Study by Ducharme et al (NEJM 2009) showed decreased exacerbation severity in subjects treated with high-dose inhaled fluticasone at the onset of a URI-induced exacerbation
Systemic Corticosteroids: Summary
Always indicated for patients with severe exacerbations
Generally not indicated for patients with mild exacerbations unless high-risk for asthma-related death
Indicated for patients with moderate exacerbations if no immediate response to SABA treatment or high-risk for asthma-related death
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Individualized decision re: hospitalization
Individualized decision re: hospitalization
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
ImproveImproveImproveImprove
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Admit to Hospital Intensive CareAdmit to Hospital Intensive Care
Modified from NAEPP Guidelines 2007
Magnesium Sulfate (IV)
Meta-analyses (adult and peds studies) show that hospitalization rates decreased when MgSO4 added to conventional Rx for severe exacerbations
Dose 25-75 mg/kg up to 2 g
NAEPP recommendation: “consider in patients with life-threatening exacerbations and patients who remain in the severe category after 1 hour of intensive conventional therapy”
Heliox
Theoretical benefit for improving gas exchange because of helium’s low density
Studies contradictory
Three studies (1 peds, 2 adult) showed improvement in subjects experiencing moderate-severe exacerbations treated with Heliox-driven SABA treatments when compared to subjects receiving O2-driven SABA treatments
Leukotriene Receptor Antagonists
RT showed significant improvement in pulmonary function within 10 minutes of administration of IV montelukast to patients with moderate-severe exacerbations
Oral montelukast does not take effect before 90 minutes from time of administration
Systemic β2 Agonists
Medication Children<12 yo Children ≥12 yo Comments
Epinephrine 1:1000 (1 mg/ml)
0.01 mg/kg up to 0.3-0.5 mg sq q20min for 3 doses
0.3-0.5 mg sq q20min for up to 3 doses
No proven benefit over aerosol
Terbutaline (1 mg/ml) 0.01 mg/kg sq q20min for up to 3 doses then q2-6h prn
0.25 mg sq q20min for up to 3 doses
No proven benefit over aerosol
When to Intubate
Signs of impending respiratory failure: Inability to speakAltered mental statusWorsening fatigueSignificant and prolonged retractionsPCO2 ≥ 42 mm Hg
Theoretical benefit of ketamine as a premedication for ETI has not born out in studies (limited data)
Assessing Response to Treatment
Serial physical examinations
Serial FEV1 or PEF
Serial pulse oximetry measurements
Signs and symptom scores
Predicting Need for Hospitalization
Kelly et al (Respir Med 2004) showed that severity assessment at 1hour after initial treatment with SABA was better predictor of need for hospitalization than initial assessment
After 1hour if meets criteria for severe exacerbation >86% chance of hospitalization; if moderate after 1 hour >84% chance of hospitalization; if mild then only 18% chance of hospitalization
SaO2 <92-94% at 1 hour better predictor of need to hospitalize than initial SaO2
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Moderate ExacerbationPhysical exam: moderate symptoms; FEV1
or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion
Individualized decision re: hospitalization
Individualized decision re: hospitalization
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation
ImproveImproveImproveImprove
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.
Admit to Hospital Intensive CareAdmit to Hospital Intensive Care
Modified from NAEPP Guidelines 2007
Plan for Discharge
Provide patients written instructions regarding dose, frequency and correct use of medications
Consider initiating or continue with ICS
Schedule follow-up appointment with PMD or asthma specialist within 4 weeks