Bronchial Asthma Attack Therapy / PGS (VPL)

Exacerbation of bronchial asthma attack

Exacerbation of asthma (= asthma attacks):

• they are states:
  • progressive worsening of shortness of breath, cough, wheezing, chest tightness or
  • combination of these symptoms.

Variability

Asthma bronchiale:

• very variable disease - interindividually, in time intraindividual.
• virtually every asthmatist sometimes underwent acute exacerbation - sometimes as the first manifestation (paradoxically, it will warn us of the disease (not yet known) in time).

Many forms:

• from light,
• to a severe life threatening condition:
  • severe form forces the patient to seek urgent medical care,ev. hospitalization is needed, systemic corticoids.

Onset of exacerbation

• gradual (progresses within a few hours / days) or
• dramatically abrupt (minutes), like some near-lethal variants.

Exacerbation is characterized by:

• reduction of expiratory flow and worsening of obstruction,
  • is possible to measure deterioration in lung function - PEF or FEV1
    • more reliable indicator st. air flow limitation, than the severity of the symptoms,
    • st. difficulties = more sensitive rate of onset of exacerbation (worsening of symptoms precedes decrease of PEF),
    • a small proportion of patients perceive symptoms poorly - may have a significant decrease in lung function without a significant change in symptoms (especially patients with so-called fatal asthma, more likely in men).

Causes of exacerbations

Acute exacerbations are usually:

• as a result of exposure to triggers, no. viral infection / allergen,
• with a more prolonged course of deterioration - may be the result of failure of long-term therapy.

Morbidity and mortality

• most often associated with:
  • inability to determine the severity of the exacerbation,
• inadequate solution to its beginning,
• its inadequate therapy.

Selection and initiation of exacerbation therapy

Exacerbation therapy depends on:

• the pacient,
• experiences of a healthcare professional ,
• the most effective therapeutic procedures for this patient,
• availability of medicines and acute care facilities.

Exacerbation is necessary to:

1. recognize in time,
2. correctly determine the burden,
3. initiate effective therapy in a time,
4. monitor the response to initial treatment of an asthma attack.

At the same time, consider:

• who will lead the treatment and where,
• whether we can handle the treatment in the home environment / outpatient clinic,
• whether to hospitalize.

With a high risk of death from asthma, we provide:

1. immediate professional care,
2. thorough monitoring.

This is what patients require:

• after an almost fatal asthma attack,
• after an acute hospitalization in last year for an acute asthma attack,
• when they are intubated for asthma,
• if they are currently/recently using p.o. corticoids,
• if they are overdependent on inhaled β2-agonists with rapid onset of action (> 1 salbutamol inhaler / equivalent),
• with psychiatric illness / psychosocial problems,
• if they are denying asthma (/severity of it) or their family does so,
• if they do not follow a long-term bronchial asthma treatment plan.

Educated patient manages at home:

• light exacerbations with a good response to initial therapy...

Seek medical help - immediately - if it is severe seizure:

• the sick patient is suffocating at rest,
• the patient is bent forward,
• the patient does not speak in sentences, only in words (infants stop eating),
• the patient is restless, confused or lethargic,
• with bradycardia/respiratory rate > 30 breaths/min,
• whistles are loud / faded ,
• pulse > 120/min (infants 160/min.),
• PEF after initial treatment is < 60% NH or ONH,
• patient is generally exhausted.

Seek medical attention necessary if:

• response to initial bronchodilator therapy is not rapid and does not last for at least 3 hours.

or

• there is no improvement within 2-6 hours after starting p.o. corticosteroid therapy

or

• further deterioration occurs.

Treatment

Exacerbation of bronchial asthma - requires immediate treatment.

The following are essential at all levels of care:

• inhaled β2-agonists with rapid onset of action in sufficient doses:
  • during the 1st hour : 2-4 doses every 20 minutes.
  • after the 1st hour: according to the severity of the exacerbation.
    • light exacerbation - response when administering 2-4 doses every 3-4 hours,
    • moderate exacerbations - response at up to 6-10 doses after 1-2 hours,
    • severe exacerbations - up to 10 breaths in (preferably via an inhalation attachment) or full doses from the nebulizer, ev. at intervals <1 hour.
  • Bronchodilator treatment - standard aerosol dispenser (MDI), preferably via an inhalation attachment, improves lung function min. as the same dose administered by the nebulizer.
  • No additional drugs are needed if fast-acting inhaled beta2-agonists lead to a complete response, with PEF returning to> 80% NH or ONH) and improvement lasting at least 3-4 hours.
  • it is better to administer salbutamol in an isotonic solution MgSO₄ than in FR .
  • the combination of an inhaled / nebulized β2-agonist with an anticholinergic (iprapropium bromide) may bronchodilate better than either drug alone.
  • if we do not have inhaled drugs, bronchodilators can be given p.o.

• Oral corticoids
  • early in moderate / severe exacerbations (0.5-1 mg / kg prednisolone (or equivalent) / 24 hours) to accelerate the improvement of all exacerbations, only in case of the most light ones.
  • guideline for the administration of p.o. corticosteroids:
    • response to inhalation of fast-acting β2-agonists not fast / permanent after 1 hour (eg. PEF is not> 80% NH or ONH ).
  • in case of vomiting of the oral dose shortly after administration - repeat its administration.
  • i.v. administration - if i.v. access is desired or absorption from the GIT is likely to be impaired ,
  • i.m. suitable for those released from the acute medicine department, especially if they do not cooperate well in treatment.
  • clinical improvement after administration of systemic corticoids is expected in 4 hours at the earliest.

• Theophyllines (= methylxanthines)
  • not suitable as an additional th. to high-dose inhaled β2-agonists.
  • possible if inhaled β2-agonists are not available.
  • if they use theophyllines for a long time, we should measure their serum concentration before administering theophyllines with short-term effect.

• oxygen supply:
  • indicated in hypoxia in medical facilities,
  • nasal cannulas ("oxygen glasses"), mask, small children can be in the oxygen tent,
  • SatO₂ of arterial blood was >/= 92% (children 95%) - carefully monitor (pulse oximetry) especially of children (measurement of lung function is usually difficult and saturation <92% is a good indicator of the need for hospitalization - if saturation cannot be measured in children, oxygen should always be given).
  • into jet nebulizers to nebulize oxygen bronchodilators instead of air,
  • examination of blood gases from arterial blood - in patients with PEF values of 30–50% NH and those who did not improve after the initial treatment.
  • allow oxygen to be inhaled even when taking a blood sample.
  • PaO₂ < 8 kPa (60mm hg) and normal / elevated PaCO₂ (ex. > 6 kPa – 45mm Hg) or threatened / developed respiratory insufficiency.
    • bed stabilization with monitoring option is recommended,
    • if the condition of the patient does not improve, the patient is tranfered to JIP.

Not suitable for asthma therapy

• Adrenaline is not indicated for the treatment of asthma exacerbations, but for the management of anaphylaxis / angioedema.
• Not suitable are:
  • sedatives, mucolytics, ATB,
  • nor high-volume hydration in adults / older children. (We must give fluids to young children / infants.)
• Respiratory RHB or physiotherapy is unsuitable for the treatment of acute exacerbations - is possible worsening of discomfort of patients.

Links

Related articles

On the VPL portal:

• Therapy of asthma bronchiale
• Asthma bronchiale‎

In Wikilectures:

• Asthma
• Asthma bronchiale/Case report
• Status asthmaticus
• Asthma bronchiale therapy

Case report:

• Asthma bronchiale/Case report

External links

www.svl.cz/....astma-2008.pdf

References

• SALAJKA, František. Asthma bronchiale : Doporučený diagnostický a léčebný postup pro všeobecné praktické lékaře [online] . 1. edition. Praha : Společnost všeobecného lékařství ČLS JEP, 2008. Available from <https://www.svl.cz/default.aspx/cz/spol/svl/default/menu/doporucenepostu/doporucenepostu5>. ISBN 978-80-86998-26-8.

• SALAJKA, F – KONŠTACKÝ, S – KAŠÁK, V. Asthma bronchiale : Doporučený diagnostický a léčebný postup pro praktické lékaře. 1. edition. Praha : Centrum doporučených postupů pro praktické lékaře, 2005. 

• SALAJKA, F – KAŠÁK, V – POHUNEK, P. Diagnostika, léčba a prevence průduškového astmatu v České republice : Uvedení globální strategie do praxe. 1. edition. Praha : Jalna, 2008.