PKB IKA XXIII BALI

FK UNUD/RSUP SANGLAH DENPASAR

MANAGEMENT OF ASTHMA EXACERBATION DURING

COVID-19 PANDEMIC

Ida Bagus Subanada

Department of Child Health
Faculty of Medicine Universitas Udayana-Sanglah Hospital Denpasar
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

OUTLINE

1 Definition of Asthma Exacerbation

2 Pathophysiology of Asthma Exacerbation

3 Severity of Asthma Exacerbation

4 Management of Asthma Exacerbation

5 Inhalation Therapy during COVID-19 Pandemic

 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

OUTLINE

1 Definition of Asthma Exacerbation

5
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

• “Asthma exacerbation are episodes by a progressive

increase in symptoms of shortness of breath, cough,
wheezing, or chest tightness, and progressive decrease in
lung function”.

• Other terminologies: episode of asthma, asthma attack, acute severe

asthma, asthma flare-up.

GINA
GINA
2021
2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

OUTLINE

1 Definition of Asthma Exacerbation

2 Pathophysiology of Asthma Exacerbation

5
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Asthma

Poor
Triggers controller
adherence

Exacerbation
PNAA 2016, GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

◆ Triggers
1 Allergen
2 Viral respiratory infection
3 Outdooor air pollution
4 Changes in weather
5 Poor adherence with ICS
6 Activity
7 Stress, laughter
8 Irritant exposure
PNAA 2016, GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR
Pathophysiology of Asthma Exacerbation

Triggers

Bronchoconstriction, edema, secretion 

Airway obstruction

Ventilation disorder Hyperinflated lung

Atelectasis V/Q mismatch Compliance abnormality

Surfactant Alveolar hypoventilation Increased WoB

Acidosis

Pulmonary  PaCO2
vasoconstricition
 PaO2 PNAA 2016
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

OUTLINE

1 Definition of Asthma Exacerbation

2 Pathophysiology of Asthma Exacerbation

3 Severity of Asthma Exacerbation

5
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Severity of Asthma Exacerbation in Adolescents

and Children 6-11 years
Mild-Moderate Severe Life-threatening

Talk in phrases Talk in words Drowsy

Prefers sitting to lying Sit hunched forwards Confused
Agitated (-) Agitated (+) Silent chest
RR increased RR >30/min

Accessory muscles use (-) Accessory muscles use (+)

PR 100-120 bpm PR >120 bpm

O2 sat. (room air) 90-95% O2 sat. (room air) <90%

PEF >50% predicted or best PEF ≤50% predicted or best

PNAA 2016, GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Severity of Asthma Exacerbation in Children ≤5 years

Mild-Moderate Severe OR Life-Threatening, any of:

Breathless Unable to speak or drink

Central cyanosis
Agitated Confusion or drowsiness
RR >40/min
PR ≤180 bpm (0-3 yrs), or ≤150 bpm
(4-5 yrs) O2 sat. <92%
PR >180 bpm (0-3 yrs) or
O2 sat. ≥92% >150 bpm (4-5 yrs)
Silent chest on auscultation

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

OUTLINE

1 Definition of Asthma Exacerbation

2 Pathophysiology of Asthma Exacerbation

3 Severity of Asthma Exacerbation

4 Management of Asthma Exacerbation

5
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Goal of Management of Asthma Exacerbation

1 Rapidly relieve airway obstruction

2 Rapidly decrease hypoxemia

3 Rapidly return of lung function to normal

4 Evaluate long-term management to prevent relapse

PNAA 2016
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Management of Asthma Exacerbations in PRIMARY CARE for Adolescent and Children 6-11 Years

GINA 2021
Management of Asthma Exacerbations in PRIMARY CARE for Adolescent and Children 6-11 Years (continuation)

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Management of Asthma Exacerbations in ACUTE CARE FACILITY for Adolescent And Children 6-11 Years

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Management of Asthma Exacerbations in ACUTE CARE FACILITY for Adolescent and Children 6-11 Years (continuation)

GINA 2021
 Management of asthma
PKB IKA in children
XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

Management of Acute Asthma or Wheezing in Children ≤5 Years

[1] GINA 2021

[2] 20GINA
dari GINA
2021
Management of Acute Asthma or Wheezing in Children ≤5 Years (continuation)

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

GINA 2021
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

OUTLINE

1 Definition of Asthma Exacerbation

2 Pathophysiology of Asthma Exacerbation

3 Severity of Asthma Exacerbation

4 Management of Asthma Exacerbation

5 Inhalation Therapy during COVID-19 Pandemic

 Inhalation Therapy during the COVID-19 Pandemic

British National Institute for Health and Care Excellence (NICE):

• Continue to use nebulizer because the aerosols are generated from fluid within
the nebulizer chamber that doesn’t carry patient–derived viral particles

• “If a particle in the aerosol comes into contact with contaminated mucous
membrane, it ceases to be airborne and therefore will not be aerosolized”
National Institute for Health and Care Excellence, COVID-19 rapid guideline: severe asthma (NICE guideline [NG166]) 2020 (cited Oct 11, 2020). Available at:
https://www.nice.org.uk/guidance/ng166.
 Inhalation Therapy during the COVID-19 Pandemic

British Thoracic Society (BTS):

• “Supports use of nebulizers because they don’t consider nebulization a ‘viral’

aerosol generating procedure”

• “Nebulization is not a viral droplet generating procedure since the droplets are
from the machine (liquid drug particles), not the patient”

British Thoracic Society, COVID-19: information for the respiratory community.

Advice about the safety of nebuliser use (cited Nov 8, 2020).
Available from: https://www.brit-thoracic.or g.uk/about-us/covid-19-information-for-the-respiratory-community/.
 Inhalation Therapy during the COVID-19 Pandemic

International Society of Aerosol and Medicine (ISAM):

• “Nebulized aerosol do not carry patient derived viral particles as they are
generated from the fluid in nebulizer chamber, which is a non-patient source”1

• “Medical aerosol produced by nebulizers contain pathogen only when the

patient or healthcare worker contaminates the nebulizers”2

1. Fink, et al. J. Aerosol Med. Pulm. Drug Deliv. (2020). Available from: https://doi.org/10.1089/jamp.2020.1615.
2. Rotherham Doncaster, South Humber NHS Foundation Trust Infection Prevention Control Manual, Aerosol generating procedures,
appendix 46 (cited Oct 11, 2020). Available from: https:// www.rdash.nhs.uk/wp-content/uploads/2017/08/Appendix-46-Aerosol-
Generating-Procedures.pdf. .
 Inhalation Therapy during the COVID-19 Pandemic

Centers for Disease Control and Prevention (CDC):

• “Jet nebulizer should be replaced, rinsed, air dried, washed, disinfected,

and/or sterilized after each treatment”1

• “Provider may contaminate nebulizer when they handle medication and the
device, but the possibility that also patients will contaminate nebulizer
and the role of nebulizer should not be overlooked”2

1. Fink, et al. Reducing aerosol-related risk of transmission in the era of COVID-19: an interim guidance endorsed by the international
society of aerosols in medicine. J. Aerosol Med. Pulm. Drug Deliv. (2020), https://doi.org/10.1089/jamp.2020.1615
2. R. Dhand, J. Li,.Coughs and sneezes: their role in transmission of respiratory viral infections, including SARS-CoV-2.
Am. J. Respir. Crit. Care Med. 202 (5) (2020) 651–9.
 Inhalation Therapy during the COVID-19 Pandemic

Centers for Disease Control and Prevention (CDC):

• “Vibrating mesh nebulizer generating aerosols via mesh plates that separate
the sealed medication reservoir from the patient interface”1

• “During nebulization, the aerosol derives from the fluid in the nebulizer
chamber and does not carry patient-derived viral particles”

• “Mesh nebulizers are LESS LIKELY to disperse patient generated bio-aerosol,

as they do not use external gas flow source”2

1. Dhand, et al. Coughs and sneezes: their role in transmission of respiratory viral infections, including SARS-CoV-2. Am. J. Respir. Crit. Care Med. 202
(5) (2020) 651–9.
2. American Association for Respiratory Care, NebulizerCleaning—Final State Survey Worksheets Released. Updated: April 20, 2017 (cited Oct 11,
2020). Available from: https://www.aarc. org/nebulizer-cleaning/.
 Inhalation Therapy during the COVID-19 Pandemic

Global Initiative for Chronic Obstructive Lung Disease (GOLD)

strategy:

• Recommended the use of nebulizer for those who need nebulizer

• MDI must be used by patients who are suitable for MDI

Global Initiative for Chronic Obstructive Lung Disease, GOLD COVID-19guidance (cited Oct 11, 2020).
Available at: https://goldcopd.org/gold-covid-19-guidance/..
.
 Inhalation Therapy during the COVID-19 Pandemic

American Thoracic Society (ATS):

• “Nebulizer could increase the risk of infecting others through the

mist that she/he exhales”

• “Nebulizer must be used in a location that is separate from others

in household”

Sockrider, et al. Managing your chronic lung disease during the COVID- 19 pandemic. Am. J. Respir. Crit. Care Med. 202 (2) (2020) P5–P6.
 Inhalation Therapy during the COVID-19 Pandemic

Italian Association of Internal Medicine ~ FADOI:

• Mesh nebulizer should be preferred when treating ventilated

patients (place an additional filter on the expiratory limb of the
ventilator circuit during nebulization)
• “Avoid opening the ventilator circuit to add medication or change
nebulizer”

• “Use MDI or pMDI with spacer for spontaneously breathing patient

who need aerosol therapy”
FADOI. Guida clinico-pratica COVID-19. Rev. 6 | 23 giugno, 2020 (cited Oct 11, 2020).. Available from: https://www.fadoi.org/wp-
content/uploads/2020/07/FADOI_Guida-clinico-pratic a-COVID-19_rev6.pdf.
 Inhalation Therapy during the COVID-19 Pandemic

The American College of Allergy, Asthma, and Immunology:

• SARS-CoV-2 may persist for 1-2h in droplet in the air

• Nebulization outside the house on a porch or patio or in garage

American College of Allergy, Asthma and Immunology. Nebulizer use during the COVID-19 pandemic (cited Oct 11, 2020). Available from:
https://college.acaai.org/publications/college -insider/nebulizer-use-during-covid-19-pandemic.
 Inhalation Therapy during the COVID-19 Pandemic

Other strategies

• Facemask should not be used with nebulizer

• Mouthpiece, filter, one-way valves1

• Clean all the surface in the room or area where nebulization is performed

• Do not share their inhalers and devices with anyone2

1. A. Ari. Practical strategies for a safe and effective delivery of aerosolized medications to patients with COVID-19. Respir. Med. 167 (2020 Jun) 105987.
2. Ong, et al. Managing asthma in the COVID-19 pandemic and current recommendations from professional bodies: a review. J. Asthma (2020),
https://doi.org/10.1080/02770903.2020.1804578.
 Inhalation Therapy during the COVID-19 Pandemic

• If possible, avoid use of nebulizers due to the risk of transmitting infection to other patients
and/ or to helthcare workers

• Use a pMDI + spacer, with a mouthpiece or tightly fitting facemask

GINA 2021

• Against the use of nebulizers unless unavoidable because generate aerosols tha can spread
infectious droplets for severals metres and remain airborne for >30 minutes.

Australian National Asthma Council. Managing asthma during the COVID-19 (SARS-CoV-2) pandemic (cited Oct 11, 2020). Available from:
https://www.asthmahandbook. org.au/clinical-issues/covid-19.
Inhalation Therapy during the COVID-19 Pandemic

Nebulization still pro cons

Cazzola M, dkk. Guidance on nebulisation during the current COVID-19 pandemic.

Respiratory Medicine 176 (2021) 106236
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

TAKE HOME MESSAGES

• Asthma exacerbate due to poor controller
adherence and contact with trigger

• Asthma exacerbation need fast and precise

management

• There are pro cons the using of nebulizer for

management of asthma exacerbation during
COVID-19 pandemic
 PKB IKA XXIII BALI
FK UNUD/RSUP SANGLAH DENPASAR

TERIMA KASIH