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Managing acute episodes

Some pharmacology

Relievers
Short-acting 2-agonists
Salbutamol Terbutaline

Anticholinergics
Ipratropium bromide

Steroids Theophylline
(Select situations)

Non selective -agonist


Adrenaline

Oxygen
Hypoxia due to V / Q mismatch.
agonists may paradoxically worsen hypoxia

Maintain SaO2 > 92%.

Use oxygen to nebulise 2 agonists


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Inhaled 2-agonists

Drugs of choice.
Salbutamol / Terbutaline are similar. Severe acute episode nebuliser preferred

Dose- < 6 months-0.25 ml of respirator soln,


> 6 months- 0.5-1ml of respirator soln Dilute in saline only, NEVER distilled water Beware of hypokalemia with high dose nebulization.

Rescue steroids
Early usage - reduces morbidity/ hospitalization Oral prednisolone 1-2 mg/kg for 3-7 days.
No tapering needed / No adverse effects

Injectables do not confer quicker benefit.


Hydrocortisone( 5-10 mg/kg) q 6hr or IV Methylprednisolone (1-2 mg/kg) q6hr IV / IM Dexamethasone (0.1 0.2 mg / Kg) q 6 hr

if patient unable to take orally (drowsy/distressed/vomiting)

High dose inhaled / nebulised steroids not proven


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Anticholinergics
Ipratropium bromide Additive effect to 2 agonist in acute severe asthma Neb soln 0.5 ml <1yr, 1ml>1 yr (Compatible with 2 agonist solution.) Limit use to 24-48 hours to prevent atropine like effects (fever)

Aminophylline
Retains its role as reliever in acute severe attacks
improves diaphragmatic contractility mucociliary function inflammatory modulation

Dose:
Loading dose 5 mg/kg slow diluted IV bolus (Avoid if patient on SR theophylline) Followed by 0.51.0mg/kg/hr as infusion (Avoid subsequent bolus doses)

Toxicity
Gl , Cardiac, CNS Monitor levels if possible
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Oral drugs as relievers

Oral 2 agonists for mild intermittent airflow obstruction. Oral prednisolone for rescue therapy

Managing acute episodes


Back to Arpit and his friends

Case..
Arpit decides to help his mother with Diwali cleaning. He starts coughing continuously and his mother rushes him to the clinic

What questions will you ask the mother?

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During an acute attack


Enquire
Duration ? Relievers taken? - Response? Brittleness (Rapid worsening) Precipitant / trigger factors On regular preventers? Number and severity of previous attacks Last theophylline dose (if relevant)

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Case contd
On examination, Arpit has a respiratory rate of 40 per minute and a mild increase in accessory muscle activity. He appears comfortable and is able to talk in sentences. Auscultation reveals a wheeze towards the end of expiration.

How will you grade Arpits acute attack and manage him?
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Grading severity
Over a period of timehelps to decide regarding need and choice of preventer drugs

At a point in time helps to decide regarding the level and drugs for acute care.

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Quick assessment
Respiratory rate Too breathless to feed / sleep Talking words, not sentences

Poor or only transient (< 2hr) response to bronchodilator


Worsening despite 23 recent doses of inhaled 2 agonists at 15 minute intervals

SaO2 < 92%

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Pulmonary score index


Score
0 1 2 3

Respiratory Rate <6 years >6 years


< 30 3145 4660 > 60 < 20 2135 3650 > 50

Wheezing*
None Terminal expiration with stethoscope Entire expiration with stethoscope During inspiration and expiration without stethoscope

Accessory muscle Sternomastoid activity


No apparent activity Questionable increase Increase apparent Maximal activity

Score

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Mild

*If no wheezing due to minimal air exchange, score>3

Those children whose score is > 6 should be admitted to a pediatric ICU

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Moderate Severe

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Home management
PS < 3 (mild grade) SA 2 agonist: 2 - 4 puffs through MDI + spacer + mask

Repeat every 15 - 20 mins for max 3 times


If response ill sustained (< 4 hrs), start 1st dose of rescue steroid
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Case..
Sanjana calls you in the middle of the night. She is proceeding to the casualty once again. You rush in to see her and find her to have a respiratory rate of 40 per min. She is wheezing audibly.

Assess her severity and manage her

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E Room plan
PS 4-6(moderate)
O2 SA 2 agonist

Nebulised q 20 min x 3 or MDI + spacer + mask 2 puffs q 2 min increasing by 2 10 puffs reached / 10 puffs q 20 min x 3 or (if inhaled therapy not available) Adrenaline / Terbutaline 0.01mg/kg sc q 20 min x 3

puffs till

Commence / Continue rescue steroid Continuous assessment SA 2 agonist neb hourly p.r.n. If good response(PS <3), initiate discharge plan
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Sanjana does not respond to this treatment. One hour later, her respiratory rate has gone up to 50 per minute. You decide to admit her to the ward. What do we do next? asks your resident doctor

Outline your plan to him

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Ward plan
Continue oxygen,
Start IV fluids, IV/oral steroid SA 2 nebulization - hourly/ back-to-back

Ipratropium neb q 30 min x 3 and then q 6 hours


Aminophylline bolus and IV infusion Monitor SaO2 and serum K+ CBC, X-Ray chest to identify complications

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Intensify if not better


Pulmonary score q 15-30 minutes Consider blood gas studies if SaO2 < 92% Terbutaline continuous iv infusion. Magnesium sulfate iv infusion over 30 mins

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Your resident doctor is new but means well. What

complications should I expect? he asks and Sir/Madam, no


antibiotics? he continues with a bewildered look.

What will you teach this young lad?

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Complications
Pneumothorax Pneumomediastinum Subcutaneous emphysema Atelectasis Secondary infection Therapy related
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Role of antibiotics
Consider only in those with poor response, purulent secretions and radiological evidence of infection. Bacterial infections seldom trigger asthma

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Case
36 hours later Sanjana is showing signs of improvement. On your morning round, you find her sitting up comfortably sipping her tea. She says she slept well through the night. On examination she is mildly tachypnoeic and her wheeze is now only in the terminal phase of respiration. Can I go home? she asks

How will you reduce her medication and when will you decide to discharge her?

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Stepping down acute care


Follow the principle last in first out
Discontinue terbutaline /aminophylline drip in 24

hours
Discontinue ipratropium neb in 24-48 hours Reduce SA 2 agonist to q 2-4 hrly and then q 46hrly Replace iv steroid with oral steroid
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Discharge criteria
Pulmonary score < 3
Slept well at night Feeding well Appears comfortable.

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Cases. contd

What will you advise Arpit and Sanjana when they are ready to go home?

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Discharge plan
Inhaled SA 2 agonist MDI + spacer + mask q 4-6 hour till symptoms Continue course of rescue steroid for 3-7 days (Tapering not necessary)

Review compliance, trigger elimination, preventer regime


Educate regarding home plan / long term strategy Plan follow up visit within 7-14 days

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If a child requires rescue steroids / 2 - agonists frequently, explore reasons for poor control.

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Case.
Meanwhile, Raju, a 8 year old with asthma is brought to the hospital in an

ambulance with oxygen by mask. He is too breathless to speak, is


sweating and quite agitated. On examination his nails are dusky and on auscultation you hardly perceive any air entry. He has shown no response to 3 doses of nebulized bronchodilator given while he was rushed in with sirens blaring.

ACT FAST beg the parents.

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Asthma
Red flag signs
Unable to talk or cry Cyanosis Feeble chest movements Absent breath sounds Fatigue or exhaustion Agitated Altered sensorium Oxygen saturation < 92%
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ICU plan
Continue / initiate intensified ward plan Blood gas studies Possible intubation and mechanical ventilation with

ketamine and midazolam / fentanyl iv infusion


Paralysis with vecuronium, if required

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To summarize
Diagnosis
Asthma is an inflammatory illness Diagnosis of asthma is clinical, and relies on history All asthma does not wheeze In children < 3 yrs, WALRI is an important differential diagnosis 2 out of 3 children outgrow their asthma

A family history of asthma / atopy increases risk of asthma

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To summarize
Long term management
Patient education is a very important part of asthma management Drugs control, but do not cure asthma Clinical grading over time, decides long term management plan Mild intermittent asthma does not merit preventers Inhaled steroids are mainstay of long term asthma management Treatment should be stepped up or stepped down depending upon patient response

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To summarize
Acute management
Grading at a point in time decides management SA inhaled 2 agonists are used to manage acute exacerbations Frequent use of SA 2 agonists indicate poor control of asthma Taking care of the home environment reduces exacerbations of asthma Devices MDI should always be used with spacer

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