Therapy of asthma attack bronchiale/PGS (VPL)

Exacerbation of an attack of bronchial asthma

Exacerbation of asthma (= asthma attacks):

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

Variability

Bronchial asthma:

• highly variable disease - inter-individual, over time intra-individual.
• practically every asthmatic has experienced an acute exacerbation at some point - sometimes as the first manifestation (paradoxically, the (as yet unrecognized) disease is alerted in time).

Many Forms:

• from light,
• to'severe life-threatening condition:
  • a severe form forces the patient to seek urgent medical care, possibly

hospitalization, systemic corticoids are needed.

Onset of exacerbation

• gradual (progresses over several hours/days) or
• dramatically and suddenlt (minutes), like some near-fatal variants.

Exacerbation is characterized by:

• reduced expiratory flow and worsening of obstruction,
  • deterioration of lung function can be measured - PEF or FEV1
    • more reliable indicator st. airflow limitation than the severity of symptoms,
    • St. difficulties = more sensitive measure of the onset of exacerbation (worsening of symptoms is preceded by a decrease in PEF),
    • a small number of patients perceive the symptoms poorly - they 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 - they may be the result of failure of long-term therapy.

Morbidity and Mortality

• nothing is associated with:
  • inability to determine the severity of exacerbations,
• inadequate solution to its beginning,
• insufficient therapy.

Selection and initiation of exacerbation therapy

Exacerbation therapy depends on:

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

Exacerbation is necessary:

1. recognize in time
2. correctly determine the weight,
3. start effective therapy in time,
4. monitor response to initial asthma attack treatment.

At the same time, continuously consider:

• who and where will conduct the treatment,
• whether we can manage the treatment in a home environment/ambulance,
• whether to hospitalize.

If there is a high risk of dying from asthma, we will ensure:

1. immediate professional care,
2. thorough monitoring.

This is what patients require:

• after a near fatal asthma attack,
• after an acute hospitalization last year for an acute asthma attack
• intubated for asthma,
• currently/recently using p.o. corticoids,
• excessively dependent on inhaled β2-agonists with rapid onset of action (>1 salbutamol inhaler/equivalent),
• with psychiatric on./psychosocial problems,
• denying asthma (/severity) or their family does,
• patients do not adhere to the long-term therapy plan for bronchial asthma.

He can do it at home (educated patient):

• mild exacerbations with good response to initial therapy...

Seek medical help - immediately - if there is a severe seizure:

• sick breathless at rest,
• bent forward,
• doesn't speak in sentences, only in words (infants stop eating),
• restless, confused or languid,
• with bradycardia/respiratory rate > 30 breaths/min,
• squeaks loud/disappeared,
• pulse > 120/min (infants 160/min),
• PEF after initial treatment < 60% of NH or ONH,
• the patient is exhausted in general.

Seek medical help if:

• response to initial bronchodilator treatment is not quick and does not last for at least 3 hours

or

• no improvement within 2-6 hours after initiation of p.o. therapy corticoids

or

• further deterioration occurs.

Own treatment

Exacerbation of bronchial asthma - requires immediate treatment.

At all levels of care, the following are essential:

• inhaled β2-agonists with rapid onset of action in adequate doses:
  • during the 1st hour: 2-4 doses every 20 minutes.
  • after the 1st hour: according to the severity of the exacerbation.
    • mild exacerbations - response to administration of 2-4 doses every 3-4 hours,
    • moderately severe exacerbations - response only at 6-10 doses after 1-2 hours.
    • severe exacerbations - up to 10 breaths (preferably through an inhalation attachment) or full doses from a nebulizer, possibly in < 1 hour intervals.
  • Bronchodilation treatment - with a standard aerosol dispenser (MDI), preferably via an inhalation attachment, improves lung function min. as the same dose administered by nebulizer.
  • No additional medication is needed if rapid-acting inhaled beta2-agonists result in a complete response where PEF returns to > 80% NH or ONH) and improvement lasts at least 3-4 hours.
  • newly, it is better to administer salbutamol in an isotonic solution of MgSO₄ than in FR.
  • combination of an inhaled/nebulized β2-agonist with an anticholinergic (iprapropium bromide) may have a better bronchodilation than the individual drugs alone.
  • if we don't have inhalation drugs, p.o. bronchodilators can be administered.

• Oral corticoids
  • in "moderately severe/severe exacerbation" (0.5-1mg/kg prednisolone (equivalent)/24 hours) give early to accelerate the improvement of all exacerbations, except for the mildest ones.
  • by submission guide p.o. corticoids:
    • response to inhalation of β2-agonists with rapid onset of action not rapid/sustained after 1 hour (e.g. PEF

not > 80% NH or ONH).

• • if the oral dose is vomited shortly after administration - repeat its administration.
  • i.v. administration - if desired i.v. access, or possibly impaired absorption from the GIT,
  • i.m. suitable for those discharged from the acute medicine department, especially if he does not cooperate well with treatment.
  • clinical improvement after the administration of systemic corticoids is expected in 4 hours at the earliest.

• Theophyllines (= methylxanthines)
  • not suitable as additional th. to high-dose inhaled β2-agonists.
  • possible if inhaled β2-agonists are not available.
  • if he uses theophyllines long-term, we should measure their serum concentration before administering short-acting theophyllines.

• giving oxygen:
  • indicated in medical facilities for hypoxia,
  • with nasal cannulas ("oxygen glasses"), a mask, small children can be in an oxygen tent,
  • SatO₂ of arterial blood was >/= 92% (children 95%) - monitor carefully (pulse oximetry) especially children (measurement of pulmonary function usually difficult and saturation < 92% is a good indicator of the need for hospitalization - if it is not possible to measure saturations in children, always administer oxygen).
  • in jet nebulizers for nebulizing bronchodilator oxygen instead of air,
  • arterial blood gas examination - in patients with PEF values of 30-50% NH and those who have not improved after initial treatment.
  • keep breathing in oxygen even when taking a blood sample.
  • PaO₂ < 8 kPa (60 mm Hg) and normal/increased PaCO₂ (especially > 6 kPa – 45 mm Hg) for impending/developed respiratory insufficiency.
    • stabilization on the bed with the possibility of monitoring is recommended,
    • if transfer to ICU does not improve.

Not suitable for asthma therapy

• Adrenaline is not indicated for the treatment of an exacerbation of asthma, but for the management of anaphylaxis/angioedema.
• They are not suitable
  • sedatives, mucolytics, ATB,
  • not even hydration with large volumes in adults/older children. (Small children/infants must be given enough fluids.)
• Respiratory RHB or physiotherapy is unsuitable for the treatment of acute exacerbation - it is possible worsening of discomfort of patients.

Links

Related Articles

On the VPL portal:

• Asthma bronchiale therapy
• Asthma bronchiale‎

On Wikilectures:

• Asthma
• Asthma bronchiale/case report
• Status asthmaticus
• Therapy of asthma bronchiale

Case report:

• Asthma bronchiale/case report

External links

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

References

• SALAJKA, František. Bronchial asthma : Recommended diagnostic and treatment procedure for general practitioners [online] . 1. edition. Prague : Society of General Medicine 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. Bronchial asthma : Recommended diagnostic and treatment procedure for general practitioners. 1. edition. Prague : Center for Recommended Practices for General Practitioners, 2005. 

• SALAJKA, F – KAŠÁK, V – POHUNEK, P. Diagnosis, treatment and prevention of bronchial asthma in the Czech Republic : Putting Global Strategy into Practice. 1. edition. Prague : Jalna, 2008.