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.

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