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:

hospitalization, systemic corticoids are needed.
 * from light,
 * to'severe life-threatening condition:
 * a severe form forces the patient to seek urgent medical care, possibly

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.

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