Friday, March 14, 2014

Asthma Exacerbation

Today in morning report we discussed an important case of a patient presenting with an asthma exacerbation.

This is an emergency and that your history/physical/investigations and management are all going to happen almost simultaneously. And of course, get help.

Some key points to consider on:

1. History:
- Questions around severity: 
# of ICU admission, # of exacerbations, # of MD visits. 
Adherence. Beta agonist use (2 more cannisters / month is sign of severity)
Other psychosocial issues
- Questions around control:
Daytime symptoms 
Nighttime symptoms
Physical exercise 
Inhaler/rescue use 
Absence work/school 

- Triggers: 
Infection, allergen, adherence

2. Physical Examination:
Appearance, # of word dyspnea
Vitals including a pulsus if possible
Peak Flow
Chest exam. Silent chest is a bad sign

3. Labs
ABG: beware the "normal" CO2

4. Treatment:
MDI via spacer just as good as nebulizer (and issues around infection control)
Beta-agonists, anticholinergics (in the acute setting for anticholinergics, and especially consider if due to beta-blocker)
Remember that HR may actually get better with treatment as you improve the hypoxia and constriction.
IV magnesium in severe exacerbations
- Corticosteroids
Likely longer duration than in COPDE
Earlier assessments important, especially if ventilation needed. 
- NIV: Considerations around non-invasive ventilation discussed, may be helpful, but be mindful of delaying needed intubation.
- Intubation: tricky, if needed should be done by experienced, skilled MD (ie Anesthesia, ICU).
- Others: Heliox discussed, still probably needs more evidence.

A word on Peak Flows:
Important. Don't forget to do them. Will help to guide treatment response and disposition.
Pre-treatment of less than 25 percent personal best or less than 100 L / min should be admitted
200-300 L/min consider admission. more than 300 consider home
(These are only guidelines and need to take into consideration all other factors of the patient to best decide if admission, ICU, or home).

See this review article on management of asthma exacerbations.