Status asthmaticus

Dr.Gireesh kumar.K.P
Asthma
• Asthma is characterised by chronic airway
inflammation and increased “airway hyper-
responsiveness” leading to dyspnoea, wheeze,
cough and chest tightness.
Triggers of asthma
• Dust, particles <2.5 mm will be carried to lower respiratory tracts
• Dust mite, animal dander
• Milk, Egg, Wheat
• Cold air,
• Exercise
• Respiratory virus infection
• Drugs can induce asthma - nonselective beta blockers – Aspirin
• Obesity,
• Gastro Esophageal Reflux Disease (GERD)
Pathogenesis of asthma
Status asthmaticus
•Status asthmaticus is an acute exacerbation of
asthma that remains unresponsive to initial
treatment with bronchodilators.
•Status asthmaticus can vary from a mild form
to a severe form with bronchospasm, airway
inflammation, and mucus plugging that can
cause difficulty breathing, carbon dioxide
retention, hypoxemia, and respiratory failure.
Acute breathlessness causes - DDs
• Status asthma
• COPD acute infective exacerbation
• Pneumotorax
• Forgin body aspiration
• Pulmonary embolism
• Pulmonary edema
Investigations
• ABG - type 1 respiratory failure
• X ray - Hyper inflate lung fields,
R/o Pneumothorax
Mangement
• ABC
• Proped up position
• High concentration humidified oxygen – 4-6 L/min
oxygen(use with face mask) to achieve arterial oxygen
saturation of >95%.
Bronchodilators
• Salbutamol 2.5 - 5 mg or Terbutaline 10 mg inhalation /
nebulisation 2-3 time 20 minutes apart (can be repeated till
get a good response and watch for adverse effects like
palpitations and tremors)
• Ipratropium bromide 0.5 mg every 20 minutes 3 doses
• Nebulised adrenaline (2 mg over 10 min) may be used in
severe asthma along with salbutamol
• Start MDI with or without a spacer device within 24 hours of
the initial dose being administered in the Emergency
Department.
Steroids
• Systemic steroids (IV/Oral) with proton pump
inhibitors
• IV – Hydrocortisone 200 mg / Methylprednisolone 125 mg
BD or
• Oral – Prednisolone 30 to 60 mg BD
• Both IV / oral steroid have same efficacy
• Give oral steroids till patient is symptomatic, taper the
dose if given more than 2 weeks
Magnesium and potassium
• IV Magnesium sulphate 2 gm over 20 minutes (It is a
bronchodilator, may be beneficial)
• Potassium supplements if hypokalemia presents
(salbutamol induced)
Amonophylline( not used now)
• IV Aminophylline (not routinely indicated)
• 250mg in 20ml 25% dextrose over 20 minutes(in severe
cases)
• IV Aminophylline infusion 500 mg in 500 ml 5% dextrose
over 24 hours
• Caution : Aminophylline is less effective than inhaled
salbutamol / terbutaline and Theophylline levels should be
estimated if the patient is already taking Theophylline, to
exclude Theophylline toxicity
 NIV /BIPAP
• Non invasive ventilation(NIV) / Bilevel positive airway pressure (BIPAP) -
• Noninvasive positive pressure ventilation (NPPV or NIV) refers to positive pressure
ventilation delivered through a noninvasive interface (nasal mask, facemask, or nasal
plugs), rather than an invasive interface (endotracheal tube, tracheostomy).
• Bilevel positive airway pressure (BIPAP) delivers both inspiratory positive airway
pressure (IPAP) and expiratory positive airway pressure (EPAP).
• Indication for NIV
• Dyspnea (moderate to severe)
• Tachypnea (>25 breaths/min)
• Increased work of breathing (accessory muscle use, pursed-lips breathing)
• Hypoxemia (PaO2/FIO2 < 200 mm Hg)
• Moderate hypercarbia (PaCO2 >45 mmHg, <92 mmHg)
• Hypercapnic encephalopathy (if not improved in 1-2 hours , intubate)
• Moderate acidemia (pH <7.35)
On discharge
• Long acting inhaled 2 agonist (LABA) daily DPI or MDI
( Salmeterol 125/ 250 / 500 mcg or Formoterol 400
mcg ) + During acute symptoms - short acting 2
adrenoreceptor agonist (Salbutamol 100 to 200 mcg,
Terbutaline 250 to 500 mcg) +
• Low dose inhaled corticosteroids daily (Beclomethasone
200 mcg, Budesonide 200 mcg,Fluticasone 100mcg) +
• Leukotriene receptor antagonist(LTRA) daily
(Montelukast 10 mg evening, Zafirlukast 20 mg BD,
Zileuton 600 mg QID)
Other advices
• Vaccination for influenza and H1N1 :Yearly one to be
taken
• Always treat GERD, avoid triggers, reduce weight,
graded exercise,Avoid anxiety stress etc