Management of asthma from home to ICU in children

2. Acute Asthma Exacerbation:
• Bronchial Asthma : consist of broncho spasm
& airway inflammation.
• Asthma exacerbations consist of acute or
subacute episodes of progressively worsening
shortness of breath, coughing, wheezing, and
chest tightness or any combination thereof.

3. Clinical Assessment
• Focused History.
• Physical examination findings: vital signs,
Respiratory distress& Chest examination.
• Pulse oximetry & PEFR
• Lung function (defer in patients with
moderate to severe distress or history of labile
disease)

4. • Often, asthma exacerbations worsen during sleep
(between midnight and 8 am), when airways
inflammation and hyperresponsiveness are at
their peak.
• A severe exacerbation of asthma that does not
improve with standard therapy is termed status
asthmaticus.
• The biologic, environmental, economic, and
psychosocial risk factors associated with asthma
morbidity and death can further guide this
assessment.
Acute Asthma Exacerbation:

5. Acute Asthma Exacerbation:
Assessment and Severity
• Severity range: mild  mod severe
• Treatment : outpatient, inpatient (floor or
ICU)
• Severity: Clinical, ABG, PEFR ( ≥ 70%, 40-69%,
< 40%)
• A chest radiograph is not recommended for
routine assessment but should be obtained
for patients suspected of having congestive
heart failure, pneumothorax/mediastinum,
pneumonia.

6. Assessment of Severity

7. In general ???
 There are two main types of drugs used for treating asthma.
Medications to reduce bronchoconstrictions:
o Beta 2 Agonist
o Anticholinergics
o Theophylline
Medications to reduce inflammations:
o Steroids ( oral, Parenteral & Inhalers)
o Not steroids:
• Leukotriene modifiers ( montelukast is available worldwide;
zafirlukast and pranlukast only in Japanese Guideline for Childhood
Asthma(JGCA).
 Cromolyn & Nedocromil (Reduction of mast cell degranulation)

8. Farther more ???
 Quick- relief medications:
o Short acting Beta Agonists (SABA’s)
o Systemic corticosteroids
o Anticholinergics
 Long-term control medications:
o Corticosteroids (mainly ICS, occasionally OCS).
o Long Acting Beta Agonists (LABA’s) including salmeterol and
formoterol,
o Leukotriene Modifiers (LTM)
o Cromolyn & Nedocromil
o Methylxanthines: (Sustained-release theophylline)

9. paediatric ICU
paediatric word
EMERGENCY DEPARTMENT
Home

10. Case scenario ?
• Ali 10 years old , a known case of bronchial
asthma
• Develop cough and SOB for 12 hours duration
after flue like illness & exposure to smock.
• O/E: in respiratory distress.

11. Home Management of Asthma Exacerbations
• Families of all children with asthma should have a
written action plan.
• A written home action plan can reduce the risk of
asthma death by 70%.
• The NIH guidelines recommend immediate
treatment with “rescue” medication (inhaled
SABA, up to 3 treatments in 1 hr).
• A good response is characterized by: resolution
of symptoms within 1hr, no further symptoms
over the next 4 hr.

12. Farther more ….
• Ali become better but still have cough & SOB
& bronchodilators are required repeatedly
over the next 24 hr.

13. • The child's physician should be contacted for
follow-up, especially if bronchodilators are
required repeatedly over the next 24-48 hr.
• Short course of oral corticosteroid therapy
(prednisone 1-2 mg/kg/day for 4 days) in
addition to inhaled β-agonist therapy should
be instituted.
Home Management of Asthma Exacerbations

14. Ali develop severe exacerbations&
deterioration
persistent signs of respiratory distress,
lack of expected response or sustained
improvement after initial treatment,
Immediate medical attention should be
sought for: ( call 122 )
Home Management of Asthma Exacerbations

15. • Initial treatment includes:
• supplemental oxygen,
• inhaled β-agonist therapy every 20 min for
1 hr, and,
• systemic corticosteroids given either orally or
intravenously.
• Close monitoring of clinical status, hydration,
and oxygenation are essential elements of
immediate management.
Emergency Department Management
of Asthma Exacerbations

16. • The patient may be discharged to home if there
is sustained improvement in symptoms, normal
physical findings, an oxygen saturation >92%
while the patient is breathing room air for 4 hr.
• Discharge medications include administration of
an inhaled β-agonist up to every 4 hr plus a 3-to
7-day course of an oral corticosteroid.
• Optimizing controller therapy before discharge is
also recommended.
Emergency Department Management
of Asthma Exacerbations

17. • Ali has poor response to intensified treatment
suggests that the exacerbation will not remit
quickly.
• Inhaled ipratropium: added to the β-agonist &
corticosteroid treatment.
Emergency Department Management
of Asthma Exacerbations

18. Hospital Management of Asthma
Exacerbations
• Ali does not adequately improve within 2 hr of
emergency department treatment, admission
to the hospital, at least overnight, is likely to
be needed.
• β-agonist up to every 4 hr
• Inhaled ipratropium 6 hr
• Corticosteroid IV (Oral)

19. • Ali deteriorated at unit & developed severe
respiratory distress, poor response to therapy,
and concern for potential respiratory failure
and arrest.
He need admission to an intensive care unit
Hospital Management (ICU)of Asthma
Exacerbations

20. Ali : require additional evaluations, such as
complete blood cell counts,
measurements of arterial blood gases and
serum electrolytes, and
chest radiograph,
to monitor for respiratory insufficiency, co-
morbidities, infection, and/or dehydration.
Hospital Management of Asthma
Exacerbations

21. • the conventional interventions for status
asthmaticus are:
• Supplemental oxygen, high-flow oxygen.
• SABAs can be delivered frequently (every
20 min)
• May need intravenous β-agonist therapy.
• Inhaled ipratropium bromide every 6 hr.
• systemic corticosteroid therapy
• Patients requiring cardiac monitoring &
oximetry.
Hospital Management of Asthma
Exacerbations

22. Nelson Textbook of Pediatrics, 20th edition, page 1114.
According to Nelson Textbook of
Pediatrics, 21th edition 2019
 The addition of ICS to a course of oral corticosteroid
in the emergency setting , reduces the risk of
exacerbation recurrence over the subsequent
month.

23. • Hydration status monitoring is especially
important (insensible losses) and decreased oral
intake but
• Further complicating this situation is the
association of increased antidiuretic hormone
(ADH) secretion with status asthmaticus.
• Administration of fluids at or slightly below
maintenance fluid requirements is
recommended.
• Chest physical therapy, and mucolytics are not
recommended .
Hospital Management of Asthma
Exacerbations

24. • Despite intensive therapy, some asthmatic
children remain critically ill and at risk for
respiratory failure, intubation, and mechanical
ventilation.
• Complications (air leaks) related to asthma
exacerbations increase with intubation and
assisted ventilation; every effort should be
made to relieve bronchospasm and prevent
respiratory failure.
Hospital Management of Asthma
Exacerbations

25. • Several therapies, including parenterally administered
• Epinephrine: Parenteral (subcutaneous, intramuscular, or
intravenous) epinephrine may be effective in patients with life-
threatening obstruction that is not responding to high doses of
inhaled β-agonists, because in such patients, inhaled medication
may not reach the lower airway.
• methylxanthines,
• magnesium sulfate (25-75 mg/kg, maximum dose 2.5 g, given
intravenously over 20 min), and
• inhaled heliox have demonstrated some benefit as adjunctive
therapies in patients with severe status asthmaticus.
• Administration of either methylxanthine or magnesium sulfate
requires monitoring of serum levels and cardiovascular status.
Hospital Management of Asthma
Exacerbations

26. • Volume-cycled ventilators, using
• short inspiratory and long expiratory times,
• 10-15 mL/kg tidal volume,
• 8-15 breaths/min,
• peak pressures < 60 cm H2O, and without positive
end-expiratory pressure are starting mechanical
ventilation parameters that can achieve these
goals.
Hospital Management of Asthma
Exacerbations

27. • In children, management of severe exacerbations
in medical centers is usually successful, even
when extreme measures are required.
• A follow-up appointment within 1 to 2 wk of a
child's discharge from the hospital after
resolution of an asthma exacerbation should be
used to monitor clinical improvement and to
reinforce key educational elements, including
action plans and controller medications.
Hospital Management of Asthma
Exacerbations

28. THANKS FOR YOUR
ATTENTION