NEAR FATAL ASTHMA

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NEAR FATAL ASTHMA

• DANIEL A. NADER, D.O., F.C.C.P., F.A.C.P.

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NEAR FATAL ASTHMA

• 5,000 DEATHS PER YEAR
• LIFE THREATENING ATTACKS MORE COMMON
• AFRICAN-AMERICANS, WOMEN, INNER-CITY PATIENTS AT
  GREATEST RISK
• LARGELY PREVENTABLE, MAY OCURR IN ANY ASTHMATIC

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PREDISPOSING RISK FACTORS

• PRIOR SEVERE ATTACKS (ESPICIALLY THOSE REQUIRING
  ASSISTED VENTILATION)
• NONADHERANCE TO THERAPY
• AGE gt 40 YEARS
• TOBACCO SMOKING

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RISK FACTORS

• INADEQUATE USE OF INHALED STEROIDS
• HOSPITALIZATION DESPITE CHRONIC ORAL STEROID USE
• PSYCHIATRIC ILLNESS
• RECREATIONAL DRUG AND ALCOHOL ABUSE
• DIMINSHED ABILITY TO SENSE AND RESPOND TO AIRWAY
  OBSTRUCTION

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RISK FACTORS

• FREQUENT USE OF BETA AGONIST DRUGS
• INDEPENDENT RISK FACTOR
• FREQUENT USE IDENTIFIES POORLY CONTROLLED DISEASE

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PATHOPHYSIOLOGY

• MUCOUS PLUGGING
• VASCULAR DILATATION
• AIRWAY EDEMA
• DESQUAMATION OF AIRWAY EPITHELIAL CELLS
• BRONCHIAL SMOOTH MUSCLE HYPERTROPHY
• INFLAMMATORY CELLULAR INFILTATE

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PATHOPHYSIOLOGY

• DEATH FROM ASPHYXIA
• MUCOUS PLUGGING, BRONCHOCONSTRICTION, AIRWAY
  EDEMA
• HYPERINFLATION, AIR TRAPPING
• HYPOXIA V/Q MISMATCH
• HYPERCARBIA RESPIRATORY MUSCLE FATIGUE

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CLINICAL PRESENTATION

• VIRAL URIS
• HEAVY ALLERGEN EXPOSURE
• NONADHEARANCE TO THERAPY
• AIR POLLUTION
• WEATHER CHANGE
• EMOTIONAL STRESS
• DRUGS ASPIRIN, BETA BLOCKERS

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CLINICAL PRESENTATION

• 90 PRESNET AFTER SEVERAL DAYS OF WORSENING
  SYMPTOMS
• 10 RAPID DETERIORATION IN MINUTES OR HOURS

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CLINICAL PRESENTATION

• DYSPNEIC, ANXIOUS, DIAPHORETIC
• SITTING UPRIGHT
• TACHYCARDIC, TACHYPNEIC
• WHEEZING TO ABSENT BREATH SOUNDS
• USE OF ACCESSORY MUSCLES

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LABORATORY

• ELEVATED WBC
• INCREASED EOSINOPHILES
• INCREASED LACTIC ACID
• ABG VARIABLE

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CHEST RADIOGRAPH

• HYPERINFLATION
• EXCLUDE INFILTRATES, PULMONARY VASCULAR
  CONGESTION
• PNEUMOTHORAX, PNEUMOMEDIASTINUM

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HYPERINFLATION
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PEAK FLOWS

• USUALLY lt 30 TO 50 OF PATIENTS PERSONAL BEST
• USE CARE IN PERFORMING PEAK FLOW AS IT MAY WORSEN
  BRONCHOSPASM
• FAILURE TO IMPROVE PF AFTER 30 MINUTES OF
  TREATMENT USUALLY REQUIRES HOSPITALIZATION

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DIFFERENTIAL DIAGNOSIS

• CHF
• PE
• COPD
• VOCAL CORD DYSFUNCTION
• HYPERVENTIALTION
• ACUTE BRONCHITIS/PNEUMONIA
• UPPER AIRWAY OBSTRUCTION

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ICU ADMISSION

• RESPIRATORY ARREST
• DEPRESSED MENTAL STATUS
• ARRHYTHMIA
• INTENSITY OF TREATMENT
• INCREASED FRQUENCY OF NEBULIZED BETA AGONIST
  SIGNIFIES A PATIENT AT RISK FOR DETERIORATION

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MANAGEMENT

• BRONCHODILATORS
• OXYGEN
• CORTICOSTEROIDS
• ADJUNCT THERAPY
• MECHANICAL VENTIALTION

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BRONCHODILATORS

• ALBUTEROL 2.5MG NEBULIZED EVERY 20 MINUTES
• AIRWAY NARROWING ADVERSLY AFFECTS THE
  DOSE-RESPONSE CURVE AND DURATION OF ACTION
• CONTINOUS NEBULIZTION IS AS EFFECTIVE AS BOLUS
  NEBULIZATION

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BRONCHODIALTORS

• IPRATROPIUM 0.5 MG COMBINED WITH ALBUTEROL
  PROVIDES IMPROVED BRONCHODILATION
• THEOPHYLLINE HELPFUL WHEN PATIENT NOT RESPONDING
  TO BETA AGONIST AND STEROIDS

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THEOPHYLLINE

• 5 MG/KG LOADING DOSE FOLLOWED BY CONTINOUS
  INFUSION AT 0.4 TO 0.7 MG/KG/HOUR
• ANTI-INFLAMMATORY
• IMPROVES MUCOCILIARY CLEARANCE
• DIAPHRAGMATIC MUSCLE FUNCTION
• ACCESSORY MUSCLE FUNCTION
• RIGHT VENTRICULAR PERFORMANCE

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CORTICOSTEROIDS

• ORAL AS EFFECTIVE AS INJECTABLE
• METHYLPREDNISOLONE 40 TO 125 MG EVERY 6 HOURS
• LOW DOSE AS EFFECTIVE AS HIGH DOSE
• PREDNISONE 40 TO 50 MG DAILY UNTIL CLINICAL
  RESPONSE, THEN TAPER

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ADJUNCT THERAPY

• HELIOX 8020, 7030, LESS DENSE GAS MAY ASSIST
  VENTILATION. AIRFLOW ACROSS NARROWED AIRWAYS IS
  LAMINAR AND LESS TURBULENT
• MAY BUY SOME TIME

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ADJUNCT THERAPY

• MAGNESIUM 2 GRAMS OVER 20 MINUTES
• MAY INTERFERE WITH CALCIUM MEDIATED SMOOTH MUSCLE
  CONTRACTION
• TOXIC LEVELS MAY PRECIPITATE HYPOTENSION AND LOSS
  OF DEEP TENDON REFLEXES

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ADJUNCT THERAPY

• LEUKOTRIENE RECEPTOR ANTAGONISTS MAY BE HELPFUL
• FURTHER STUDIES NEEDED BEFORE THEY CAN BE
  RECOMMENDED IN NEAR FATAL ASTHMA

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ADJUNCT THERAPY

• OXYGEN
• POTASSIUM
• PROTON PUMP INHIBITORS OR H2 BLOCKERS
• DVT PROPHALAXIS

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OTHER MANGEMENT

• ANTIBIOTICS, MOST COMMON IFECTION WHICH
  PRECIPITATES ASTHMA IS VIRAL
• INTRAVENOUS FLUIDS, REPLACEMENT ONLY
• MUCOLYTICS
• ANTIHISTAMINES

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MECHANICAL VENTILATION

• CONSIDER NON-INVASIVE VENTIALTION (NIPPV)
• DISADVANTAGES LACK OF AIRWAY CONTROL, SKIN
  PRESSURE ULCERATION, VOMINTIN/ASPIRATION
• ADVANTAGES COMFORT, DECREASE NEED FOR SEDATION,
  LOWER RISK FOR VAP

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INTUBATION INDICATIONS

• PROGRESSIVE RESPIRATORY FAILURE
• ALTERED MENTAL STATUS
• HEMODYNAMIC INSTABILITY, REGARDLESS OF ABG

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DYNAMIC HYPERINFLATION

• INSUFFICINET EXPIRATORY TIME
• END EXHALATION VOLUME RISES
• HEMODYNAMIC COMPROMISE AND BAROTRAUMA

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MECHANICAL VENTILATION

• ENSURE OXYGENATION
• AVOID DYNAMIC HYPERINFLATION
• PHYSICAL EXAM AND CXR DO NOT CORRELATE WELL WITH
  DHI
• PLATEAU PRESSURES, PEAK AIRWAY PRESSURES,
  INTRINSIC (AUTO) PEEP

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MECHANICAL VENTIALTION

• PLATEAU PRESSURE AT END INSPIRATORY HOLD (30-35
  CM H20)
• PEAK FLOW RATE CORRELATES POORLY WITH RISK OF
  DHI
• AUTO-PEEP PRESSURE MEASURED AT END EXPIRATORY
  HOLD. REFLECTS DEGREE OF DHI POORLY,
  UNDERESTIMATES DHI

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MECHANICAL VENTILATION

• MINIMIZE DHI BY ENSURING SUFFICIENT EXPIRATORY
  TIME
• 1. INCREASE INSPIRATORY FLOW RATE
• 2. DECREASE RESPIRATORY RATE
• 3. DECREASE TIDAL VOLUME

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MECHANICAL VENTILATION

• HYPERCAPNIA MAY BE A CONSEQUENCE OF PROTECTIVE
  VENTIALTION
• PERMISSIVE HYPERCAPNIA
• HYPERCAPNIA SIDE EFFECTS CEREBRAL
  EDEMA,DECREASED MYOCARDIAL CONTRACTILITY,
  SYSTEMIC VASODILATATION, PULMONARY
  VASOCONSTRICTION

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MECHANICAL VENTIALTION

• REQUIRES HEAVEY SEDATION
• NARCOTIC PLUS BENZODIAZEPINE
• PROPOFOL
• NEUROMUSCULAR BLOCKADE

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COMPLICATIONS

• NOSOCOMIAL PNEUMONIA
• STRESS GASTRITIS
• DVT
• PE
• MALNUTRITION
• SEPSIS/MULTISYSTEM ORGAN FAILURE

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OUTCOMES

• USING PRESENTED VENTILATION TECHNIQUES 0 TO 4
  MORTALITY
• 21 MORTALITY WITH MV REALTED TO TENSION
  PNEUMONTHORAX, CARDIAC ARREST, NOSOCOMIAL
  INFECTION, MULTISYSTEM ORGAN FAILURE
• EXCESSIVELY AGGRESSIVE POSITIVE PRESSURE
  VENTIALTON

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FOLLOW-UP

• MORTALITY POST MV HOSPITALIZATION
• YEAR 1 10.1
• YEAR 3 14.4
• YEAR 6 22.6

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FOLLOW-UP

• CLOSE PHYSICIAN COMMUNICATION
• PATIENT EDUCATION
• THERAPUETIC PLAN CENTERED AROUND INHALED
  CORTICOSTEROIDS

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QUESTIONS ???
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NEAR FATAL ASTHMA