STEP BY STEP MANAGEMENT OF STATUS ASTHMATICUS

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STEP BY STEPMANAGEMENT OF STATUS ASTHMATICUS

• See details in the Asthma protocol guidelines
• Dr. D. Alvarez
• August 2006

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INITIAL PROCES

• Call from the ED/4-B requesting bed for a patient
  with Status Asthmaticus in respiratory distress.
• Resident / Supervisor (if applicable) obtains
  information on patients condition, on the phone
  or going to the ED/4-B, (as activity in the unit
  warrants).
• Information needed
• Base line patients chronic condition
• If previous diagnosed with asthma, state
  Severity Intermittent Mild / Moderate /
  Severity Persistent (complete detail Asthma
  history later)
• Has patient had previous PICU admissions?
  Intubations?
• Last Hospitalization? last intubation?.
• Has patient been seen in the Asthma / Pulmonary
  clinic? date last visit

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INITIAL PROCESS (continue)

• Current event/exacerbation details
• Duration of symptoms of exacerbation
• Triggering factors
• Treatments / management at home.
• Do they have an AAP?. if yes
• Did they follow their AAP, including given
  steroids at home?. Time and dose given did
  patient tolerated? or patient vomited.

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ED Events.

• 4.- Review of ED-Events
• Severity of Respiratory Distress /Assessment (See
  chart assessment)on presentation to ED and after
  therapies.
• Studies / labs done (Start laboratory flow sheets
  record)
• CXR in patients with severe respiratory distress
  and/or fever.
• Look for significant atelectasis, air leaks ,
  infiltrates?
• CBC with diff and Electrolytes in patient in
  moderate to Severe respiratory distress,
  receiving frequent bronchodilator treatments.
• Look for signs of dehydration, HYPOKALEMIA, AND
  ACIDOSIS.
• 5.- Communicate with PICU Attending and inform on
  patients condition.
• 6.- Inform PICU Nurses that patient was accepted
  and up-date them on patients condition.

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Asthma History Focus

• A. Asthma symptoms SINCE Or First wheezing
  episode
• since/at (age)GIVE SOME DETAILS OF
  SEVERITY
• B. Frequency of subsequent symptoms /
  Seasonality
• and Course. .Overall improving ,
  same, worse
• or up and down
• C. Asthma therapy received / duration /
  effect.
• D. Symptoms control for the past year.
• E. Asthma Risk Factors (Index) Positive Risk
  Factors if
• - Family hx of asthma /
  allergies.(parents),
• - Eczema
• - Allergies (Pt. and/or Fly),
• - Eosinophillia in CBC
• - Smoke exposure, etc.
• - Hx of RSV bronchiolitis.

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ASSESSMENT
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Physiological Problems that need to be Address /
Assess.

• Severity of Respiratory distress (See chart
  criteria)
• Mild
• Moderate
• Severe

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• Severity of Respiratory Distress

Mild Moderate Severe
Mental Status Normal -Alert Mild affected Irritable/ Affected- Lethargy
Tachypnea Norm Mild 1 ½ x standard 2 x standard
Work of Breathing Mild SC retractions SC-IT and Supra-clav Retrac- SC-IC-SC Retrac. nasal flaring ? fatigue
Air Entry Normal Mild decrease Decreased
Wheezing Mild () Moderate (2-3) (3- 4 ) OR None gt imminent RF
Hypoxia / O2 Sat in RA gt 95 lt 95 gt 90 lt 90
PCO2 / PEFR Norm/gt75 lt 45 / gt50 lt75 gt 45 / 50
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• 3. Assess cardiovascular compromise. Examples
• Mild Tachycardia / good perfusion
• HR lt than one standard deviation of normal for
  age.
• Moderate Tachycardia /mild decrease perfusion.
• HR gt 1 lt than 2 standard deviation of normal for
  age
• Severe Tachycardic / poor perfusion.
• HR gt 2 standard deviation of normal for age
• 4. Assess Fluid-Electrolyte and AB Imbalance.
  Examples
• (Look for sings of dehydration, hypokalemia,
  Metabolic acidosis and hyperglycemia)
• Well hydrated / No electrolyte imbalance.
• Mild dehydrated / mild acidosis, lowish K
• Moderate dehydrated / moderate metabolic acidosis
  (Bic lt 17), low K, hyperglycemia, high BUN and
  Creatitine.

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• 3. Assess gt If associated overlapping infection
  Process.
• By History
• Hx suggestive of Upper respiratory infection?
  Viral Vs Bacterial
• Nasal symptoms URI, Infected Rhinitis, Sinusitis
• Pharyngeal symptoms Pharingitis? Post Nasal
  drip.
• Hx suggestive of Lower respiratory bacterial
  infection
• Prolonged productive cough with thick yellow
  sputum
• Fever

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• 3. Assess gt If associated overlapping infection
  Process.
• By Physical exam
• Signs of Upper respiratory infection? Viral
  /Bacterial (See features of nose exam check list)
• Examination of nose
• - Nasal crease/ allergic salute
• - Turbinate Normal size
• - Hypertrophy
• - Color- pale/red
• - Secretion-amount scanty/copious
         
• . color- yellow/green/clear
• - Patency of nose- patent /blocked.
• Signs of Lower respiratory bacterial infection
  Signs of consolidation (decrease breath sounds,
  bronchophony, fine crackles POSITIVE RACKLE
  DOES NOT MEANS PNEUMONIA)

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• 3. Assess If associated /overlapping infection
  Process. (Continue)
• By Studies
• CBC with diff (manual count) if clinically
  indicated
• CRP if highly suspicious
• CxR, looking for alveolar filling processes, NOT
  just atelectasis, although atelectasis can be
  infected.
• DONT FORGET TO CHECK PPD STATUS.
• 4.-Other associated pathology
• Snoring? Obstructive sleep apnea?

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MANAGEMENT
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RESPIRATORY SUPPORT

• OXYGEN
• Assess patients oxygen requirements and provide
  oxygen as needed to keep O2Sats gt 95 in the
  acute processes.
• Provide Oxygen using the devices as per
  guidelines
• - Low Flow Oxygen Nasal Canula lt than 3 L/min
  ( 35 )
• - Moderate Flow Oxygen USE AEROSOLIZE MASK,
  start with 40 if switching from nasal canula OR
  as much as patient needs to keep saturation gt 95
  
• - High Flow Oxygen USE SAME AEROSOLIZE MASK.
  With this system flow can be adjusted from 28 to
  100 just dialing up and down. Besides it
  delivers humidify oxygen.
• If patients is requiring gt 55 FiO2 to keep
  Saturation gt 90 , patient is in HYPOXIC
  RESPIRATORY FAILURE. NEED TO HAVE AN ABG.
  (Capillary blood gasses may suffice, NOT VENOUS)

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RESPIRATORY SUPPORT (Continue)

• 2. Systemic Steroids
• Use IV Solumedrol for patient who are in moderate
  to Severe respiratory distress.
• Initial dose is 2 mg/kg/dose to a max of 125 mg.
• Follow up doses is 1 mg/kg/dose to a max of 60
  mg Q6H
• PO steroids (Prednisone tablets or Prelone
  liquid). The dose is 2 mg /kg/day to a max of 60
  mg if patient is in mild to moderate respiratory
  distress.
• IF SOLUMEDROL IS NOT AVAILABLE THIS CAN BE
  REPLACED BY DECADRON gtgt THE DOSE IS
• 0.05 mg/kg/dose IM or IV Q 6 -12 hrs. (Max 10
  mg/24 hrs)
• (0.08 -0.3 mg/kg/24 hr)
• Adult dose 10 mg Q 6 hrs

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RESPIRATORY SUPPORT (Continue)

• 3. Bronchodilators
• Albuterol Nebulizer is the main bronchodilator
• Q2H in patient in Mild to Moderate respiratory
  distress.
• If requiring more than Q2H, add Atrovent Neb and
  give it
• Back to Back alternated (Alb Atrovent) in
  patients with severe respiratory distress
  /Impending respiratory failure. Order x 4 Cycles
  and reassess. When improving, (usually expect it
  after 6 hrs of the start of Steroids)Frequency
  can be spaced it gradually.
• Q1-2 H still alternated (Alb Atrovent) gtgt if
  doing well, mild respiratory distress gt d/c
  Atrovent
• Continue with Albuterol Q2-3 hours.

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RESPIRATORY SUPPORT (Continue)

• 3. Bronchodilators (Continue)
• B. Terbutaline SC and / OR IV drip. To be use in
  patients who are not improving on back to back
  Nebulizer bronchodilators to avoid intubation.
  (See drip chart)
• The initial dose is
• C. MgSulfate is a weaker bronchodilator than
  Albuterol or Atrovent. Recommended for its
  additional effect in the initial management in
  the ED. It should not be repeated at the risk to
  cause Hypermagnesemia.

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Fluid Therapy

• NPO if patient is in moderate to Severe distress.
• Calculate patients maintenance fluids
  (requirements) Wt. base OR per SA(m2)
• A. Basic Requiremente
• Wt base 100 ml/kg for the first 10 kg
• 50 ml/kg for the next 10 kg
• 20 ml/kg for
  the rest. kg.
• Per SA (m2) 1500 mL/M2
• Add Insensitive extra loses given by
• Tachypnea
• Fever
• Replace deficit take in account
• Duration of symptoms
• PO intake, vomiting.
• Fluid Requirement for patients in moderate to
  severe respiratory distress may be estimated as 1
  ½ maintenance.

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Fluid Therapy (CONTINUES)

• 3. Follow up studies
• Electrolytes abnormalities
• Hypo, hypernatremia / dehydration
• Hypokalemia
• May need to increase KCL concentration in IV
  solution
• DO NOT HOLD KCL IN IV SOLUTION WAITING FOR URINE
  OUTPUT, AS LONG AS THE SERUN K AND BUN AND
  CREATININE ARE NORMAL IN INITIAL LYTES.
• Hyperglycemia
• Check gt F/U FS and UA till normalize
• D/C glucose from IV if necessary
• ABB (Acid Base Balance)
• Check and follow up metabolic acidoses than can
  be a sign of fatigue to be use as indication for
  respiratory support (intubation).

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Indication for intubation(Impending /
Respiratory Failure)

• Altered Sensorium /coma
• Fatigue
• Inhability to speak
• Diaphoresis in the recumbent position
• Lactic acidosis
• Silent chest despite respiratory effort
• Refractory hypoxemia (PaO2 lt 60 mmHg /O2 Sat lt 90
  on Max O2)
• Increasing PCO2 (50 mmHg and rising gt 5 mmHg/hr)
• Acute Barotrauma /Tension Pneumothorax
  (Pneumomediastinum in a patient in no distress is
  not an indication for intubation)
• Respiratory or cardiac arrest

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Intubation Process

• Call anesthesia (Emergency Beeper in the board)
  if PICU attending not in house.
• Calculate / Order / Prepare Sedation Medication
• RSI INTUBATION MEDICATIONS
• Penthobarbital OR
• Midazolan and Ketamine
• Lidocaine
• Vecuronium
• Call Respiratory therapy (Emergency Beeper in the
  board
• Order initial Mechanical Ventilator setting
  according to guidelines after discussion with
  PICU attending

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Principles of Mechanical Ventilation in patients
with Status Asthmaticus.

• There is and increase resistence and decrease
  compliance therefore be aware of checking PIP if
  you are ventilating with volume control (SIMV or
  CMV)
• High risk for barotrauma
• If patient is started on Volume control and the
  reached PIP is gt 30, consider changing to
  Pressure control
• Because the high resistance and decrease
  compliance, the time Constance is increase (need
  more time to fill up the alveoli) therefore need
  to use lower rates to decrease airtraping/AutoPEEP
  and barotrauma.

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Principles of Mechanical Ventilation in patients
with Status Asthmaticus. (CONTINUE)

• REMEMBER THE VENTILADOR WILL NOT RESOLVE THE
  IMFLAMATORY PROCESS NOR THE BRONCHOSPASM ON THE
  CONTRARY IT MAY MAKE IT WORSE. BE READY TO DEAL
  WITH CIRCULATORY COMPROMISE IMMEDIATELY AFTER
  INTUBATION. THIS SHOULD BE TREATED WITH FLUIDS.
• NEED GENTLE VENTILATORY SUPPORT WAITING FOR THE
  MEDICATIONS (Steroids and bronchodilators) TO
  WORK
• The main goals of respiratory support are
• Ensure oxygenation
• Decrease work load of a fatigue patient, reverse
  lactic acidosis.
• Prevent cardio-respiratory arrest
• Avoid barotrauma using permisive hypercarbia.
  DO NOT AIM TO NORMALIZE ABG

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Intubation Process (Continue)

• 5. Connect and read ETCO2 and O2 Sats.
• 6. Order Chest x Rays.
• DO NOT FORGET TO REMOVE CHEST C-R LEADS
  BEFORE X RAYS TAKEN.
• 7. DO ABG and correlate ETCO2 with PaCO2

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TREATMENTS DURING MECHANICAL VENTILATION

• Bronchodilators
• Continue frequent albuterol and atrovent given by
  MDI alternated every 30 gt 60 minutes.
• 4 puffs for younger child
• 6 puffs for older child gt 5 yo
• Continue Or start terbutaline drip (as per
  protocol)
• Continue IV steroids.
• Sedation Deep sedation, avoid paralysing agent
  after the initial use for intubation and
  stabilization.
• Ketamine drip is the drug of choice plus
  midazonal PRN or drip.