Recent withdrawal of oral corticosteroids OCS suggests that the patient is at greater risk for a severe exacerbation. Lack of a written asthma action plan is another risk factor.
Limited access of the patient to appropriate health care and lack of education about appropriate management strategies are additional risk factors. Socioeconomic factors associated with severe asthma exacerbations include the non-adherent adolescent or elderly asthmatics living in inner city environments. Certain ethnic groups within a population may have a higher incidence of severe asthma, such as Americans of African or Spanish inheritance. Comorbidities, such as chronic lung, psychiatric, and cardiovascular diseases are other risk factors [15,17].
Serial measurements of lung function facilitate quantification of the severity of airflow obstruction and response to therapy. A peak expiratory flow PEF rate provides a simple, quick, and cost-effective assessment of the severity of airflow obstruction. Patients can be supplied with an inexpensive PEF meter and taught to perform measurements at home to detect deterioration of their asthma. An individual management plan will be based upon the personal best PEF value.
In non-acute settings, assessment of PEF and spirometry before and after administration of a bronchodilator can indicate the likely degree of improvement in lung function which can be achieved by adequate therapy.
SABA dose, response, and further management is depicted in Figure 2 [3, ]. The forced expiratory volume in one second FEV 1 is measured by spirometry to assess the volume of air exhaled over one second and is the most sensitive test for airflow obstruction.
Fractional exhaled nitric oxide FeNO testing is a measure of lower airway eosinophilic inflammation that is assessed through an exhaled breath into a device. Most patients do not require laboratory testing for the diagnosis of acute asthma. If laboratory studies are obtained, they must not delay asthma treatment.
Laboratory studies may assist in detecting other comorbid conditions that complicate asthma treatment, such as infection, cardiovascular disease, or diabetes. A measurement of brain natriuretic peptide BNP and a 2-D transthoracic echocardiogram aid in the diagnosis of congestive heart failure. For patients taking diuretics who have co-morbid cardiovascular disease, serum electrolytes may be useful as frequent SABA administration can cause transient decreases in serum potassium, magnesium, and phosphate.
A baseline electrocardiogram and monitoring of cardiac rhythm are appropriate in patients older than 50 years of age and in those with comorbid cardiovascular disease or COPD. A complete blood cell count CBC may be useful in patients with fever or purulent sputum; however, modest leukocytosis is common in asthmatics, and patients using corticosteroids may have a corticosteroid-induced neutrophil leukocytosis.
Serum theophylline levels are essential for patients taking theophylline due to its narrow therapeutic window [17]. Chest radiographs are not usually necessary for the diagnosis of acute asthma if the examination of the chest reveals no abnormal findings other than the expected clinical signs and symptoms associated with an acute exacerbation.
If a complication is suspected, such as pneumonia, pneumothorax, pneumomediastinum, congestive heart failure, or atelectasis secondary to mucous plugging, a chest X-ray should be obtained [17]. Lactic acidosis is common in severe acute asthma. Venous blood gases VBG have been evaluated as a substitute for arterial measurements since venous blood is easier to obtain. Therefore, it may be used as a screening test to exclude hypercapnic respiratory distress [17,25].
Figure 1. Acute asthma severity: clinical signs and symptoms. Originally published as Figure in the Expert Panel Report 3. Figure 2. Treatment is based not only on assessment of lung function parameters but on clinical findings and the efficacy of previous treatment.
A seasonal exacerbation of asthma in a pollen-sensitive patient is more easily treatable than an exacerbation triggered by a viral infection. Physician knowledge of an individual patient will suggest whether a SCS is required or whether an exacerbation can be managed on high doses of ICS [17,26]. There are various national and international guidelines available for the diagnosis and management of acute asthma.
In particular, the EPR-3 guidelines are referenced in this manuscript as it is centered upon a systematic review of the published scientific literature and provides the best evidence for clinical practice guidelines. EPR-3 recommended treatment choices in order of introduction in the acute setting are listed below and depicted in Figure 3.
Treatment options and their recommended doses are listed in Figure 4. However, the EPR-4 does not include any new recommendations for the evaluation and management of acute asthma [21]. Some patients may not respond to primary treatment and show signs of worsening asthma. Other treatments are sometimes used in these patients and may include:.
Figure 3. Treatment should be continued until the patient has stabilized or a decision to hospitalize is made. Nebulizer treatment may be preferred in patients who are unable to cooperate using an MDI because of the severity of acute asthma, age or agitation. Additionally, continuous nebulization should be considered in very severe asthma based on evidence of reduced admissions and improved pulmonary function [17, ].
Levalbuterol R-albuterol nebulizer solution can be given in a similar fashion. Notably, levalbuterol administered at one-half the mg dose of albuterol is found to deliver comparable efficacy and safety.
However, the efficacy of continuous nebulization has not been evaluated. Continuous administration of albuterol via large volume nebulizers may be more efficacious when compared to intermittent administration in patients with severe asthma [17]. At this time, there is no proven advantage of use of epinephrine over SABA.
If there is no immediate response to epinephrine, treatment should be discontinued, and the patient hospitalized [17]. Ipratropium bromide is a quaternary derivative of atropine sulfate available as a nebulizer solution.
It provides competitive inhibition of acetylcholine at the muscarinic cholinergic receptor, thus relaxing smooth muscle in large central airways. Recently, scientists have mapped out some of the genetic changes that may play a role in its development.
In some cases, epigenetic changes are responsible. These occur when an environmental factor causes a gene to change. Around 5. For example, during their reproductive years, symptoms may worsen during menstruation, compared with other times of the month. Doctors call this perimenstrual asthma. During menopause , however, asthma symptoms may improve. Some scientists believe that hormonal activity may impact immune activity, resulting in hypersensitivity in the airways. People with intermittent asthma may also have symptoms only some of the time.
Learn more about intermittent asthma here. A doctor will ask the person about their symptoms, their family medical history, and their personal medical history.
They will also carry out a physical examination, and they may conduct some other tests. When the doctor makes their diagnosis, they will also note whether the asthma is mild, intermittent, moderate, or severe. They will also try to identify the type.
People can keep a log of their symptoms and possible triggers to help the doctor make an accurate diagnosis. This should include information about potential irritants in the workplace. The doctor will focus on the upper respiratory tract, the chest, and the skin.
They will listen for signs of wheezing, which can indicate an obstructed airway and asthma. They will also check the skin for signs of eczema or hives. A spirometry test is one example of a lung function test. The person will need to breathe in deeply and then breathe out forcefully into a tube. The tube links up to a machine called a spirometer, which shows how much air a person inhales and exhales and the speed at which they expel the air from the lungs. The doctor will then compare these results with those of a person who is similarly aged but who does not have asthma.
To confirm the diagnosis, the doctor may then give the person a bronchodilator drug — to open the air passages — and repeat the test. If these second results are better, the person may have asthma. This test may not be suitable for young children, however. Instead, the doctor may prescribe asthma medicines for 4—6 weeks and monitor any changes in their symptoms.
A challenge test. Tests to rule out other conditions. Asthma is a chronic inflammatory condition that causes swelling in the airways. It can affect people of any age, and the symptoms can range from mild to severe.
In most cases, effective treatment is available that can help a person live a full and active life with asthma. Learn about some options for treating asthma here. Asthma is far from a new disease, and people have had different ways of understanding its causes across the course of history.
Researchers expect the…. Asthma can kill individuals with mild symptoms - even those who do not routinely take medication. Find out why experts say it's time for a rethink. Chronic obstructive pulmonary disease COPD refers to two lung diseases that cause difficulty breathing.
Smoking is the most common cause. Learn more…. Asthma attacks can be frightening, especially if a person is unprepared. Beyond medication, what can help? We discuss what to do when an attack hits…. Written by : Dr. Amita Fotedar -Dr. Managing asthma exacerbations in the emergency department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations.
Proceedings of the American Thoracic Society, 6 4 , Management of acute asthma exacerbations. American family physician, 84 1. User assumes all risk of use, damage, or injury. You agree that we have no liability for any damages. Acute Asthma Exacerbation Acute Asthma Exacerbation happens when there is a sudden episode of progressive worsening of symptoms of asthma, like wheezing, chest tightness, cough, and shortness of breath. Triggers include Acute exacerbations can be triggered by a variety of things.
Some of the more common triggers are: Colds, dry and cold air Upper respiratory infections Allergens such as mold, dust mites, and pollen Smoke of tobacco Exercise Cats and Dogs Gastroesophageal Reflux Disease Chronic Asthma Exacerbation Chronic Asthma Exacerbation happens when the asthma symptoms are intense and there is chronic inflammation and narrowing of the airways in the lungs.
Triggers include: Respiratory viral infection, mainly rhinovirus Sensitizing agents Allergens like pollen, cockroach droppings, weeds, animals, mold, grass, and dust mite Air pollution, chemical fumes, household cleaners, strong alcoholic perfumes or other substances in the air Stress and anxiety Some medications like aspirin and other NSAIDs nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen.
Asthma triggers vary from person to person.
0コメント