Ebook ABC of asthma (6/E): Part 2
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Ebook ABC of asthma (6/E): Part 2
CHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2 from under-treatment and failure to appreciate severity•Forty to soty percent oxygen should be given with a reservoir mask to achieve oxygen saturations above 94%•A spacer device can delr.er bronchodilators as effectively as a netuliser in most cases of acute asthma•Corticosteroids should be used e Ebook ABC of asthma (6/E): Part 2arly n acute attacks of asthma . Discharge too early after an acute attack IS assooated withincreased readmission and mortalityIntroductionThe initialEbook ABC of asthma (6/E): Part 2
assessment of a patient with increased symptoms of asthma is very important. .Most problems result from undertreatment and failure to appreciate seveCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2ak flow should be monitored at least four times daily for the duration of the stay. A flow chart for the management of asthma at home is shown in Chapter 8 and a flow chart for management in hospital is shown later in this chapter. The various aspects of treatment arc considered individually in this Ebook ABC of asthma (6/E): Part 2 chapter.or 28% oxygen by Venturi mask until the results of blood gas measurements are available.Details of oxygen deliveryand target saturation shoulEbook ABC of asthma (6/E): Part 2
d be written clearly on the prescription sheet. Nasal cannulae, simple facemasks or reservoir masks should be prescribed to obtain a target saturationCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2h as salbutamol and terbutaline have replaced the earlier non-selective preparations for acute use. There are no great differences in practice between the commonly used agents. If long-acting bronchodilators are used they can be continued during the attack.Use and availability of nebulisersIn acute Ebook ABC of asthma (6/E): Part 2asthma, metered dose in halers often lose thei reflectiveness. This is largely due to difficulties in the delivery of the drugs to the airways becauseEbook ABC of asthma (6/E): Part 2
of coordination problems and narrowing and occlusion of the airways.An alternative method of giving p-agonist is necessary - usually by nebuliser or CHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2 grave sign. Death in asthma is caused by severe hypoxia: oxygen should be given as soon as possible. It is very unusual to provoke carbon dioxide retention with oxygen treatment in asthma, so oxygen should be given freely aiming for saturations above 93% during transfer to hospital where blood gas Ebook ABC of asthma (6/E): Part 2measurement can be made. Masks can provide 40-60% oxygen.Nebulisers should be driven by oxygen whenever possible. In older subjects with an exacerbatiEbook ABC of asthma (6/E): Part 2
on of chronic obstructive pulmonary disease (COPD) there is a potential danger of carbon dioxide retention. In these cases, treatment should begin witCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2ition, By I. Rees. p. Kaiwtur and s. Pattani. Publiibed 2010 by lUickwell I'ublijhinfc.44Asthma in AdultFigure 9.2 Attaching a spacer to a metered dose inhaler avoids the need for coodnaton betwwn firing and inhalation.Figure 9.3 In acute asthma p-stmulants should be ghen try oxygen-drr.en netouiise Ebook ABC of asthma (6/E): Part 2f.Nebuhaler or Volumatic) can be as effective as a nebuliser in most cases (Figure 9.2). Like the nebuliser, it has the advantage of removing the needEbook ABC of asthma (6/E): Part 2
to coordinate inhaler actuation and breathing. There is little or no difference in the effectiveness of drugs that are nebulised or given intravenousCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2e asthmatic attacks (Figure 9.3). p’-agonists arc best given by nebulisers driven by oxygen in acute asthma, as they may even worsen hypoxia slightly through an effect on the pulmonary vasculature. In general practice the use of oxygen as the driving gas is not usually practical. Domiciliary oxygen Ebook ABC of asthma (6/E): Part 2sets do not produce a flow rate adequate to drive most nebulisers. If available they can be used with nasal cannulae at the same time as an air drivenEbook ABC of asthma (6/E): Part 2
nebuliser for a patient having an acute attack. Many ambulance services are aide to give nebulised drugs and oxygen during transfer to hospital.In hoCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2s. flow rate, drug diluent and volume of till should be clearly written on the prescription chart. Dilutions should always be done with saline to avoid bronchoconstriơion from nebulisation of hypotonic solutions. There is no real advantage of nebulisation with a machine capable of producing intermit Ebook ABC of asthma (6/E): Part 2tent positive pressure.For adults the initial dose should be 5 mg salbutamol or its equivalent. This should be halved if the patient has ischaemic heaEbook ABC of asthma (6/E): Part 2
rt disease. It is essential to continue the intensive treatment after the first response; many of the problems in acute asthma arise because of complaCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2 given continuously at 5-10 mg per hour with the same effect.Parenteral deliveryIf nebulised drugs are not effective then parenteral treatment should be considered. A reasonable plan is to give a P’-agonist the first time, combine with an anticholinergic drug for the second nebulisation or initially Ebook ABC of asthma (6/E): Part 2 in life-threatening asthma and move to intravenous bronchodilators if there is no improvement. If life-threatening features such as a raised carbon dEbook ABC of asthma (6/E): Part 2
ioxide tension, an arterial oxygen tension less than 8 kPa on oxygen or a low pH are present, the intravenous agent should be considered front the staCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result Ebook ABC of asthma (6/E): Part 2 has been on theophylline and a level is not immediately available it is safer to use the Pi-agonist. Salbutamol or terbutaline can be given intravenously over 10 minutes, or as an infusion, usually at 5 to 15 pg per minute. The adverse effects of tachycardia and tremor are much more common after in Ebook ABC of asthma (6/E): Part 2travenous injection than after nebulisation.Anticholinergic agentsCHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma result CHAPTER 9Treatment of Acute AsthmaJohn ReesSherman Education centre. Guy’s Hospital, l-ondon, UKOVERVIEW•Most p'cblerrs in acute severe asthma resultGọi ngay
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