Status asthmaticus medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Initial severity assessment is evaluated using [[Asthma laboratory tests#Arterial Blood Gas|arterial blood gas]] and [[Asthma pulmonary function test|pulmonary function test]] and aggressive therapy is initiated to prevent progression to [[respiratory failure]] | Initial severity assessment is evaluated using [[Asthma laboratory tests#Arterial Blood Gas|arterial blood gas]] and [[Asthma pulmonary function test|pulmonary function test]] and aggressive therapy is initiated to prevent progression to [[respiratory failure]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
* | *Non-invasive ventilation using [[Positive airway pressure|C-PAP]] or tight-fitting [[Medical ventilator|face mask]] may be used to reduce the work of breathing without intubation. | ||
*[[ | *[[Tracheal intubation|Endotracheal intubation]] and [[mechanical ventilation]] should be used with caution in asthmatics who are non-responsive to medical therapy or non-invasive methods of ventilation, due to the substantial risk of [[barotrauma]]. Common indications include impending [[respiratory failure|respiratory arrest]], [[hypoxia|severe hypoxia]] non-responsive to supplemental [[oxygen]], [[CO2 retention]] with PaCO<sub>2</sub> greater than 50 mmHg, [[acidosis]] and/or altered mental status. | ||
* | *Supplemental [[oxygen]] via nasal canula or [[face mask]] is recommended to alleviate severe [[hypoxia]]. Oxygen saturation is maintained above 92% and is monitored using [[Asthma laboratory tests#Pulse Oximetry|pulse Oximetry]] | ||
===Therapy | *Helium with oxygen mixture has shown to reduce airway resistance and thereby reduce the work of breathing and also improve [[bronchodilator]] efficacy. | ||
*Use of [[Magnesium sulfide|magnesium sulphate]] administered either IV or nebulized in addition to [[Bronchodilator|β2-agonists]] remains controversial.<ref name="pmid11097697">Scarfone RJ, Loiselle JM, Joffe MD, Mull CC, Stiller S, Thompson K et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11097697 A randomized trial of magnesium in the emergency department treatment of children with asthma.] ''Ann Emerg Med'' 36 (6):572-8. [http://dx.doi.org/10.1067/mem.2000.111060 DOI:10.1067/mem.2000.111060] PMID: [http://pubmed.gov/11097697 11097697]</ref><ref name="pmid12023699">Bessmertny O, DiGregorio RV, Cohen H, Becker E, Looney D, Golden J et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12023699 A randomized clinical trial of nebulized magnesium sulfate in addition to albuterol in the treatment of acute mild-to-moderate asthma exacerbations in adults.] ''Ann Emerg Med'' 39 (6):585-91. PMID: [http://pubmed.gov/12023699 12023699]</ref><ref name="pmid12501154">Glover ML, Machado C, Totapally BR (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12501154 Magnesium sulfate administered via continuous intravenous infusion in pediatric patients with refractory wheezing.] ''J Crit Care'' 17 (4):255-8. [http://dx.doi.org/10.1053/jcrc.2002.36759 DOI:10.1053/jcrc.2002.36759] PMID: [http://pubmed.gov/12501154 12501154]</ref><ref name="pmid15846687">Blitz M, Blitz S, Beasely R, Diner BM, Hughes R, Knopp JA et al. (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15846687 Inhaled magnesium sulfate in the treatment of acute asthma.] ''Cochrane Database Syst Rev'' (2):CD003898. [http://dx.doi.org/10.1002/14651858.CD003898.pub2 DOI:10.1002/14651858.CD003898.pub2] PMID: [http://pubmed.gov/15846687 15846687]</ref> | |||
*Mainstay drugs for the management include nebulized [[Bronchodilator|β2-agonists]] such as [[albuterol]], [[salbutamol]] or [[terbutaline]], parenteral [[steroids]] such as [[hydrocortisone]] or [[prednisolone]] and [[Bronchodilator#Theophylline|theophylline]] | |||
*[[Bronchodilator#Anticholinergics|Anti-cholinergics]] such as [[ipratropium bromide]] may be indicated in patients who are unable to tolerate inhaled [[Bronchodilator|β2-agonists]]. | |||
*In patients non-responsive to nebulized [[bronchodilator]], IV-[[aminophylline]] or oral-[[Leukotriene antagonist|leukotriene inhibitor]] may be used.<ref name="pmid1934839">Press S, Lipkind RS (1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1934839 A treatment protocol of the acute asthma patient in a pediatric emergency department.] ''Clin Pediatr (Phila)'' 30 (10):573-7. PMID: [http://pubmed.gov/1934839 1934839]</ref> | |||
===Therapy Based on the Severity of the Disease Assessed by [[Arterial Blood Gas Analysis]]=== | |||
====Stage 1==== | ====Stage 1==== | ||
*[[Hyperventilation]] with normal PO<sub>2</sub> | *[[Hyperventilation]] with normal PO<sub>2</sub> | ||
| Line 32: | Line 42: | ||
*[[FEV1]] lower than 20% predicted is suggestive of an impending [[respiratory failure|respiratory arrest]] that may require [[intubation]] and [[mechanical ventilation]] | *[[FEV1]] lower than 20% predicted is suggestive of an impending [[respiratory failure|respiratory arrest]] that may require [[intubation]] and [[mechanical ventilation]] | ||
*Metered-dose inhalation of [[Bronchodilator|β2-agonist]] and [[Bronchodilator#Anticholinergics|anticholinergics]] are recommended. Administration of parenteral [[steroids]] and/or [[Bronchodilator#Theophylline|theophylline]] has also shown to be beneficial. | *Metered-dose inhalation of [[Bronchodilator|β2-agonist]] and [[Bronchodilator#Anticholinergics|anticholinergics]] are recommended. Administration of parenteral [[steroids]] and/or [[Bronchodilator#Theophylline|theophylline]] has also shown to be beneficial. | ||
====Contraindicated medications==== | |||
{{MedCondContrAbs|MedCond = Status asthmaticus|Budesonide|Budesonide And Formoterol Fumarate Dihydrate|Formoterol|Flovent|Fluticasone/salmeterol|Mometasone}} | |||
==References== | ==References== | ||
{{ | {{reflist|2}} | ||
[[Category:Asthma]] | [[Category:Asthma]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
| Line 43: | Line 56: | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | [[Category:Intensive care medicine]] | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 14:39, 6 October 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Initial severity assessment is evaluated using arterial blood gas and pulmonary function test and aggressive therapy is initiated to prevent progression to respiratory failure.
Medical Therapy
- Non-invasive ventilation using C-PAP or tight-fitting face mask may be used to reduce the work of breathing without intubation.
- Endotracheal intubation and mechanical ventilation should be used with caution in asthmatics who are non-responsive to medical therapy or non-invasive methods of ventilation, due to the substantial risk of barotrauma. Common indications include impending respiratory arrest, severe hypoxia non-responsive to supplemental oxygen, CO2 retention with PaCO2 greater than 50 mmHg, acidosis and/or altered mental status.
- Supplemental oxygen via nasal canula or face mask is recommended to alleviate severe hypoxia. Oxygen saturation is maintained above 92% and is monitored using pulse Oximetry
- Helium with oxygen mixture has shown to reduce airway resistance and thereby reduce the work of breathing and also improve bronchodilator efficacy.
- Use of magnesium sulphate administered either IV or nebulized in addition to β2-agonists remains controversial.[1][2][3][4]
- Mainstay drugs for the management include nebulized β2-agonists such as albuterol, salbutamol or terbutaline, parenteral steroids such as hydrocortisone or prednisolone and theophylline
- Anti-cholinergics such as ipratropium bromide may be indicated in patients who are unable to tolerate inhaled β2-agonists.
- In patients non-responsive to nebulized bronchodilator, IV-aminophylline or oral-leukotriene inhibitor may be used.[5]
Therapy Based on the Severity of the Disease Assessed by Arterial Blood Gas Analysis
Stage 1
- Hyperventilation with normal PO2
- No hypoxemia
- Patients may benefit from nebulized ipratropium used adjunctive to β2-agonist therapy
Stage 2
- Hyperventilation with hypoxemia (low PO2 and PCO2)
- Patients may require corticosteroids in addition to bronchodilator therapy
Stage 3
- CO2 retention due to respiratory muscle fatigue
- Markedly elevated PCO2 levels are an indicator for mechanical ventilation
- Aggressive β2-agonist therapy along with parenteral steroids and/or theophylline is indicated
Stage 4
- Severe hypoxia with markedly elevated PCO2
- FEV1 lower than 20% predicted is suggestive of an impending respiratory arrest that may require intubation and mechanical ventilation
- Metered-dose inhalation of β2-agonist and anticholinergics are recommended. Administration of parenteral steroids and/or theophylline has also shown to be beneficial.
Contraindicated medications
Status asthmaticus is considered an absolute contraindication to the use of the following medications:
- Budesonide
- Budesonide And Formoterol Fumarate Dihydrate
- Formoterol
- Flovent
- Fluticasone/salmeterol
- Mometasone
References
- ↑ Scarfone RJ, Loiselle JM, Joffe MD, Mull CC, Stiller S, Thompson K et al. (2000) A randomized trial of magnesium in the emergency department treatment of children with asthma. Ann Emerg Med 36 (6):572-8. DOI:10.1067/mem.2000.111060 PMID: 11097697
- ↑ Bessmertny O, DiGregorio RV, Cohen H, Becker E, Looney D, Golden J et al. (2002) A randomized clinical trial of nebulized magnesium sulfate in addition to albuterol in the treatment of acute mild-to-moderate asthma exacerbations in adults. Ann Emerg Med 39 (6):585-91. PMID: 12023699
- ↑ Glover ML, Machado C, Totapally BR (2002) Magnesium sulfate administered via continuous intravenous infusion in pediatric patients with refractory wheezing. J Crit Care 17 (4):255-8. DOI:10.1053/jcrc.2002.36759 PMID: 12501154
- ↑ Blitz M, Blitz S, Beasely R, Diner BM, Hughes R, Knopp JA et al. (2005) Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst Rev (2):CD003898. DOI:10.1002/14651858.CD003898.pub2 PMID: 15846687
- ↑ Press S, Lipkind RS (1991) A treatment protocol of the acute asthma patient in a pediatric emergency department. Clin Pediatr (Phila) 30 (10):573-7. PMID: 1934839