notes by dr Claudio Italiano
The patient reaches his attention in the grip of a severe asthmatic crisis. When I was writing, as a young man, at the dawn of his career, he had to treat a patient in severe, cyanotic, confused bronchospasm, in a state of collapse.
The patient presented:
•
Cyanosis
• Tachypnea
• Tachycardia
• Respiratory silence
• Collapse
• He could not express himself
• he was doing gestures
At that time it was necessary to give the patient oxygen with a mask of Bossignauc at positive pressure and high flow, adrenaline for aerosol and adrenaline subcutaneous, obviously diluted, high dose cortisone (see below), theophylline, beta 2 agonists for aerosols and ipatropium bromide.
When we breathe, the air goes down through the trachea, which then divides into
two smaller tubes, the bronchi. The bronchial tubes allow air to reach the lungs
and, once inside the lungs, they are divided into many small tubes (the
bronch́oli), which resemble the branches of a tree.
The walls of all the airways up to the lungs are covered by several layers of
muscles, able to contract and change the width of their caliber. If a person
suffers from asthma, his airways become periodically narrower than normal.
This means that there is less space for air entering and leaving and therefore
it is harder to breathe. Moreover the bronchial mucosa goes into edema, mucus is
produced and this aggravates the respiratory picture.
The patient of our clinical case, after about an hour of intensive care,
recovered from the crisis and was therefore not intubated by the resuscitator (see
resuscitation). Most severe seizures develop within a period of 6 hours or more
(most often over 48 hours), allowing the patient and healthcare personnel to
take effective action.
When the patient arrives at the observation affected by an asthmatic crisis, the
clinical signs and symptoms must be noted and it is necessary to proceed with
the implementation of objective clinical measures. Clinical measurements such as
PEF or FEV1 (expressed as a percentage of the best personal value) and oxygen
saturation must be reported. The saturimetry determines the adequacy of oxygen
therapy and the need for arterial blood gas analysis (see acid-base balance).
The goal of oxygen therapy is to maintain Sp02> 92%. Preprinted forms can be a
useful tool to perform a systematic initial assessment of asthma severity. The
BTS / SIGN guidelines (the British Thoracic Society - BTS and the Scottish
Intercollegiate Guidelines Network - SIGN) to establish the severity of asthma
during a crisis. (see also the treatment of asthma)
Potentially lethal asthma (PEF <33% of the best personal value)
• Organize immediate hospitalization
• Administer oxygen at 40-60%
• Administration of steroids: prednisolone 40-50 mg or hydrocortisone 100 mg
e.v.
• Administer bronchodilators preferably with nebuliser - salbutamol 5 mg or
terbutaline 10 mg - and ipratropium bromide 0.5 mg. (In the absence of a
nebuliser deliver
• Beta2agonist puff by spacer, repeated 10-20 times)
Characteristics of asthma |
||
| Severity | Features | |
| Potentially lethal asthma |
PEF <33% of the theoretical or of the best personal value Sp02 <92% Pa02 <60 mmHg PaC02 normal (35-45 mmHg) Respiratory silence Cyanosis Low respiratory efforts bradycardia Arrhythmia Hypotension Muscle exhaustion Confusion Coma |
|
| Severe acute asthma |
PEF 33-50% of the theoretical or of the best personal value Respiratory rate> 25 apm Heart rate> 110 bpm Inability to complete sentences with only one breath |
|
| Moderate asthma |
Aggravating symptoms, PER 50-75% of the theoretical of greater personal value Absence of features of severe acute asthma |
|
|
Unstable asthma Type 1 |
Wide variability of PEF (daytime variability> 40% for> 50% of the time over a period> 150 days) despite intensive treatment |
• Consider hospitalization
• Administer oxygen at 40-60%
• Administer bronchodilators preferably with nebuliser - salbutamol 5 mg or
terbutaline 10 mg-and ipratropium bromide 0.5 mg (in the absence of a nebulizer,
deliver 1 puff of Beta 2 agonist by spacer, repeated 10-20 times)
•Administer
steroids: prednisolone 40- 50 mg or hydrocortisone 100 mg ev In the absence of
an answer, admit to the hospital
• Administer bronchodilators preferably with nebuliser - salbutamol 5 mg or
terbutaline 10 mg (in the absence of a nebulizer, deliver 1 puff of Beta2
agonist by means of a spacer, repeated 10-20 times)
• If PEF is 50-75% of theoretical / best personal value, administer prednisolone
40-50 mg
• Continue or enhance the usual treatment
•Administer oxygen immediately, maintaining saturation above 95% to prevent maternal and fetal hypoxia
Provide immediate hospitalization in case of severe or potentially lethal asthma.
Administer drugs at the same dosages used outside of pregnancy. Provide
hospitalization in case of one or more features of severe or life-threatening
asthma, or if the patient reports a previous life-threatening crisis.
In the case of an acute attack, an oral steroid dose should be administered as
early as possible (40-50 mg of prednisolone in the adult, 30-40 mg of soluble
prednisolone in the child over 5 years of age, 20 mg of soluble prednisolone in
children aged 2 to 5 years) and thereafter for at least 5 days or until clinical
improvement.
Furthermore, as soon as possible it is necessary to administer high doses of
Beta2-agonists by means of a spacer (10-20 puffs in adults, 10 puffs in children
aged 2 to 5 years with severe seizures or 2-4 puffs in children aged between 2
and 5 years with moderate crisis). In case of inadequate response to treatment,
continuous doses of Beta2-agonists should be given at intervals of 15-30 minutes.
All patients with severe acute asthma should be treated with high-flow oxygen
(Beta2-agonist nebulisations should be performed with oxygen-activated or
compressed-air devices), except for patients with COPD, in which case it is more
indicated the compressed air nebulization.
Immediate admission is necessary for patients with life-threatening asthma and
for patients with severe acute asthma who do not respond to emergency treatment.
Pregnant women with severe asthma or life-threatening asthma should also be
treated in the hospital setting, and hospitalization must be immediate.
Hospital admission should also be considered in patients who come to the
observation with severe acute asthma, in those with a history of previous
serious incidents, in the attacks that occur in the afternoon or in the evening,
in case of recent nocturnal symptoms or in the presence of elements of concern
related to the patient's psychosocial circumstances.
In acute asthma during pregnancy, oxygen should be administered immediately, in
order to maintain arterial saturation over 95% and prevent both maternal and
fetal hypoxia. Pregnant patients should be sent to the hospital immediately and
the drugs can be administered at the same dosages used in non-pregnant patients.
All patients with acute asthma should be re-evaluated within 48 hours of
discharge from the hospital (or within 48 hours of emergency treatment if they
are not hospitalized).
On this occasion it is necessary:
• Monitor symptoms and PEF
• Check the patient's inhalation technique
• Change treatment according to the guidelines for chronic asthma
• Persistent
• Provide a written intervention plan
• Eliminate potentially preventable triggering factors.
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Bronchial asthma
Allergy and allergens