1 In the Name of God Asthma in Pregnancy Obstetrics and Gynecology Department Hormozgan University of Medical Sciences Presentation by Mitra Ahmad Soltani

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In the Name of God

Asthma in Pregnancy

Obstetrics and Gynecology DepartmentHormozgan University of Medical Sciences

Presentation by Mitra Ahmad Soltani 2006

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Guideline on the Guideline on the Management of AsthmaManagement of Asthma

A national clinical guidelineA national clinical guideline

ThoraxThorax 2003; 2003; 5858 (Suppl I): i1-i92 (Suppl I): i1-i92

Williams Obstetrics 2005- Asthma in pregnancyWilliams Obstetrics 2005- Asthma in pregnancy

www.cdc.gov/www.cdc.gov/asthmaasthma/speakit/slides/managing_/speakit/slides/managing_asthmaasthma..pptppt

www.spirxpert.com/indices7.htm

The British Thoracic Society Scottish Intercollegiate Guidelines Network

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Assessment of PEFAssessment of PEF

Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92

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Definition of asthmaDefinition of asthma

Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

“A chronic inflammatory disorder of the airways …

in susceptible individuals, inflammatory symptoms

are usually associated with widespread but

variable airflow obstruction and an increase in

airway response to a variety of stimuli.

Obstruction is often reversible, either

spontaneously or with treatment.”

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Diagnosis of asthma in adultsDiagnosis of asthma in adults


Consider the diagnosis of Consider the diagnosis of asthma in patients with asthma in patients with

some or all of these featuressome or all of these features

Symptoms (episodic/variable)Symptoms (episodic/variable)• wheezewheeze• shortness of breathshortness of breath• chest tightnesschest tightness• coughcough

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Symptoms (episodic/variable)• wheeze• shortness of breath• chest tightness• cough

SignsSigns• none none (common)(common)• wheeze – diffuse, bilateral, wheeze – diffuse, bilateral,

expiratory (expiratory ( inspiratory) inspiratory)• tachypneatachypnea



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Helpful additional informationHelpful additional information• personal/family history of asthma or atopy personal/family history of asthma or atopy • history of worsening after aspirin/NSAID,history of worsening after aspirin/NSAID,

blocker use blocker use• recognised triggers – pollens, dust, animals, recognised triggers – pollens, dust, animals,

exercise, viral infections, chemicals, irritantsexercise, viral infections, chemicals, irritants• pattern and severity of symptoms and pattern and severity of symptoms and

exacerbationsexacerbations


Signs• none (common)• wheeze – diffuse, bilateral,

expiratory ( inspiratory)• tachypnea



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Objective measurementsObjective measurements• >20% diurnal variation on >20% diurnal variation on 3 days in3 days in

a week for 2 weeks on PEF diarya week for 2 weeks on PEF diary• oror FEV FEV11 15% (and 200ml) increase after 15% (and 200ml) increase after

short acting ßshort acting ß22 agonist or steroid tablets agonist or steroid tablets

• oror FEV FEV1 1 15% decrease after 6 minutes of 15% decrease after 6 minutes of

running exerciserunning exercise• histamine or methacholine challenge in histamine or methacholine challenge in

difficult casesdifficult cases


Signs• none (common)• wheeze – diffuse, bilateral,

expiratory ( inspiratory)• tachypnea

Helpful additional information• personal/family history of asthma or atopy • history of worsening after aspirin/NSAID,

blocker use• recognised triggers – pollens, dust, animals,

exercise, viral infections, chemicals, irritants• pattern and severity of symptoms and

exacerbations



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Differential diagnosis ofDifferential diagnosis ofasthma in adultsasthma in adults


Some of symptoms of asthma are shared with diseases of other systemsSome of symptoms of asthma are shared with diseases of other systems

Numerous relatively common lung diseasesNumerous relatively common lung diseases

Need to differentiate from infections and restrictive lungNeed to differentiate from infections and restrictive lungdisorders, and between local and generalised obstructiondisorders, and between local and generalised obstruction

Differential diagnoses include:Differential diagnoses include:

• COPDCOPD• cardiac diseasecardiac disease• laryngeal, tracheal or lung tumourlaryngeal, tracheal or lung tumour• bronchiectasisbronchiectasis• foreign bodyforeign body

• interstitial lung diseaseinterstitial lung disease• pulmonary embolipulmonary emboli• aspirationaspiration• vocal cord dysfunctionvocal cord dysfunction• hyperventilationhyperventilation

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Indications for referral ofIndications for referral ofadults with suspected asthmaadults with suspected asthma

• Diagnosis unclear or in doubt

• Unexpected clinical findings e.g. crackles, clubbing, cyanosis, heart failure

• Spirometry or PEF measurements do not fit the clinical picture

• Suspected occupational asthma

• Persistent shortness of breath (not episodic, or without associated wheeze)

• Unilateral or fixed wheeze

• Stridor

• Persistent chest pain or atypical features

• Weight loss

• Persistent cough and/or sputum production

• Non-resolving pneumonia


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Diagnosis of asthma inDiagnosis of asthma inadults: practice pointsadults: practice points


Record presence of wheeze in patient’s notesRecord presence of wheeze in patient’s notes

Try to confirm diagnosis with objective tests beforeTry to confirm diagnosis with objective tests beforelong-term therapy is startedlong-term therapy is started

Question diagnosis if little response to treatmentQuestion diagnosis if little response to treatment

Perform chest X-rays in patients with atypical symptomsPerform chest X-rays in patients with atypical symptoms

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Overview: DiagnosisOverview: Diagnosisand natural historyand natural history


• Diagnose before treating

• Try to confirm diagnosis with objective tests before long-term therapy is started

• Differentiate from other respiratory and non-respiratory conditions

• Question the diagnosis if little response to treatment

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Non-pharmacological Non-pharmacological managementmanagement


Non-pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

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Rationale forRationale fornon-pharmacological managementnon-pharmacological management


Although little evidence, possible that avoiding certain factors might:

• facilitate management of asthma

• reduce requirement for pharmacotherapy

• modify fundamental causes of asthma.

Factors that induce the disease not necessarily same as those thatincite a pre-existing problem so distinction between:

• primary prophylaxis – interventions before any evidence of disease

• secondary prophylaxis – interventions after onset of disease to reduce its impact

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Potential strategies forPotential strategies forprimary prophylaxisprimary prophylaxis


AA Breast-feeding should be encouraged as protects against Breast-feeding should be encouraged as protects against early life wheezingearly life wheezing

BBParents and parents-to-be who smoke should be advised to Parents and parents-to-be who smoke should be advised to stop and given appropriate support as there is increased stop and given appropriate support as there is increased wheezing in infants exposed to smokewheezing in infants exposed to smoke

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Potential strategies forPotential strategies forsecondary prophylaxissecondary prophylaxis


In committed families with evidence of house In committed families with evidence of house dust mite allergy and who wish to try mite dust mite allergy and who wish to try mite avoidance, the following are recommended:avoidance, the following are recommended:

• complete barrier bed covering systemscomplete barrier bed covering systems

• removal of carpetsremoval of carpets

• removal of soft toys from bedremoval of soft toys from bed

• high temperature washing of bed linenhigh temperature washing of bed linen

• acaricides to soft furnishingsacaricides to soft furnishings

• dehumidificationdehumidification

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Non-pharmacologicalNon-pharmacologicalmanagement of asthmamanagement of asthma


Use of Use of ionisersionisers cannot be encouraged as no evidence of benefit cannot be encouraged as no evidence of benefit and suggestion of adverse effectand suggestion of adverse effect

In difficult childhood asthma, may be a role for In difficult childhood asthma, may be a role for family therapyfamily therapy as as adjunct to pharmacotherapyadjunct to pharmacotherapy

CC Weight reductionWeight reduction recommended in obese patients with asthma recommended in obese patients with asthma

Treat gastro-oesophageal Treat gastro-oesophageal refluxreflux if present but generally no if present but generally no impact on asthma controlimpact on asthma control

• No consistent evidence or recommendations about complementary or alternative treatment for asthma (e.g acupuncture, Buteyko or other breathing exercises, hypnosis, homeopathy or manipulation therapy)

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Pharmacological Pharmacological managementmanagement


Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

All doses of inhaled steroids in this section refer to beclomethasone (BDP) given viametered dose inhaler. Adjustment may be necessary for fluticasone and/or other devices

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21 Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

Stepwise management ofStepwise management ofasthma in adultsasthma in adults

Step 1: Mild intermittent asthmaStep 1: Mild intermittent asthma

Step 5: Continuous or frequent Step 5: Continuous or frequent use of oral steroidsuse of oral steroids

Step 4: Persistent poor controlStep 4: Persistent poor control

Step 3: Add-on therapyStep 3: Add-on therapy

Step 2: Regular preventer therapyStep 2: Regular preventer therapy

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Asthma controlAsthma control


Asthma control means:Asthma control means:• minimal symptoms during day and nightminimal symptoms during day and night• minimal need for reliever medicationminimal need for reliever medication• no exacerbationsno exacerbations• no limitation of physical activityno limitation of physical activity• normal lung function (FEVnormal lung function (FEV

11 and/or PEF >80% predicted or and/or PEF >80% predicted or

best)best)

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Asthma control means:• minimal symptoms during day and night• minimal need for reliever medication• no exacerbations• no limitation of physical activity• normal lung function (FEV1 and/or PEF >80% predicted or best)

Aim for early control, with stepping up or down as requiredAim for early control, with stepping up or down as required

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Asthma control means:• minimal symptoms during day and night• minimal need for reliever medication• no exacerbations• no limitation of physical activity• normal lung function (FEV1 and/or PEF >80% predicted or best))

Aim for early control, with stepping up or down as required

Before initiating a new drug therapy:Before initiating a new drug therapy:• check compliance with existing therapiescheck compliance with existing therapies• check inhaler techniquecheck inhaler technique• eliminate trigger factorseliminate trigger factors

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Step 1: Mild intermittent asthmaStep 1: Mild intermittent asthma

Inhaled short acting ßInhaled short acting ß22 agonist as required agonist as required



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Step 2: Regular preventer therapyStep 2: Regular preventer therapy

Add inhaled steroid 200-800mcg/day *Add inhaled steroid 200-800mcg/day *400mcg is an appropriate starting dose for many patients400mcg is an appropriate starting dose for many patients


Step 1: Mild intermittent asthma

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Step 3: Add-on therapyStep 3: Add-on therapy

1. Add inhaled long-acting ß1. Add inhaled long-acting ß22 agonist (LABA) agonist (LABA)

2. Assess control of asthma:2. Assess control of asthma:• goodgood response to LABAresponse to LABA – continue LABA – continue LABA• benefit from LABA but control still inadequatebenefit from LABA but control still inadequate – continue LABA and – continue LABA and

increase inhaled steroid dose to 800mcg/day * (if not already on this dose)increase inhaled steroid dose to 800mcg/day * (if not already on this dose)• no response to LABAno response to LABA – stop LABA and increase inhaled steroid to – stop LABA and increase inhaled steroid to

800mcg/day *. If control still inadequate, institute trial of other therapies800mcg/day *. If control still inadequate, institute trial of other therapies(e.g. leukotriene receptor antagonist or SR theophylline)(e.g. leukotriene receptor antagonist or SR theophylline)



Step 2: Regular preventer therapy Start at dose of inhaled Start at dose of inhaled steroid appropriate to steroid appropriate to severity of disease.severity of disease.

* BDP or equivalent* BDP or equivalent

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Step 4: Persistent poor controlStep 4: Persistent poor control

Consider trials of:Consider trials of:• increasing inhaled steroid up to 2000mcg/day *increasing inhaled steroid up to 2000mcg/day *• addition of fourth drug (e.g. leukotriene receptor addition of fourth drug (e.g. leukotriene receptor

antagonist, SR theophylline, ßantagonist, SR theophylline, ß22 agonist tablet) agonist tablet)



Step 3: Add-on therapy



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Step 5: Continuous or frequent use of oral steroidsStep 5: Continuous or frequent use of oral steroids

Use daily steroid tablet Use daily steroid tablet in lowest dose providing adequate controlin lowest dose providing adequate controlMaintain high dose inhaled steroid at 2000mcg/day *Maintain high dose inhaled steroid at 2000mcg/day *Consider other treatments to minimise the use of steroid tabletsConsider other treatments to minimise the use of steroid tabletsRefer patient for specialist careRefer patient for specialist care



Step 3: Add-on therapy



Step 4: Persistent poor control

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Overview: PharmacologicalOverview: Pharmacologicalmanagementmanagement


• Add inhaled long-acting 2 agonists rather than

increasing the dose of inhaled steroids (above 800mcg/day in adults and 400mcg/day in children)

• Step down therapy to lowest level consistent with maintained control

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Inhaler devicesInhaler devices


Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92

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Peak flow meter

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Spacer

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Dry powder inhaler

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BBPrescribe inhalers only after patients have been trained and Prescribe inhalers only after patients have been trained and have demonstrated satisfactory techniquehave demonstrated satisfactory technique

• Reassess inhaler technique as part of structured clinical reviewReassess inhaler technique as part of structured clinical review

• The choice of device may be determined by choice of drugThe choice of device may be determined by choice of drug

• If patient unable to use a device satisfactorily, find alternativeIf patient unable to use a device satisfactorily, find alternative

• Titrate medication needs against clinical response to ensure Titrate medication needs against clinical response to ensure optimum efficacyoptimum efficacy

Device selectionDevice selection


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AA AAUse pMDI and large volume spacer for adults and Use pMDI and large volume spacer for adults and children aged 2-12 years with mild and moderate children aged 2-12 years with mild and moderate exacerbations of asthmaexacerbations of asthma

pMDI + spacer preferred delivery method for pMDI + spacer preferred delivery method for children aged 0-5 yearschildren aged 0-5 years

AAIn children aged 5-12 years with chronic asthma, pMDI + In children aged 5-12 years with chronic asthma, pMDI + spacer is as effective as any other hand held inhalerspacer is as effective as any other hand held inhaler

AAIn adults, pMDI ± spacer is as effective as any other hand held In adults, pMDI ± spacer is as effective as any other hand held inhaler, but patients may prefer dry powder inhalersinhaler, but patients may prefer dry powder inhalers

Base choice of reliever inhaler for stable asthma on patient Base choice of reliever inhaler for stable asthma on patient preference/ability to use, as many patients will not carry a spacerpreference/ability to use, as many patients will not carry a spacer

AASalbutamol non-CFC pMDI can be substituted for CFC pMDI atSalbutamol non-CFC pMDI can be substituted for CFC pMDI at1:1 dosing1:1 dosing

Delivery of ßDelivery of ß22 agonists agonists


AdultsAdults Children Children 5-12 5-12 yearsyears

Children Children <5 <5

yearsyears

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pMDI + spacer preferred delivery method for pMDI + spacer preferred delivery method for children aged 0-5 yearschildren aged 0-5 years

AA For children aged 5-12 years, pMDI + spacer is as For children aged 5-12 years, pMDI + spacer is as effective as any dry powder inhalereffective as any dry powder inhaler

AAIn adults, a pMDI ± spacer is as effective as any In adults, a pMDI ± spacer is as effective as any dry powder inhalerdry powder inhaler

HFA-BDP pMDI can be substituted for CFC-BDP HFA-BDP pMDI can be substituted for CFC-BDP pMDI at 1:2 dosing, but should incorporate period pMDI at 1:2 dosing, but should incorporate period of close monitoringof close monitoring

AAFluticasone non-CFC pMDI can be substituted for Fluticasone non-CFC pMDI can be substituted for CFC pMDI at 1:1 dosingCFC pMDI at 1:1 dosing

Delivery of inhaled steroidsDelivery of inhaled steroids


AdultsAdults Children Children 5-12 5-12 yearsyears

Children Children <5 <5

yearsyears

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Use and care of spacersUse and care of spacers


• Ensure spacer compatible with pMDI usedEnsure spacer compatible with pMDI used• Administer drug by repeated single actuations of pMDI into Administer drug by repeated single actuations of pMDI into

spacer, each followed by inhalationspacer, each followed by inhalation• Minimise delay between pMDI actuation and inhalationMinimise delay between pMDI actuation and inhalation• Tidal breathing is as effective as single breathsTidal breathing is as effective as single breaths• Spacers should be cleaned monthly by washing in detergent Spacers should be cleaned monthly by washing in detergent

and air drying, with mouthpiece wiped clean of detergent and air drying, with mouthpiece wiped clean of detergent before usebefore use

• Drug delivery may vary significantly due to static chargeDrug delivery may vary significantly due to static charge• Replace after 6-12 monthsReplace after 6-12 months

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Overview: Inhaler devicesOverview: Inhaler devices


• pMDI + spacer is preferred delivery method in children aged 0-5 years

• pMDI + spacer is as effective as other delivery methods for other age groups

• Choice of inhaler should be based on patient preference and ability to use

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Asthma in pregnancyAsthma in pregnancy


Asthma in pregnancy. Thorax 2003; 58 (Suppl I): i1-i92

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• 5 to 9 percent of pregnant women suffer from asthma

• PGF2 alfa is contraindicated in asthmatic women/ LT inhibitors are contraindicated in pregnancy

• Asthma is a risk factor for preeclampsia, preterm labor, LBW babies, and perinatal mortality

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Changes in respiratory system in pregnancy

• Reduced FRC• PCO2 more than 35 is considered as abnormal

(non pregnant state is 40 mmHg)• No change in PEF or FEV1• Stress dose of hydrocortisone (100 mg IV

TDS) for those who receive systemic steroids• Fentanyl as narcotic• NVD is preferred- Epidural is a better choice

than general anesthesia

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DDOffer pre-pregnancy Offer pre-pregnancy counsellingcounselling about continuing asthma about continuing asthma medications during pregnancy to ensure good asthma controlmedications during pregnancy to ensure good asthma control

CCMonitor Monitor pregnant women with asthma closely to ensure therapy is pregnant women with asthma closely to ensure therapy is appropriate for symptomsappropriate for symptoms

Advise women who smoke about dangers and give appropriate Advise women who smoke about dangers and give appropriate support to support to stop smokingstop smoking

Asthma in pregnancyAsthma in pregnancy


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CC Give drug therapy for acute asthma as for the non-pregnant patientGive drug therapy for acute asthma as for the non-pregnant patient

DDAcute severe asthma in pregnancy is an emergency and should be Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospitaltreated vigorously in hospital

DD Deliver oxygen immediately to maintain saturation above 95%Deliver oxygen immediately to maintain saturation above 95%

Continuous fetal monitoring is recommended for severe acute asthmaContinuous fetal monitoring is recommended for severe acute asthma

For women with poorly controlled asthma during pregnancy there For women with poorly controlled asthma during pregnancy there should be close liaison between the respiratory physician and should be close liaison between the respiratory physician and obstetricianobstetrician

Management of acute asthmaManagement of acute asthmain pregnancyin pregnancy


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CCUse Use 22 agonists, inhaled steroids and oral/IV theophyllines as agonists, inhaled steroids and oral/IV theophyllines as normal during pregnancynormal during pregnancy

DDCheck blood levels of theophylline in acute severe asthma and in Check blood levels of theophylline in acute severe asthma and in those critically dependent on therapeutic theophylline levelsthose critically dependent on therapeutic theophylline levels

CCUse steroid tablets as normal when indicated during pregnancy for Use steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because severe asthma. Steroid tablets should never be withheld because of pregnancyof pregnancy

DD Do not commence leukotriene antagonists during pregnancyDo not commence leukotriene antagonists during pregnancy

CCEncourage women with asthma to breast feed. Use asthma Encourage women with asthma to breast feed. Use asthma medications as normal during lactationmedications as normal during lactation

Drug therapy for asthmaDrug therapy for asthmaduring pregnancy and lactationduring pregnancy and lactation


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Advise women that acute asthma is rare in labourAdvise women that acute asthma is rare in labour

Advise women to continue their usual asthma medications in labourAdvise women to continue their usual asthma medications in labour

In the absence of acute severe asthma, reserve caesarean section In the absence of acute severe asthma, reserve caesarean section for the usual obstetric indicationsfor the usual obstetric indications

CCIf anaesthesia is required, regional blockade is preferable to general If anaesthesia is required, regional blockade is preferable to general anaesthesia in women with asthmaanaesthesia in women with asthma

Women receiving steroid tablets at a dose exceeding prednisolone Women receiving steroid tablets at a dose exceeding prednisolone 7.5mg per day for more than 2 weeks prior to delivery should receive 7.5mg per day for more than 2 weeks prior to delivery should receive parenteral hydrocortisone 100mg 6-8 hourly during labourparenteral hydrocortisone 100mg 6-8 hourly during labour

DDUse prostaglanding F2Use prostaglanding F2 with extreme caution in women with asthma with extreme caution in women with asthma because of the risk of inducing bronchoconstrictionbecause of the risk of inducing bronchoconstriction

Management of asthmaManagement of asthmaduring labourduring labour


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Overview: Asthma in pregnancyOverview: Asthma in pregnancy


• Continue treatment as usual

• Monitor pregnant women with asthma closely to ensure therapy is appropriate for symptoms

• Acute severe asthma in pregnancy should be treated as usual, but in a hospital setting

• If anaesthesia is required, regional blockade is preferred

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Management ofManagement ofacute asthmaacute asthma



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Patients at risk of developingPatients at risk of developingnear fatal or fatal asthmanear fatal or fatal asthma


Severe asthmaSevere asthma Adverse behavioural orAdverse behavioural orpsychosocial featurespsychosocial features

and

Recognised by combination of:

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and Adverse behavioural orAdverse behavioural orpsychosocial featurespsychosocial features

Severe asthmaSevere asthmarecognised by one or more of:recognised by one or more of:

• previous near fatal asthma previous near fatal asthma (previous ventilation or (previous ventilation or respiratory acidosis)respiratory acidosis)

• previous asthma admissionprevious asthma admission• requiring requiring 3 classes of asthma 3 classes of asthma

medicationmedication

• heavy use of ßheavy use of ß22 agonist agonist

• repeated attendances at A&E for repeated attendances at A&E for asthma careasthma care

• brittle asthmabrittle asthma


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Severe asthmaSevere asthma Adverse behavioural or psychosocial featuresAdverse behavioural or psychosocial featuresrecognised by one or more of:recognised by one or more of:• non-compliance with treatment or monitoringnon-compliance with treatment or monitoring• failure to attend appointmentsfailure to attend appointments• self-discharge from hospitalself-discharge from hospital• psychosis, depression, other psychiatric illness or deliberate psychosis, depression, other psychiatric illness or deliberate

self-harmself-harm• current or recent major tranquilliser usecurrent or recent major tranquilliser use• denialdenial• alcohol or drug abusealcohol or drug abuse• obesityobesity• learning difficultieslearning difficulties• employment problemsemployment problems• income problemsincome problems• social isolationsocial isolation• childhood abusechildhood abuse• severe domestic, marital or legal stresssevere domestic, marital or legal stress

and


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Lessons learnt fromLessons learnt fromstudies of asthma deathsstudies of asthma deaths


BBHealth care professionals must be aware that patients with severe Health care professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of asthma and one or more adverse psychosocial factors are at risk of deathdeath

Keep patients who have had near fatal asthma or brittle asthma Keep patients who have had near fatal asthma or brittle asthma under specialist supervision indefinitelyunder specialist supervision indefinitely

Respiratory specialist should follow up patients admitted with severe Respiratory specialist should follow up patients admitted with severe asthma for at least a year after admissionasthma for at least a year after admission

Many deaths from asthma are preventable – 88-92% of attacks requiringhospitalisation develop over 6 hours

Factors include:• inadequate objective monitoring• failure to refer earlier for specialist advice• inadequate treatment with steroids

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Initial assessment – the role of Initial assessment – the role of symptoms, signs and measurementssymptoms, signs and measurements


Clinical featuresClinical features Clinical features, symptoms and respiratory and cardiovascular signs Clinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attackdoes not exclude a severe attack

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Clinical features Clinical features, symptoms and respiratory and cardiovascular signs helpful in recognising severe asthma, but none specific, and their absence does not exclude a severe attack

PEF or FEVPEF or FEV11 Measurements of airway calibre improve recognition of severity and guide Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and hospital or at home management decisions. PEF is more convenient and cheaper than FEVcheaper than FEV11. PEF as % previous best value or % predicted most . PEF as % previous best value or % predicted most usefuluseful

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PEF or FEV1Measurements of airway calibre improve recognition of severity and guide hospital or at home management decisions. PEF is more convenient and cheaper than FEV1. PEF as % previous best value or % predicted most useful

Pulse oximetryPulse oximetry Necessary to determine adequacy of oxygen therapy and need for arterial Necessary to determine adequacy of oxygen therapy and need for arterial blood gas measurement. Aim of oxygen therapy is to maintain SpOblood gas measurement. Aim of oxygen therapy is to maintain SpO22 92%92%

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Pulse oximetry Necessary to determine adequacy of oxygen therapy and need for arterial blood gas measurement. Aim of oxygen therapy is to maintain SpO2 92%

Blood gases Blood gases (ABG)(ABG)

Necessary for patients with SpONecessary for patients with SpO22 <92% or other features of life threatening <92% or other features of life threatening asthmaasthma

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Blood gases (ABG)

Necessary for patients with SpO2 <92% or other features of life threatening asthma

Chest X-rayChest X-ray Not routinely recommended in patients in the absence of:Not routinely recommended in patients in the absence of:• suspected pneumomediastinum or suspected pneumomediastinum or

pneumothoraxpneumothorax• suspected consolidationsuspected consolidation• life threatening asthmalife threatening asthma

• failure to respond to treatment failure to respond to treatment satisfactorilysatisfactorily

• requirement for ventilationrequirement for ventilation

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Blood gases (ABG)

Necessary for patients with SpO2 <92% or other features of life threatening asthma

Chest X-ray Not routinely recommended in patients in the absence of:• suspected pneumomediastinum or

pneumothorax• suspected consolidation• life threatening asthma

• failure to respond to treatment satisfactorily

• requirement for ventilation

Systolic paradoxSystolic paradox Abandoned as an indicator of the severity of an attackAbandoned as an indicator of the severity of an attack

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Management of acute severe asthma Management of acute severe asthma in adults : potential dischargein adults : potential discharge


• In all patients who received nebulised ßIn all patients who received nebulised ß22 agonists prior to agonists prior to

presentation, consider an extended observation period prior to presentation, consider an extended observation period prior to dischargedischarge

• If PEF <50% on presentation, prescribe prednisolone 40-50mg/day If PEF <50% on presentation, prescribe prednisolone 40-50mg/day for 5 daysfor 5 days

• In all patients ensure treatment supply of inhaled steroid andIn all patients ensure treatment supply of inhaled steroid andßß22 agonist and check inhaler technique agonist and check inhaler technique

• Arrange GP follow up for 2 days post presentationArrange GP follow up for 2 days post presentation

• Refer to asthma liaison nurse/chest clinicRefer to asthma liaison nurse/chest clinic

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Assessment and management of acute Assessment and management of acute asthma in adults in general practiceasthma in adults in general practice


Moderate asthmaModerate asthma Acute severe asthmaAcute severe asthma Life threatening asthmaLife threatening asthma

INITIAL ASSESSMENTINITIAL ASSESSMENTPEF >50% best or predictedPEF >50% best or predicted PEF 33-50% best or predictedPEF 33-50% best or predicted PEF <33% best or predictedPEF <33% best or predicted

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INITIAL ASSESSMENTPEF >50% best or predicted PEF 33-50% best or predicted PEF <33% best or predicted

FURTHER ASSESSMENTFURTHER ASSESSMENT• Speech normalSpeech normal• Respiration <25 breaths/minRespiration <25 breaths/min• Pulse <110 beats/minPulse <110 beats/min

• Cannot complete sentencesCannot complete sentences• Respiration Respiration 25 breaths/min25 breaths/min• Pulse Pulse 110 beats/min110 beats/min

• SpOSpO22 <92% <92%• Silent chest, cyanosis, or poor Silent chest, cyanosis, or poor

respiratory effortrespiratory effort• Bradycardia, dysrhythmia or Bradycardia, dysrhythmia or

hypotensionhypotension• Exhaustion, confusion or comaExhaustion, confusion or coma

Caution: Patients with severe or life threatening attacks may not be distressed and may not have all the abnormalities listed. The presence of any should alert the doctor.

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INITIAL ASSESSMENTPEF >50% best or predicted PEF 33-50% best or predicted PEF <33% best or predicted

FURTHER ASSESSMENT• Speech normal• Respiration <25 breaths/min• Pulse <110 beats/min

• Cannot complete sentences• Respiration 25 breaths/min• Pulse 110 beats/min

• SpO2 <92%• Silent chest, cyanosis, or poor

respiratory effort• Bradycardia, dysrhythmia or

hypotension• Exhaustion, confusion or coma

MANAGEMENTMANAGEMENTTreat at home or in surgery Treat at home or in surgery and ASSESS RESPONSE and ASSESS RESPONSE

TO TREATMENTTO TREATMENTConsider admissionConsider admission Arrange immediate Arrange immediate

ADMISSIONADMISSION

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Treatment of acute asthmaTreatment of acute asthmain adults in general practicein adults in general practice


Moderate asthma Moderate asthma exacerbationexacerbation

Acute severeAcute severeasthmaasthma

Life threateningLife threateningasthmaasthma

• High dose bronchodilator:High dose bronchodilator:

- ideally via oxgen driven- ideally via oxgen driven nebuliser (salbutamol 5mg nebuliser (salbutamol 5mg or terbutaline 10mg) or terbutaline 10mg)

- Or via spacer/air driven- Or via spacer/air driven nebuliser (1 puff nebuliser (1 puff 10-20 times) 10-20 times)

If PEF >50-75% predicted/best:If PEF >50-75% predicted/best:

• give prednisolone 40-50mggive prednisolone 40-50mg

• continue or step up usual continue or step up usual treatmenttreatment

• Oxygen 40-60% if availableOxygen 40-60% if available

• High dose ßHigh dose ß22 bronchodilator bronchodilator

as for moderate asthmaas for moderate asthma

• Prednisolone 40-50mg or Prednisolone 40-50mg or intravenous hydrocortisone intravenous hydrocortisone 100mg100mg

If no response: ADMITIf no response: ADMIT

• Oxygen 40-60%Oxygen 40-60%

• Prednisolone 40-50mg or Prednisolone 40-50mg or intravenous hydrocortisone intravenous hydrocortisone 100mg immediately100mg immediately

• High dose ßHigh dose ß22 bronchodilator bronchodilator

as for moderate asthma as for moderate asthma exacerbation and exacerbation and ipratropium 0.5mgipratropium 0.5mg

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Management of acute severe asthma Management of acute severe asthma in adults : PEF >75% predictedin adults : PEF >75% predicted


TimeTime Measure PEF and arterial saturationsMeasure PEF and arterial saturations

PEF >75% best or predicted: mildPEF >75% best or predicted: mild

5 min5 min Give usual bronchodilatorGive usual bronchodilator

15-30 15-30 minmin Clinically stable AND PEF >75%Clinically stable AND PEF >75%

60 min60 min

120 min120 min POTENTIAL DISCHARGEPOTENTIAL DISCHARGE

67


PEF 33-75% best/predicted:PEF 33-75% best/predicted: moderate/severemoderate/severe

features of severe asthmafeatures of severe asthma

• PEF <50% best of predictedPEF <50% best of predicted• Respiration Respiration 25/min25/min• Pulse Pulse 110 breaths/min110 breaths/min• Cannot complete sentence in one breathCannot complete sentence in one breath

5 min5 min Give salbutamol 5mg byGive salbutamol 5mg byoxygen-driven nebuliseroxygen-driven nebuliser

15-30 15-30 minmin

Clinically Clinically stablestableANDAND

PEF >75%PEF >75%


PEF <75%PEF <75%

No life No life threatening threatening

features AND features AND PEF 50-75%PEF 50-75%

Life Life threatening threatening features ORfeatures ORPEF <50%PEF <50%

Management of acute severe asthmaManagement of acute severe asthmain adults : PEF 33-75% predictedin adults : PEF 33-75% predicted


IMMEDIATE MANAGEMENTIMMEDIATE MANAGEMENT

• High concentration oxygenHigh concentration oxygen(>60% if possible)(>60% if possible)

• Give salbutamol 5mg plus Give salbutamol 5mg plus ipratropium 0.5mg viaipratropium 0.5mg viaoxygen-driven nebuliseroxygen-driven nebuliser

• AND prednisolone 40-50mg orally AND prednisolone 40-50mg orally or IV hydrocortisone 100mgor IV hydrocortisone 100mg

68


PEF 33-75% best/predicted: moderate/severePEF 33-75% best/predicted: moderate/severe

15-30 15-30 minmin


PEF >75%PEF >75%


PEF <75%PEF <75%

No life No life threatening threatening

features AND features AND PEF 50-75%PEF 50-75%

Life Life threatening threatening features OR features OR PEF <50%PEF <50%

Repeat Repeat salbutamolsalbutamol5mg nebuliser5mg nebuliser

Give prednisoloneGive prednisolone40-50mg orally40-50mg orally

60 min60 minPatient Patient

recoveringrecoveringANDAND

PEF >75%PEF >75%

No signs of No signs of severe asthma severe asthma

ANDANDPEF 50-70%PEF 50-70%

Signs ofSigns ofsevere asthma severe asthma

ORORPEF <50%PEF <50%



IMMEDIATE MANAGEMENTIMMEDIATE MANAGEMENT

• Give/repeat salbutamol 5mg with Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen-ipratropium 0.5mg by oxygen-driven nebuliser after 15 minutesdriven nebuliser after 15 minutes

• Consider continuous salbutamol Consider continuous salbutamol nebuliser 5-10mg/hr nebuliser 5-10mg/hr

• Consider IV magnesium sulphate Consider IV magnesium sulphate 1.2-2g over 20 minutes1.2-2g over 20 minutes

• Correct fluid/electrolytes, Correct fluid/electrolytes, especially Kespecially K++ disturbances disturbances

• Chest X-rayChest X-ray

69

• Give/repeat salbutamol 5mg with Give/repeat salbutamol 5mg with ipratropium 0.5mg by oxygen-ipratropium 0.5mg by oxygen-driven nebuliser after 15 minutesdriven nebuliser after 15 minutes


• Consider IV magnesium sulphate Consider IV magnesium sulphate 1.2-2g over 20 minutes1.2-2g over 20 minutes

• Correct fluid/electrolytes, Correct fluid/electrolytes, especially Kespecially K++ disturbances disturbances


ADMITADMITPatient should be accompanied Patient should be accompanied by a nurse or doctor at all timesby a nurse or doctor at all times

15-30 15-30 minmin

Clinically stableClinically stableAND PEF >75%AND PEF >75%

60 min60 minPatient Patient

recoveringrecoveringANDAND

PEF >75%PEF >75%

No signs of No signs of severe asthma severe asthma

ANDANDPEF 50-70%PEF 50-70%

Signs ofSigns ofsevere asthma severe asthma

ORORPEF <50%PEF <50%

OBSERVEOBSERVEmonitor SpOmonitor SpO22, , heart rate and heart rate and respiratory raterespiratory rate

Patient stablePatient stableAND PEF >50%AND PEF >50%

Signs of severe Signs of severe asthma OR PEF <50%asthma OR PEF <50%

120 min120 min POTENTIAL DISCHARGEPOTENTIAL DISCHARGE




PEF 33-75% best/predicted: moderate/severePEF 33-75% best/predicted: moderate/severe

70

Management of acute severe asthma Management of acute severe asthma in adults : PEF <33% predictedin adults : PEF <33% predicted



PEF <33% best or predicted OR anyPEF <33% best or predicted OR any life threatening featureslife threatening features::• SpO2 <92%SpO2 <92%• Bradycardia, arrhythmia, hypotensionBradycardia, arrhythmia, hypotension

• Silent chest, cyanosis, poor respiratory effortSilent chest, cyanosis, poor respiratory effort• Exhaustion, confusion, comaExhaustion, confusion, coma

5 min5 min

15-30 15-30 minmin

Obtain senior/ICU help now if any life-threatening features are presentObtain senior/ICU help now if any life-threatening features are present

IMMEDIATE IMMEDIATE MANAGEMENTMANAGEMENT

• High concentration oxygen (>60% if possible)High concentration oxygen (>60% if possible)• Give salbutamol 5mg plus ipratropium 0.5mg via oxygen-driven nebuliserGive salbutamol 5mg plus ipratropium 0.5mg via oxygen-driven nebuliser• AND prednisolone 40-50mg orally or IV hydrocortisone 100mgAND prednisolone 40-50mg orally or IV hydrocortisone 100mg

Measure arterial blood gasesMeasure arterial blood gasesMarkers of Markers of severity:severity:

• Normal or raised PaCONormal or raised PaCO22

(PaCO(PaCO22 >4.6 kPa; 35mm Hg) >4.6 kPa; 35mm Hg)• Severe hypoxiaSevere hypoxia (PaO (PaO22 <8 kPa; 60mm Hg) <8 kPa; 60mm Hg)• Low pHLow pH (or high H (or high H++))

60 min60 min • Give/repeat salbutamol Give/repeat salbutamol 5mg with ipratropium 5mg with ipratropium 0.5mg by oxygen-driven 0.5mg by oxygen-driven nebuliser after 15 minutesnebuliser after 15 minutes


• Consider IV magnesium Consider IV magnesium sulphate 1.2-2g over 20 minutessulphate 1.2-2g over 20 minutes

• Correct fluid/ Correct fluid/ electrolytes, especially electrolytes, especially KK++ disturbances disturbances


120 min120 min ADMIT – Patient should be accompanied by a nurse or doctor at all timesADMIT – Patient should be accompanied by a nurse or doctor at all times

71

Patient educationPatient educationand concordanceand concordance


Patient education and self-management. Concordance and compliance. Thorax 2003; 58 (Suppl I): i1-i92

Documents

1 In the Name of God Asthma in Pregnancy Obstetrics and Gynecology Department Hormozgan University of Medical Sciences Presentation by Mitra Ahmad Soltani