Asthma, Adult

Asthma, Adult

Description

• Increased expiratory resistance:




• Bronchospasm


• Airway inflammation


• Mucosal edema


• Mucous plugging




• Consequences:




• Air trapping


• Increased dead space


• Hyperinflation




• Risk factors for life-threatening disease:




• Prior intubations


• Intensive care unit admissions


• Chronic steroid use


• Hospital admission for asthma during the past year


• Inadequate medical management


• Increasing age


• Ethnicity (African Americans)


• Lack of access to medical care

Etiology

Mechanism

• Pollen


• Dust mites


• Molds


• Animal dander


• Other environmental allergens


• Viral upper respiratory infections


• Occupational chemicals


• Tobacco smoke


• Environmental change


• Cold air


• Exercise


• Emotional factors


• Drugs:




• Aspirin


• NSAIDs


• Beta-blockers

Diagnosis

Signs and Symptoms

• Wheezing


• Dyspnea


• Chest tightness


• Cough


• Tachypnea


• Tachycardia


• Respiratory distress:




• Posture sitting upright or leaning forward


• Use of accessory muscles


• Inability to speak in full sentences


• Diaphoresis


• Poor air movement




• Altered mental status

Essential Workup

• Primarily a clinical diagnosis


• Measure and follow severity with peak expiratory flow rate (PEFR)


• Assess for underlying disease


• Pneumonia:




• Pneumothorax

Tests

Lab

• Arterial blood gas:




• Not helpful during the initial evaluation


• The decision to intubate should be based on clinical criteria.


• Mild-moderate asthma: respiratory alkalosis


• Severe airflow obstruction and fatigue: respiratory acidosis




• Pulse oximetry:




• Less than 90% is indicative of severe respiratory distress


• Patients with impending respiratory compromise may still maintain saturation above 90% until sudden collapse.




• WBC:




• Leukocytosis is nonspecific


• Pneumonia


• Chronic steroid use


• Stress of an asthma exacerbation


• Demargination occurs after administration of epinephrine and steroids.

Imaging

• Peak expiratory flow rate:




• Estimates the degree of airflow obstruction:




• Normal peak flow in an adult is 400–600


• Between 100 and 300 indicates moderate airway obstruction.




• Use serially as an objective measure of the response to therapy






• Forced expiratory volume (FEV):




• More reliable measure of lung function than PEFR


• More operator dependent


• Difficult to use as a screening tool


• Often unavailable in the ED


• Severe airway obstruction: FEV₁ less than 30–50%




• Chest radiograph:




• Indications:




• Fever


• Suspicion of pneumonia


• Suspicion of pneumothorax or pneumomediastinum


• Foreign body aspiration


• First episode of asthma


• Comorbid illness


• Diabetes


• Renal failure


• AIDS


• Cancer




• Findings:




• Hyperinflation


• Scattered atelectasis






• ECG:




• Indicated in patients at risk for cardiac disease:




• Dysrhythmias


• Myocardial ischemia




• Transient changes in severe asthma:




• Right axis deviation


• Right bundle branch block


• Abnormal P waves


• Nonspecific ST-T wave changes

Differential Diagnosis

• Congestive heart failure


• Myocardial ischemia


• Pulmonary embolus


• Pneumonia


• Bronchitis


• Bronchiolitis


• Croup


• Foreign body aspiration


• Upper airway obstruction


• Angioedema


• Allergic reaction


• Chronic obstructive pulmonary disease


• Chronic cor pulmonale


• Chemical pneumonitis


• Carcinoid tumors


• Smoke inhalation


• Immersion injury


• Venous air embolus

Treatment

Pre Hospital

• Recognize the ‘quiet chest’ as respiratory distress.


• Supplemental oxygen


• Continuous nebulized β2-agonist


• Administration of subcutaneous epinephrine


• Severe disease with decreased breath sounds

Initial Stabilization

• Immediate initiation of inhaled β2-agonist treatment


• Intubate for fatigue and respiratory distress.


• Steroids

ED Treatment

β2Adrenergic Agonist

• Mild-moderate asthmatic:




• Administer every 20 minutes




• Severe asthmatic:




• Continuous nebulized treatment




• Selective β2-agonists (albuterol)


• Subcutaneous β-agonist:




• Severe exacerbations


• Limited inhalation of aerosolized medicine


• More side effects because of systemic absorption:




• Tachycardia


• Tremors




• Relative contraindications: age >40 years and coronary disease




• 
  Corticosteroids:
  




• Reduce airway wall inflammation


• Administered early


• Onset of action may take 4-6 hours


• Administer intravenously or orally


• IV Solu-Medrol in the treatment of severe asthma exacerbation


• Mild-moderate exacerbations may be treated with oral prednisone.


• Inhaled corticosteroids are currently not recommended as initial therapy.




• Oxygen:




• Maintain an oxygen saturation above 90%




• Aminophylline:




• Rare utility in acute management


• Toxicity:




• Nausea


• Tremor


• Anxiety


• Palpitations


• Tachycardia






• Anticholinergic agents:




• If minimal response to initial β2-agonist treatment


• Severe airflow obstruction


• Inhaled anticholinergic agents should be used in conjunction with β2-agonists.




• Magnesium sulfate:




• No benefit in mild-moderate asthma


• Benefit of magnesium remains unclear in severe asthma




• Heliox:




• Mixture of helium and oxygen (80:20, 70:30, 60:40)


• Less dense than air


• Decrease airway resistance.


• Decrease in respiratory exhaustion


• Not currently recommended for routine use:




• Consider in severe asthma






• Ketamine:




• Bronchodilator and an anesthetic agent


• Useful as an induction agent during intubation


• Contraindications:




• Hypertension


• Coronary disease


• Pre-eclampsia


• Increased intracranial pressure






• Halothane:




• Inhalation anesthetics are potent bronchodilators.


• Refractory asthma in intubated patients




• Intubation of the asthmatic patient:




• Rapid sequence intubation:




• Lidocaine to attenuate airway reflexes


• Etomidate or ketamine as an induction agent


• Succinylcholine should be administered to achieve paralysis.


• A large endotracheal tube >7 mm should be used to facilitate ventilation.


• May need to mechanically exhale for the patient


• Permissive hypercapnia

Medication (Drugs)

• β2-agonists




• Albuterol: 2.5 mg in 2.5 mL normal saline q20min inhaled (peds: 0.1-0.15 mg/kg/dose q20min [minimum dose 1.25 mg])


• Epinephrine: adult: 0.3 mg (1:1,000) SC q0.5h-q4.0h × three doses (peds: 0.01 mg/kg up to 0.3 mg SC)


• Terbutaline: 0.25 mg SC q0.5h × two doses (peds: 0.01 mg/kg up to 0.3 mg SC)




• Corticosteroids:




• Methylprednisolone: 60-125 mg IV (peds: 1-2 mg/kg/dose IV or PO q6h × 24 hours)


• Prednisone: 40-60 mg PO (peds: 1-2 mg/kg/day in single or divided doses)




• Anticholinergics




• Ipratropium bromide: 0.5 mg in 3 mL NS q1h × three doses




• Magnesium: 2 g IV over 20 minutes


• Aminophylline: 0.6 mg/kg/h IV infusion


• Rapid sequence intubation:




• Etomidate: 0.3 mg/kg, or ketamine: 1-1.5 mg/kg


• Lidocaine: 1-1.5 mg/kg


• Succinylcholine: 1.5 mg/kg

Follow-Up

Disposition

Admission Criteria

• Persistent respiratory distress


• PEFR


• Intubated patients

Medical Wards or Observation Unit

• PEFR


• Patients without subjective improvement


• Patients with continued wheeze and diminished air movement


• Patients with moderate response to therapy and no respiratory distress:




• Factors that should favor admission


• Prior intubation


• Recent ED visit


• Multiple ED visits or hospitalizations


• Symptoms for more than 1 week


• Failure of outpatient therapy


• Use of steroids


• Inadequate follow-up mechanisms


• Psychiatric illness




• Complications:




• Pneumothorax


• Pneumomediastinum


• Pneumonia


• Fatigue

Discharge Criteria

• Patient reports subjective improvement


• Clear lungs with good air movement


• PEFR or FEV₁ greater than 70% of predicted


• Peak flow should be greater than 300.


• Adequate follow-up within 48–72 hours

References

1. Corbridge TC, Hall JB. The assessment and management of adults with status asthmaticus. Am J Respir Crit Care Med. 1995;151:1296-1316.

2. Guidelines for the diagnosis and management of asthma: National Asthma Education Program Expert Panel Report. Bethesda, MD: Department of Health and Human Services; 1991. NIH 91-3042.

3. Jagoda A, Shepherd SM, Spevitz A, et al. Refractory asthma, part 1: epidemiology, pathophysiology, pharmacologic interventions. Ann Emerg Med. 1997;29:262-274.

4. Jagoda A, Shepherd SM, Spevitz A, et al. Refractory asthma, part 2. Airway interventions and management. Ann Emerg Med. 1997;29:275-281.

5. Manthous CA. Management of severe exacerbations of asthma. Am J Med. 1995;99:298-308.

Codes

ICD9-CM

493

ICD10

J45.9

Adult Onset Asthma: The Unknown Causes

The onset of asthma in adults may appear in the most unexpected moments. Whether you are 20 years or asthma than ever to work with less breath, swelling of the lining of the airways, coughing, wheezing and pain of these irritants in your chest? You may have asthma. The difference between asthma and adult asthma in children is that while the symptoms of asthma can be for children to come and go, the symptoms of asthma in adults may be continuous, requiring medication regularly to control the disease. This article covers all the necessary things you need to know about asthma.

Onset of asthma. People who are capable of this type of illness, women with hormonal changes, such as pregnant women and women in transition. It also includes women taking estrogen after menopause, but a cold or flu obese people. People with allergies develop asthma and allergies, such as cats, and humans are constantly exposed to environmental irritants such as tobacco, snuff, tobacco, mold, dust, feather beds and perfumes which can act as triggers of the disease. These are the reasons that adults often overlook. We always think they do very little for our health, but actually lead to serious consequences, especially with his appearance.

The value of Asthma

Onset of asthma. Knowing the symptoms is to avoid damage. Symptoms should be known for a more effective treatment. The airways of the lungs are regularly checked and monitored, so the medicine can adapt to changes in the level of activity in the airways of the lungs. Diabetes, asthma can lead to thickening of the lining of the airways of the lungs, increased production of large amounts of mucus, thicker than normal production would lead to narrowing of the airways in the lungs by the muscular contraction.

These physiological changes may include trouble breathing, coughing, especially at night, wheezing, difficulty breathing and even frequent chest pain. Asthma can be based on a story, because it can be genetically acquired, after the doctor listen to you breathing, perform a lung function test, a test to meth choline and the doctor diagnosed a chest x ray results. Read more about this condition ensures that you do not do the wrong thing.

Diabetes, asthma can be fatal in extreme cases. It is very important to control your symptoms and your doctor to help create an action plan called asthma. Based on the history and the severity of your condition, the action plan anchored properties. Your action plan describes when and how the drugs we use, the procedures to take when your asthma is getting worse should be strong, and provides information on when needed and who is seeking care during the emergency. Make sure your plan and do not forget your trusted supplier to asthma. Though it sounds cliché, but remembers, it is true that health is wealth. Onset of asthma.

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