status asthmaticus - critical careold.criticalcare.org.za/images/15h05_giles_fri_plenary.pdf ·...
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Status Asthmaticus
B. Louise Giles MD FRCPC
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Status Asthmaticus: Objectives VTAS 2015
• Define status asthmaticus
• Describe the problem (epidemiology)
• Understand the pathophysiology of status asthmaticus
• Know the treatment options
• Have an understanding of status asthmaticus management outside the guidelines
• Have an understanding of prevention strategies, and the barriers to treatment
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Disclosures VTAS 2015
• Chair: Comer Children’s Hospital Asthma Quality Committee
• Member: AsthmaNet
• Member: CAPriCORN
• Member: CHICAGO 1 trial
• No financial interests
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Scenario 1 VTAS 2015
• 3 yo Caucasian female
• PMHx of mild asthma – no prior exacerbations
• ED: 1-2 day hx of viral URTI (cough, rhinorrhea, worsening dyspnea)
– Tachypneic (RR >40), hypoxic (SpO2 85%)
– “silent chest”
– Management: β2 agonist; Steroids; Mg; ipratropium bromide
– BiPAP initiated
• PICU: Type 2 respiratory failure (pCO2 > 50)
– Intubated, ventilated
– Systemic β2 agonist; aminophylline
– Anesthesia (ketamine; inhaled)
– ECMO
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Scenario 2 VTAS 2015
• 15 yo African American male
• PMHx of severe asthma – previous PICU admissions
• Has not seen a Respirologist; non-compliant with “controller” medication; takes SABA
daily
• S/S of viral URTI <12 hours; increases use of SABA
• Parent decides to take to local ER
• Collapses
• No pulse, CPR initiated, EMS activated
• Asystole. Full resuscitation including epinephrine, CPR
• Resuscitation - unsuccessful
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What is this… VTAS 2015
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Asthma: A review VTAS 2015
Chronic illness Narrow airways
Most often starts in childhood
Wheeze, cough,
chest tightness,
short of breath
Mild - Severe
Treatment
multi-modal
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Asthma: USA VTAS 2015
• Asthma in USA
• >10 million children have asthma; 25 million overall
• Death rate increasing (in children)
• Nine Americans die daily from Asthma
• >2/3 have had an asthma exacerbation in the past 12 months
• Leading cause of school absence (>14 million school days lost/year)
• Costs 5-14% of income to the family
• Highest prevalence in African American children
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Asthma: Chicago VTAS 2015
• Asthma in Chicago
• Mortality due to asthma 5x higher in African American (non-Hispanic vs. White non-
Hispanic)
• Hospitalization rate double national average
• >50% of children with asthma had exacerbation in the past year
• 28%of people with asthma awoken with breathing problems weekly
• Almost 60% of children with asthma live with a smoker
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Asthma: South Africa VTAS 2015
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• Mortality: One of the highest reported mortality rate worldwide (GINA)
• ~3.9 million South Africans with asthma
• ~20% of school age children have asthma
• 3rd most common cause of hospital admissions in children
• Treatment & education is key
– Estimated only ~2% receive treatment
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Asthma – worldwide prevalence VTAS 2015
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Asthma deaths - worldwide VTAS 2015
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Status Asthmaticus VTAS 2015
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Asthma exacerbations VTAS 2015
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Status asthmaticus VTAS 2015
• Acute
• Doesn’t respond to the “standard” treatment (SABA & ICS)
• Leads to …
– Respiratory insufficiency
– Circulatory failure
• Pathophysiology:
– Bronchoconstriction
– Mucous plugging
– Airways inflammation
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Status asthmaticus VTAS 2015
• Type I (Slow onset)
– Inadequate treatment (provider, patient, other)
– Poor control
– Progressive – already using SABA’s
– Poor response
• Type II (Rapid onset)
– Sudden, occurs within hours
– Severe bronchospasm, minimal inflammation & edema
– “Silent chest”
– Responds quickly
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Status asthmaticus VTAS 2015
• Complications:
– Airleak (↑ intrathoracic pressure)
– Myocardial infarction (hypotension, ↑ intrathoracic pressure)
– Atelectasis (mucous plugging)
– Electrolyte disorders (salbutamol)
– Myopathy & rhabdomyolysis (steroids & neuromuscular blockers)
– Lactic acidosis (cell injury)
– Anoxic brain injury
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What are the guidelines for management VTAS 2015
• Overall …. Prevention
For exacerbation/status asthmaticus
• Supplemental oxygen – correct hypoxemia
• Short acting β2 agonists – bronchodilation
• Inhaled anti-cholinergics – bronchodilation
• Systemic steroids – anti-inflammatory
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But what if they “don’t work?” VTAS 2015
• Systemic bronchodilators
• High flow O2
• Anesthetics
• Heliox
• NIPPV
• Intubation/mechanical ventilation
• Inhalational anesthetics
• ECMO
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Systemic bronchodilators VTAS 2015
• β2 agonists: IV salbutamol; terbutaline
• Magnesium
• Methylxanthines
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Mechanism of action of bronchodilators VTAS 2015
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B2 – increases cAMP
A2 – prevents AcH release
MA– block AcH
XO – prevent breakdown
cAMP
Mg– block Ca; inhibit
AcH release
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High Flow Oxygen (HFO)/High Flow Nasal Cannula (HFNC) VTAS 2015
• Delivery of oxygen at a rate that exceeds patients inspiratory flow
• Air/oxygen blend; Heated, humidified (37C; 100%); delivery tube heated
• Nasal cannula (ensure that occlusion of nares <50%)
• Flow rates up to 60 lpm (usual nasal airflow adults ~ 12 lpm at rest; 30 lpm with
respiratory distress)
• Benefits:
– Increased FiO2
Anatomic O2 reservoir
Wash out dead space
– CPAP effect
• Decrease atelectasis
• Decrease WOB/intrinsic PEEP
– Patient comfort
• Tolerated as heated, humidified
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Heliox VTAS 2015
• Mixture of helium with oxygen (20-40%)
• Lower resistance – less turbulent airflow
• Helpful to bring inhaled medication to lower airways
• No evidence that this works…
– If hypoxic, not really helpful as need enough supplemental O2 (if FiO2
requirements >40%, shouldn’t use)
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BiPAP VTAS 2015
• Reduces work of breathing/dyspnea
– Helps with auto-PEEP
– iPAP relieves work against airway resistance
• Retains spontaneous breathing
– Reduces intubation
• Retains cough
• Comfort
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Intubation/mechanical ventilation VTAS 2015
• Oxygenate/ventilate
• Minimize barotrauma
– PRVC mode
– Know the auto-PEEP
– VT 5ml/kg (start) & watch the auto-PEEP
– Set PEEP to match auto-PEEP
– RR – must allow for full expiration- may mean lower RR (resist temptation to
increase the rate)
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Meds “outside” the box VTAS 2015
• NaHCO3:
– Correct metabolic acidosis
– No clinical trials examining use
• Ketamine:
– Inhibits re-uptake of norepinephrine
– May be used to prevent intubation – low dose
– No clinical trials examining use
• Inhalation anesthetics:
– Halothane, sevoflurane & isoflurane
– Lowers vagal tone
– No clinical trials examining use
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ECMO VTAS 2015
• “Hail Mary” – rescue & nothing to lose
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http://www.pic2fly.com/ECMO+Machines.html
Improved survival (>80% for asthma
vs.~50% non-asthma respiratory
failure)
No guidelines
Case studies suggest that early use
may be beneficial
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Prevention VTAS 2015
• All patients who have been in an ICU with asthma – Respirologist/Pulmonologist
– If intubated for asthma – increased mortality due to asthma for 10 years!
• Education is key… and South Africa has asthma education resources!!
– National Asthma Education Programme (www.asthma.co.za)
– Asthma Action Plans (USA –tracks hospital rates of providing an asthma action
plan or home management plan of care & this is a mandatory reportable QI
measure)
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Barriers to prevention VTAS 2015
• Education
– “I can’t have asthma”
• Feels better
– “I don’t have symptoms anymore so I don’t need medicines”
• Poor perceiver of symptoms
– “I don’t have symptoms”
• Economics
– “I can’t afford my medications”
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Resources VTAS 2015
• Status Asthmaticus:
– Curr Opin Pulm Med, 2008;14:13-23
– Paed Resp Rev, 2013 Jun;14(2):78-85
• BiPAP:
– Curr Opin Pulm Med, 2014; 20(1):118-123
– Cochrane Rev, 2012; 12
• ECMO:
– J. Med Cases, 2011: 2(3):124-126
– J.Asthma, 2011; 48:111-113
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Thank you VTAS 2015
• Our Challenge – prevention!
• Questions?
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Thank you VTAS 2015
• Our Challenge – prevention!
• Questions?
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