Acute Management of Bronchial Asthma 2

8/3/2019 Acute Management of Bronchial Asthma 2

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Acute Exacerbation of Bronchial

AsthmaBy Tengku Abdul Kadir B Tengku

Zainal Abidin.


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A&E HSNZ at 7:30pm


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CASE STUDY

Elisya, a 5 year old girl with underlying bronchialasthma since 1 yo on MDI Budesonide 200 mcg BDand MDI Salbutamol 2 puffs PRN came with c/o

rapid breathing since 3 pm today


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The parents brought the patient to KK

Seberang Takir at 5 pm after the symptoms

were not relieved after taking 4 puffs of MDI

salbutamol. At KK Seberang Takir, she was

given neb Ventolin x 2, but still had rapid

breathing thus was referred to HSNZ


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What further questions do you want to ask ?

What are the differential diagnoses? What are you going to do next?


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From the hx, there is no URTI sx, no

fever, patient was still active andtolerating orally well before the

episode of rapid breathing

Patient had hx of visiting her uncle

today at 2pm and was exposed to

cigarette smoke from her uncle. She

developed rapid breathing after

that.


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Interval symptoms

Last exacerbation was in November last year

No nocturnal cough

No daytime symptoms No need for reliever since last exacerbation

Patient was active, no exercise induced sx

Symptoms usually precipitated by URTI, coldweather or exposure to cigarette smoke


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From the physical examination, patient was alert, goodcry, mildly tachypnoeic with mild subcostal recession,pulse volume good and capillary refill immediate

Vital signs:

BP 98/50 HR 110

RR 40

spO2 97% under NPO2 2L/min

Lungs: A/E equal, PEP, no crepts, bilateral rhonchi CVS: S1S2 No murmur

PA: Soft, not distended, non tender


9/21

This patient was given neb Ventolin x 1. 1 hour

post neb, patient still had rapid breathing but

she was less tachypnoeic and was able to talk

to her mother

i i i


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Do you want to a mit t is c i


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Criteria for admission

failure to respond to standard home treatment

failure of those with mild or moderate acute

asthma to respond to nebulised -agonists

relapse within 4 hours of nebulised -agonists

severe acute asthma


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In 6EF, patient was put under NPO2, was

given neb Ventolin 2 hourly, neb Combivent

4hourly, IV Hydrocortisone 4mg/kg stat then

qid for one day

Patients condition improved after 4hours, was

less tachypnoeic, able to tolerate orally and

able to sleep comfortably. The lungs hadminimal rhonchi with no crepitations.


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Initial steps for assessment

Diagnosis

- symptoms e.g. cough, wheezing, breathlessness,pneumonia

Triggering factors- food, weather, exercise, infection, emotion, drugs,aeroallergens

Severity- respiratory rate, colour, respiratory effort,conscious level


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Ref: Paediatric Protocol 2nd Edition Page:95


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Management Consideration

monitor pulse, colour, PEFR, ABG and SpO:

close monitoring for at least 4 hours

hydration - give maintenance fluids

antibiotics indicated only if bacterial infection

suspected

avoid sedatives and mucolytics


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Ref: Paediatric Protocol 2nd

Edition Page:96


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Medication given


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On discharge, patients must be provided with

an Asthma Action Plan to assist parents or

patients to prevent/terminate asthma attacks.

The plan must include:

- how to recognize worsening asthma

- how to treat worsening asthma

- how & when to seek medical attention


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Take home message

Good initial assessment based on diagnosis,

triggering factors and severity

Initial treatment with oxygen and medication

Discharge patient with Asthma Action Plan


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References

Paediatric Protocol For Malaysian Hospitals 2ndedition

GINA guidelines of Bronchial Asthma

Classifying Asthma Severity and TreatmentDeterminants : National Guidelines Revisitedby R Khajotia MBBS (Bom), MD (Bom), MD

(Vienna), FAMA (Vienna), FAMS (Vienna).International Medical University, Seremban,Malaysia


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THANK YOU!

ANY QUESTIONS? NO? GOOD!

Acute Management of Bronchial Asthma 2

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