Pharmaco2 asthma

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Transcript of Pharmaco2 asthma

  • 1. MANAGEMENT
    • A&E

2. 9:30 am

  • BP 140/83, HR 87bpm, spO 295%, T 36.4C
  • Generalised rhonchi
  • Plan
    • IV HCT 200mg stat given @ 9:35am.
    • Neb. Combivent
    • PEFR

3. 10:10am

  • Speak in full sentence
  • PEFR 300L/min, RR 30/min, O 2sat 98%
  • Generalized rhonchi
  • Plan
    • ABG
    • CXR
    • Cont neb

4. 10:26am

  • VBG?
    • pH: 7.377
    • pCO 2 : 42.0mmHg
    • pO 2:30.6mmHg
    • Base: -0.4
    • HCO 3 : 22.9mmol/L
  • WBC: 8.8x10 9 /L
  • Lymph#: 3.2x10 9 /L
  • Gran#: 4.8x10 9 /L
  • Lymph%: 35.8%
  • Gran%: 54.1%
  • Hb: 16.5 g/dL
  • RBC: 5.13x10 12 /L
  • HCT: 47%
  • MCV: 91.8fL
  • MCH: 32.1pg
  • MCHC: 35.1 g/dL
  • Plt: 252x10 9 /L

5. 6. 7. 11:30am

  • BP 140/83; HR 87bpm; T 37C; spO 295%RA, 98% NPO 23L/min
  • O/E generalized rhochi
  • Plan
    • Admit 7S
    • Cont a/b (h/o admission for similar problem 10 days ago)
      • T azithromycin 500mg od
      • IV claforan 1g tds
    • NPO 23L/min
    • Neb combivent 4hourly
    • IV HCT 100mg qid
    • ABG RA

8. 11:30am

  • ABG
    • pH 7.498
    • pCO2: 29.4mmHg
    • pO2: 147mmHg
    • HCO3: 25.2mmol/L
    • Base: -0.3mmol/L
  • CXR
    • Hyperinflated lungs
    • Bilateral lung hazziness
  • Coagulation profile
    • PT: 13.2s (11.9 13.9)
    • INR: 1.01 (0.86 1.14)
    • aPTT: 40.5s (control 37.9)
  • BUSE/creat
    • Na: 139mmo/L
    • K: 4.1mmol/L
    • Creat: 106umol/L
    • Urea: 2.7mmol/L
    • Cl: 108mmol/L

9. MANAGEMENT

  • Medical ward

10. 3:20pm

  • Assessment: infective exarcebation COPD
    • Partially treated pneumonia
    • Haemodynamically stable
    • Not in respiratory failure
  • Investigations: FBC, BUSE/creat, LFT, aPTT/INR, ESR, ECG, sputum C+S, sputum AFB (D/S x3, C+S)

11. Plan

  • Strict I/O, encourage orally
  • IVD 2 NS/24hrs
  • Antibiotic
    • IV claforan 2g stat & 1g tds
    • T azithromycin 500mg stat & OD
  • Acute reliever
    • Neb combivent hourly x2 then 2hourly x2 then 6hourly
    • Monitor BUSE/creat on neb combivent
    • PEFR
  • Controller
    • IV HCT 200mg stat & 100mg qid
  • Chest physiotherapy
  • Stop smoking education

12. 11:40pm

  • Plan
    • Refer quit smoking clinic
    • Increase neb combivent 4hourly
    • Continue a/b
    • Continue IV hydrocort
    • Inhaler technique
    • MDI becotide 2puffs bd
    • MDI combivent 2puffs tds

13. PEFR chart L/min TimeDay 1 Day 2 day3 day4 14. DIAGNOSING ASTHMA 15.

  • Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors.

16.

  • Symptoms & medical history
  • Lung function
    • Spirometry
    • PEF
  • Additional diagnostic tests
    • Airway responsiveness
    • Skin tests with allergens or measurement of specific IgE in serum

17. MANAGEMENT

  • Exacerbations

18. 19. 20. 21. 22. Prompt tx

  • Inhaled rapid-acting 2 -agonists in adequate doses are essential.
    • begin with 2 to 4 puffs every 20 minutes for 1 sthour;
    • then mild exacerbations will require 2 to 4 puffs every 3 to 4 hours, and
    • moderate exacerbations 6 to 10 puffs every 1 to 2 hours.
  • Oral glucocorticoids (0.5 to 1 mg of prednisolone/kg or equivalent during a 24 hr period) introduced early in the course of a moderate or severe attack.
  • O 2is given if patient is hypoxemic (achieve O 2saturation of 95%).

23. Prompt tx

  • Combination 2 -agonist/anticholinergic therapy is associated with lower hospitalization rates.
  • Methylxanthines are not recommended if used in addition to high doses on inhaled 2 -agonists.

24.

  • Monitor response to tx
    • Evaluate symptoms, peak flow, O 2saturation
  • After exacerbations is resolved
    • Identify precipitating factors
    • Implement avoidance strategies
    • Review pts medication

25. MANAGEMENT

  • Ward

26.

  • Continue oxygen > 40%
  • IV HCT 100-200 mg 6 hourly or prednisolone 30-60 mg daily.
  • Neb 2 -agonist 2-4 hourly preferably in combination with anticholinergic.
  • If patient is still not improving, commence aminophylline infusion (0.5-0.9 mg/kg/hour); monitor blood levels if aminophylline infusion is continued for more than 24 hours.
  • Terbutaline or salbutamol infusion at 3-20 mcg/min after an initial IV bolus dose of 250 mcg over 10 mins can be given as an alternative.
  • In cases where response to the above treatment is inadequate, IV MgSO 42 g in 50 ml NS infused over 10-20 mins may be given.

27. Monitoring the response to treatment

  • Repeat measurement of PEF 15-30 minutes after starting treatment.
  • Aim to maintain arterial oxygen saturation above 92%.
  • Repeat arterial blood gas measurements if initial results are abnormal or if patient deteriorate.
  • Monitor PEF at least 4 times daily throughout the hospital stay.
  • Other I(x):
    • BUSE
    • ECG if indicated

28. Transfer pt to ICU or prepare to intubate if there is:

  • Deteriorating PEF
  • Worsening hypoxaemia, or hypercapnia
  • Exhaustion or feeble respiration
  • Confusion or drowsiness
  • Coma or respiratory arrest

29. MANAGEMENT

  • ICU

30.

  • Cont O 2
  • Cont IV HCT
  • If the patient is mechanically ventilated, administer neb 2 - agonist with anticholinergic via the ETT. This can be given up to every 15-30min.
  • IVI aminophylline or terbutaline or salbutamol should be continued
  • IVI MgSO 4may be added.

31. DISCHARGE PLAN FOR HOSPITALISED PATIENT

  • Before discharge, the patient should be:
    • started on inhaled steroids for at least 48 hours in addition to a short course of oral prednisolone and bronchodilators
    • Stable on the medications he is going to take outside the hospital for at least 24 hours
    • Having PEF of > 75% of predicted or best value and PEF diurnal variability of < 20%
    • Able to use the inhaler correctly and if necessary, alternative inhaler devices could be prescribed
    • Educated on the discharge medication, home peak flow monitoring and self
    • Management plan (for selected, motivated patients), and the importance of regular follow up
    • Given an early follow-up appointment within 2-4 weeks for reassessment of the condition and for adjustment of the medicines