Asma Acute Attack Gabungan

8/8/2019 Asma Acute Attack Gabungan

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HEDA MELINDA NATAPRAWIRA

RESPIROLOGY DIVISION DEPARTEMENT OF CHILD HEALTH

PADJADJARAN UNIVERSITY ± HASAN SADIKIN HOSPITAL

RESPIRATORY DISTRESS

IN CHILDHOOD ASTHMA



Asthma is a chronic inflammation Asthma is a chronic inflammation

Asthma Asthma Respiratory distr essRespiratory distr ess

Asthma attack (acute exacerbation) Asthma attack (acute exacerbation)followed by r espiratory distr essfollowed by r espiratory distr ess

Pulmonary function tests (PEFR, FEVPulmonary function tests (PEFR, FEV11)) Asthma attack (acute exacerbation) Asthma attack (acute exacerbation) lif e lif e

savingsaving



S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)S ALUR AN NAF AS ANAK NORM AL (BUKAN ASM A)

Tetap lebar(tidak rentan, tidak sensitif ,

tidak mudah goncang, stabil)



S ALUR AN NAF AS ANAKS ALUR AN NAF AS ANAK

AS

M A AS

M A

S ALUR AN NAF AS ANAKS ALUR AN NAF AS ANAK

AS

M A AS

M A

Tidak timbul ser angan Timbul ser angan

Otot salur an nafas mengkerut

Salur an nafas menebal/membengka

Lendir lebih banyak dan kental/leng

Hiperreaktif :

Sangat rentan

Sangat sensitif

Mudah mengkerut



INFLAMASIINFLAMASIDeskuamasi epitel

Mucus plug

Penebalan

membrana basalis

Infiltrasi neutrofil dan

eosinofilHipertrofi dan konstriksi

otot polos

Edema

Hiperplasi

kelenjar mukus

Barnes PJ



Fatal asthma is combination obstructive Fatal asthma is combination obstructive

and hipertrophy airwaysand hipertrophy airways

Autopsy in adults and childr en Autopsy in adults and childr en Biopsy of sever e asthmaBiopsy of sever e asthma Fatal asthmaFatal asthma

LongLong--term tr eatmentterm tr eatment = pulmonary function= pulmonary function



Both parent noallergies

One sibling with allergy

One parent with allergy

Both parent with allergies

10 %risk of allergy

20-30 %risk of allergy

20-40 %risk of allergy

60% - 80 %risk of allergy

Koning,1996; Bousquet,2002Sensitivity 61 %;Specificity 83%

Genetic FactorsGenetic Factors A Positive family history for allergy A Positive family history for allergy

Risk of allergyRisk of allergy

74



Clinical findingsClinical findings

Sever e asthmaSever e asthma

attackattack

Coughwheezing

silent chest sever e obstruction

Tachypnea, Dyspnea, Retractions, Nasal flar eTachypnea, Dyspnea, Retractions, Nasal flar e

Wheezing, Sweating, ExhaustedWheezing, Sweating, Exhausted

Agitation, Cyanosis, Coma Agitation, Cyanosis, Coma

Tripod sitting positionTripod sitting position

Pulsus paradoxusPulsus paradoxus



ComplicationsComplications

Atelectasis Atelectasis

PneumomediastinumPneumomediastinum

Tension pneumothoraxTension pneumothorax

PneumoniaPneumonia

DehydrationDehydration Abnormal secr etion of ADH Abnormal secr etion of ADH

Theophyllin overdoseTheophyllin overdose

Respiratory failur eRespiratory failur e



Severity asthma attackSeverity asthma attack

Acute sever e asthma attack Acute sever e asthma attack

Lif e thr eatened asthmaLif e thr eatened asthma

WheezingWheezing

Retractions, pulse rateRetractions, pulse rate

Pulsus paradoxusPulsus paradoxus

CyanosisCyanosisPEFR, OPEFR, O22 saturationsaturation



Acute sever e asthma attack Acute sever e asthma attack

--To tight to eat/speakTo tight to eat/speak

RetractionsRetractions

RR > 50 x/minuteRR > 50 x/minute

Pulse rate > 140 x/minutePulse rate > 140 x/minute

PEFR < 50%PEFR < 50%



Lif e thr eatened asthmaLif e thr eatened asthma

Decr ease of consciousness/agitationDecr ease of consciousness/agitation

ExhaustedExhausted

Br eathlessnessBr eathlessness

OO22 saturation < 85%saturation < 85%Silent chestSilent chest

PEFR 33%PEFR 33%



Table 1 Peak Expiratory Flow Rate inTable 1 Peak Expiratory Flow Rate in

Childr enChildr en

Height (cm)Height (cm) PEFR (L/minute)PEFR (L/minute)

110110

120120

130130

140140

150150

160160

170170

150150

200200

250250

300300

350350

400400

450450



Patient with asthma who has a high risk of Patient with asthma who has a high risk of

having a heavy acute asthma attack that couldhaving a heavy acute asthma attack that couldbe lif e thr eatening ar e those with :be lif e thr eatening ar e those with :

-- A history of lif e thr eatening A history of lif e thr eatening

-- asthma attackasthma attack-- Intubation caused by acute asthma attackIntubation caused by acute asthma attack

--Pneumothorax and/or pneumomediastinumPneumothorax and/or pneumomediastinum



-- Long periodic syndrome Long periodic syndrome

-- last one year last one year -- Low compliance of medicationLow compliance of medication

-- Misunderstanding or unknowingnessMisunderstanding or unknowingness

of the

definition of of th

ed

efinition of

-- asthmaasthma

-- A visit to the Emergency Room or A visit to the Emergency Room or being hospitalized for the being hospitalized for the

-- Psychological disorder or PsychosocialPsychological disorder or Psychosocialproblemsproblems



Devices to assess the severity of asthma attackDevices to assess the severity of asthma attack ::

Spyrometer Spyrometer

Accurate Accurate Easy to use Easy to use

Rar ely found in the Rar ely found in the Emergency RoomEmergency Room

Peak Flow meter Peak Flow meter

SimpleSimple Resemble the caliber of the Resemble the caliber of the

r espiratory tractr espiratory tract

Used to assess the severityUsed to assess the severityof obstructionof obstruction

Assess PEFR which r elated Assess PEFR which r elatedwith FEVwith FEV1 1

PEFR is not always r elatedPEFR is not always r elatedwith the severity of with the severity of obstructionobstruction Needs a Needs a

good technique andgood technique andcooperation with patientcooperation with patient



The newest objective assessment is by using the Pulmonal Index Scor e (PIS)The newest objective assessment is by using the Pulmonal Index Scor e (PIS)

(table below) which has a good corr elation with APE on a child with mild to(table below) which has a good corr elation with APE on a child with mild to

sever e acute asthma attack.sever e acute asthma attack.

Scor eBr eathe

<6 years

Fr equency

>6 yearsWheezing

The use of additional

r espiratory muscle

(M.sternocleidomastoideus

activity )

0 <30 <20 None No activity

1 31-45 21-35End of

expiration

Incr ease, questionable with

stethoscope

2 46-60 36-50 All expirationIncr ease, clearly with

stethoscope

3 >60 >50Inspiration +

Expiration

Max. activity without

stethoscope

Table.2 Pulmonal Index Scor e

Scor e 3 = Mild attack If ther e isn¶t any wheezing because of

4-6 = Moderate attack minimum air exchange (weak), thus

> 6 = Sever e attack scor e = 3



Table.3 Assessment of the severity of Asthma Attack

Clinical parameter , lung function, laboratory

Mild Moderate Sever e Respiratory Arr est

Br eathless If walkingBaby : cries hard

TalkingBaby :-Short and weak

cries-Difficulty oneating/br eastf eeding

RestingBaby :Doesn¶t want to eat /

drink

Position Could lay down Pr ef er to sit Sit with handsupport

Talking Phrases Piece of phrases words

Consciousness Maybe I rritable Usually I rritable Usually I rritable Confusion

Cyanoses None None Positive Real

Wheezing Moderate, often atthe end of expiration

Loud, all the way alongexpiration + inspiration

Very loud, could be heard withoutstethoscope

Hard/difficult tohear

The use of additionalr espiratory muscle Usually no Usually yes Yes Thoracoabdominal paradox movement

Retraction Shallow, intercostalr etraction

Mild, in addition withsuprasternal r etraction

Deep, in additionwith nose br eathing

Shallow, lost

Br eathe fr equency Tachipneu Tachipneu Tachipneu Bradipneu



Standard conscious child br eathe fr equencyStandard conscious child br eathe fr equency

Pulse Fr equency Normal Tachycardia Tachycardia Bradycardia

Age Normal br eathe fr equency

< 2 Months < 60 x/minutes

2 ±12 Months < 50 x/minutes

1 ± 5 years < 40 x/minutes


Standard child Pulse fr equency

Age Normal Pulse Fr equency

2 ±1

2 months <16

0x/minut

es



Pulsus Paradoksus

(the examination isnot pactical)

None

< 10 mmHg

Positive

10 ± 20 mmHg

Positive

> 20 mmHg

None, sign of tir ed

r espiratory muscle

PEFR or FEV1

-Pr ebronchodilator -Postbronchodilator

(%suspected value)

> 60%> 80%

40 ± 60%60 ± 80%

Response <2 hours

< 40%< 60%

SaO2 % > 95% 91 ± 95% 90%

PaO2 Normal (doesn¶tneed to examined)

> 60% < 60%

Pa < 45 mmHg < 45 mmHg



Pitfalls inPitfalls in Assessment Assessment of Child Asthmaof Child Asthma

An accurate assessment of severity on An accurate assessment of severity on

child asthma could only be done if child asthma could only be done if

pitfalls pitfalls below could be avoided :below could be avoided : Unlisted anamnesis of pr eviouslyUnlisted anamnesis of pr eviously

asthma attackasthma attack

Does not understand that persistentDoes not understand that persistentcough is a sign of Bronchospasmcough is a sign of Bronchospasm



Does not r ecognized or understand the Does not r ecognized or understand the

child normal vital signchild normal vital sign Inadequate physical diagnosisInadequate physical diagnosis

especially for the r espiratory systemespecially for the r espiratory system

Doesn¶t have the ability to do the LungDoesn¶t have the ability to do the Lungfunction testfunction test

Relying too much on laboratory dataRelying too much on laboratory data

for decision makingfor decision making



Diagnosis on Exacerbation Asthma or Diagnosis on Exacerbation Asthma or

Asthma attack Asthma attack

Inhalation of Inhalation of 2 2 could be use ascould be use asconfirmation on diagnosis and also r educe confirmation on diagnosis and also r educe clinical symptoms (less than 15¶ ~ usually inclinical symptoms (less than 15¶ ~ usually in5¶ ther e is a r educe in bronchoconstriction )5¶ ther e is a r educe in bronchoconstriction )

Laboratory findings doesn¶t support asthmaLaboratory findings doesn¶t support asthma

diagnosisdiagnosis



Radiologic examination does notRadiologic examination does not

needed on first attack of asthmaneeded on first attack of asthma Indication of phototoraks postIndication of phototoraks post

medication is:medication is:

TachypneaTachypneaTachycardiaTachycardia

Wheezing promoted by other cause :Wheezing promoted by other cause :

mycoplasma,viral inf ection, Tracheamycoplasma,viral inf ection, Tracheaobstruction, Mediastinum tumorsobstruction, Mediastinum tumors



Acute Asthma Attack Guidance Acute Asthma Attack Guidance

The purpose of acute asthma attackThe purpose of acute asthma attackguidance ar e :guidance ar e :

Relieve the constriction of the r espirationRelieve the constriction of the r espiration

tract as soon as possible.tract as soon as possible. Reduce Hipoxemia.Reduce Hipoxemia.

Return lung function to its normal state asReturn lung function to its normal state as

soon as possible.soon as possible. Planning on guidance to pr eventPlanning on guidance to pr event

r eccurr ency.r eccurr ency.



Asthma is a chronic inflammatory Asthma is a chronic inflammatory

disorders of the airways in which manydisorders of the airways in which manycells and cellular elements play a rolecells and cellular elements play a role

The chronic inflammatory causes anThe chronic inflammatory causes an

associated incr ease in airwayassociated incr ease in airway

hyperr esponsiveness (HRBhyperr esponsiveness (HRB)) that leads tothat leads to

r ecurr ent episodes of wheezing, r ecurr ent episodes of wheezing,

br eathlessness, chest tightness, andbr eathlessness, chest tightness, and

coughing, particularly at night or in earlycoughing, particularly at night or in earlymorningmorning



Medications that is used to r elieves asthmaMedications that is used to r elieves asthmaattacksattacks OO22, inhaled, inhaled 22--agonist, agonist,

corticosteroids, inhaled anticholinergic, corticosteroids, inhaled anticholinergic, intravenous aminophyllineintravenous aminophylline

OXYGENOXYGEN Ventilation missmatchVentilation missmatch hypoxiahypoxia

Sever e hypoxiaSever e hypoxia no r espons with oxygenno r espons with oxygentherapytherapy complications?complications?

NHLBI NAEPP: ONHLBI NAEPP: O22 11--3 L/ minutes3 L/ minutescontinuous until Pa Ocontinuous until Pa O22 > 92%> 92%



GLUCOCORTICOIDGLUCOCORTICOID

Inflammation pr edominantlyInflammation pr edominantly onlyonly

corticosteroids r educes inflammationcorticosteroids r educes inflammation

dir ectlydir ectly

Pr ednison ( 2 mg/kg, max 80 mg) andPr ednison ( 2 mg/kg, max 80 mg) and

methylpr ednisolonemethylpr ednisolone

Mild RD: oralMild RD: oral

Sever e RD: intravenousSever e RD: intravenous

Inhaled corticosteroids: chronic asthma, Inhaled corticosteroids: chronic asthma,

acute astma attack (controversion)acute astma attack (controversion)



BRONCHODILATORSBRONCHODILATORS

22--agonistagonist drug of choisedrug of choise

Salbutamol ( MDI / nebules)Salbutamol ( MDI / nebules) APE APE 80%80%

continuous every4

hourscontinuous every4

hours Incomplete r esponse Incomplete r esponse continuously or continuously or

intermittent nebulization (every 20 minutes, intermittent nebulization (every 20 minutes,

in 1in 1--2 hours)2 hours)

during medications : Oduring medications : O22

No r esponsesNo r esponses selective selective 22--agonistagonist

intravenousintravenous



Ipratropium Br Ipratropium Br sever e asthma attacksever e asthma attack

NHLBINHLBI--NAEPP 1997 r ecommendation:NAEPP 1997 r ecommendation:additional therapy with albuteroladditional therapy with albuterol

(salbutamol) to r elieves acute asthma(salbutamol) to r elieves acute asthma

attackattack

THEOPHYLLINETHEOPHYLLINE

Rar ely used in acute asthma attack inRar ely used in acute asthma attack in

childr enchildr en

UsedUsed no r esponses with other therapy or no r esponses with other therapy or

sever e cases in PICU)sever e cases in PICU)



CRITIC AL ILL P ATIENTSCRITIC AL ILL P ATIENTS

Difficult to pr edictDifficult to pr edict

IntubationIntubation rar e in acute asthma attackrar e in acute asthma attack

Risk factors : passive smokers, RTI, Risk factors : passive smokers, RTI, steroid dependence, hospitalized, steroid dependence, hospitalized,

psychological & psychosocial problemspsychological & psychosocial problems



Another tr eatment as adjuvant medication Another tr eatment as adjuvant medication

Epinef r inIt was drugs of choice f or acute

Asthma attack

At patient with mild ± severe respir atory distressSubcutan epinef r in has no excess than

2-agonist inhalation

Epinef r in 0,01 mg /kgBW ± 0,3-0,5 mg scconsider f or severe respir atory distress, worse

aer ation, fall to decompensated stage, no respons to

Another medication




Ter butalin

Initiated with bolus (10 mcg /kgBW)continue with

dr ip 0,2 mcg /kgBW /minute




Magnesium sulfat Calcium channel modulation

Decrease acetyl choline

bronchodilation

Delayed histamin and mast cell

release



Another treatment as adjuvant medicationAnother treatment as adjuvant medication

Heliox Another inhalation

anestesi

Halotan

Enflur an

Isoflur an



Intubation

Absolut Indication

Apnea

Respir atory failure (PaCO2 > 60 mmHg)Coma

Another reason

Severe hypoxia

Increase hypercapnia with respir ator ic acidosis,

Difficulty conversation, decrease of consciousness,

tired



Mechanic VentilationMechanic Ventilation

PURPOSE

Completely oxygenation

and ventilation to decrease

wor k of breathing

Child with asthma

Permissive Hypercapnia

Methods of mechanic

ventilation



ALGORITMA SERANGANALGORITMA SERANGAN

ASMAASMAKlinik / IGDKlinik / IGDNilai der ajat ser angan

Tatalaksana awal nebulisasi F2-agonis 1-3x, selang 20 menit

nebulisasi ketiga + antikolinergik

jika ser angan ber at, nebulisasi F2-agonis +antikolinergik)

Ser angan sedang

(nebulisasi 2-3x,respons parsial )

ber ikan O2

nilai ulang p sedangp Ruang Rawat

Sehar i pasang inf us

Ser angan r ingan

(nebulisasi 1xrespons

baik) observasi 1-2 jam

ef ek ber tahan boleh

pulang

jika ge jala timbul lagi,

per lakukan seper ti

ser angan sedang

Ser angan ber at( nebulisasi 3x,

respons buruk) O2 se jak awal

steroid iv

nilai ulang p ber at,

r awat inap

f oto Ro tor aks

pasang inf us



Rng. Rawat Sehar i Oksigen teruskan

steroid or al nebulisasi tiap 2 jam

8-12 jam klinis sta-

bilp boleh pulang

12 jam tetap belumbaikp r awat inap

Ruang Rawat Inap Oksigen teruskan

atasi dehidr asi &

asidosis jika ada

steroid IV tiap

6-8 jam

nebulisasi tiap1-2 jam aminofilin IV awal,

lan jutkan rumatan

nebulisasi 4-6x p

baik, interval 4-6 jam

24 jam stabil p

boleh pulang dengan steroid &

aminofilin IV tetap

tidak baik p ICU

Boleh pulang

bekali F2-agonis(hirupan /or al)

jika ada obat

pengendali, te-

ruskan

inf .virus (+),

steroid or al 24-48 jam kon-

trol proevaluasi

Catatan:

Jika penilaianserangan berat, nebulisasi pertamalangsung F-agonis +antikolinergik

Jika ada ancaman henti nafas segera ke ICU

Bila belum ada alat nebulisasi, dapat diganti

dengan adr enalin sk. 0,01 ml/kgbb/kali, maksimal

0,3 ml/kali.

Asma Acute Attack Gabungan

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