Asthma/COPD

LITERATURE

ASTHMA EXACERBATION MANAGEMENT GOALS:

  • Assess Severity
  • Correct hypoxemia/hypercarbia
    • Intubation is necessary for worsening gas exchange, fatigue/exhaustion, altered mental status
  • Rapidly reverse obstruction – MDIs are technically superior to nebulizers but may not be tolerated by a patient in extremis, continuous nebulizer should be used for severe cases
    • Consider Magnesium in severe cases 
    • Utilize NIPPV as an external diaphragm to help prevent intubation (also reduces mortality)
    • Steroids take about 6 hours to work.  Note that oral prednisone is equally effective as IV methylprednisolone
      • Inhaled steroids are not needed if patient is on systemic therapy
    • Antibiotics only for true signs of bacterial infection
  • Prevent complications
  • Reduce recurrence by providing controller medications and close follow-up
  • Risks for death:  previous ICU admission, previous intubation, two or more hospitalizations in the last year, three or more emergency department visits in the last year, use of >2 canisters/month of rescue inhaler, lack of written action plan, low socioeconomic status, illicit drug use, major psychosocial issues

COPD EXACERBATION MANAGEMENT GOALS:

  • Assess Severity
  • Trial of NIPPV: BPAP (need insp and exp pressures to ventilate, think of BPAP as external diaphragm)
    • Check ABG at start and within 45 min, if PCO2 is getting worse, intubate
    • Indications for immediate intubation: insufficient mental status for BPAP, copious secretions, respiratory acidosis (pH<7.2 – 7.25) worsening on NIPPV, hemodynamic instability
      • Allow long enough expiratory phase
      • Make sure no auto-PEEP
      • Goal is pt’s baseline pCO2 not a normal pCO2
      • Extubating to BiPAP is not recommended but NIPPV may be utilized as a trial rescue therapy prior to reintubation if the pt fails extubation
  • Standard treatment:
    • O2 > 88-90%
    • Prednisone 40 daily x5 days (methylprednisolone is only required for IV administration if pt cannot take po, IV STEROIDS ARE NOT “STRONGER”)
    • Albuterol (SABA) + ipratroprium (SAMA) or tiotroprium (LAMA)
    • Budesonide = LABA (not indicated if patient is on systemic steroids)
    • Abx: 5-10 days, choice depends on patient (increased sputum volume, increased sputum purulence)
      • High-risk: Levofloxacin or Zosyn
      • Low-risk: Augmentin or Doxycycline (beware azithromycin and arrhythmias)

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