Asthma is a respiratory disease which is affects the airways. It is usually a chronic inflammatory disease which occurs slowly to patients and in most case, it cannot be managed effectively (Murphy 2007). For patients suffering from asthma, developing exacerbations is very easy which can in turn lead to a respiratory failure. To be successful in the management of asthma, it is crucial that all patients at risk are identified and a through assessment and give the appropriate treatment at the appropriate time (Anonymous 2011). An acute asthma attack can lead to confusion to the patient and even the people who are supposed to be caring for the patient (Barnard 2005). Acute asthma attacks are one of the most emergency conditions which medical practitioners encounter. Deaths from acute asthmatic attacks occur mostly to the elderly and people living in the rural areas who do not have an easy access to the doctors or other health practitioners (Alexander 2000). Some of the deaths which occur due to acute asthmatic attack can be controlled if the severity of the asthma and attack were recognized in advance (Dutta 2007).
Management of Acute Asthmatic Attack
Asthma attacks can be adequately managed in outpatient care but if it is poorly controlled or it is in severe cases, it can be challenging to manage. The main aim of asthma management is to control the symptoms associated with it and prevent development of exacerbations (Barnard 2005). Before a health practitioner starts on the management of the patient, they should first get a brief history about the patient and do a rapid physical examination (Jevon 2010). A wheeze should not be relied on as the indication for the severity of the asthma attack. In some cases, a wheeze may be absent in cases of an acute asthmatic attack (Soubra 2005). Acute asthmatic attacks should be managed in a high density unit (HDU) since it a very serious condition which if care is not taken can be fatal. In management of an acute asthmatic attack, it is crucial that the doctor goes step by step (Barnard 2005). When a patient is brought in the HDU for admission, it is important that the doctor listens to the case description first which includes the case history, physical examination and then intervention.
The case I encountered in my practice involved the following as the case history. In HDU, there was a 57 old lady who had developed acute exacerbation asthmatic attack. She had a loud wheeze, experienced shortness in breath and was distressed. She could not produce a complete sentence and was anxious. According to her care taker, she used a puffer frequently that same day but it seemed not to produce any positive response. Her pulse rate was at 120. According to the lady, she had a vey severe asthma when she was a child but had become better in the past few years. She ceased using a preventer long time when the severity of her asthma became less and she was feeling better. She could use a puffer 5-6 times a week depending how many times she feels the need to use it. In the last one week, she was suffering from cold which interfered with her sleep. Due to the cold night that day, the cold had become worse and she had used her puff frequently. The last time she was it was forty five minutes before she was hospitalized. According to her, smoking affects her very much which makes hr use the puff more. She does not smoke herself. There was no particular night her sleep was interrupted by a cough or wheeze except the time she had a cold. When she was a child, she was hospitalized severally due to asthma, but for the past five years, she had not consulted a doctor due to asthma (Barnard 2005). She had not taken anything to treat her cold and her temperatures were at 37 degrees Celsius.
In order to effectively manage this case, the six steps of problem solution were used. The steps include; patient assessment, defining the problem, determining goals, identifying appropriate techniques, applying the techniques and then re-evaluation of the patients’ situation (Tawfiq 2011). In patient assessment, I used the information I got from the case history and the physical examination. This helps in determining the kind of treatment appropriate or this particular patient. It is in this step that the severity of the attack was determined. It was identified that the patient had a relapse of the severe acute attacks she had when she was a child. This was associated with failure to see a doctor and cessation of using a preventer. In defining the problem shortness of breath and a loud wheeze were due to the asthma attack. Cold could have precipitated the attack. In defining goals, the goal of the management was to reduce the asthma related symptoms like wheeze, irregular pulse rate and shortness of breath (Tawfiq 2011). The other goal was to prevent development of exacerbations. In identifying the appropriate techniques, shortness of breath was to be addressed by placing the patient in a position which facilitated smooth breathing (Goldberger 1966). When shortness of breath is addressed, other issues like speech problems and irregular pulse rate were addressed also (Murphy 2007). To address exacerbations, oxygen and β2 agonist were to be used. In applying the techniques, the patient was placed in a good position and oxygen and β2 agonist were administered to the patient (Tawfiq 2011). In the reevaluation, assessment is done on extend to which the patient is responding to the medicines used (Donna & Frownfelter 1987). It is also done on whether or not the wheeze has disappeared, if the pulse has gone to the recommended rate and if the shortness of breath has disappeared and the speech become smooth.
Current Issues Involved In Maintaining a Holistic Approach to Patient Care in Management of Acute Asthmatic Attack
Initial Assessment of Asthma Severity
Once the patient is brought in the HDU, the doctor gets a brief history and does a physical examination which helps in identifying the immediate needs of the patient (Elton 2006). This information helps in identifying factors which can increase mortality rate. In the history information is collected on previous acute exacerbations, prior endotracheal intubations, previous admissions in HDU, increased use of short acting beta 2 agonists (SABAs) and if there is history of withdrawal of systemic steroid use (Soubra 2005). This information is useful in determining the severity of the asthmatic attack directing the doctor to start a comprehensive management. Physical examinations include assessment of body activities like breathlessness, changes in the mental status of the patient, changes in heart rate, respiratory rate, presence/absence of wheezing, if the patient if utilizing accessory muscles or if there is presence of pulsus paradoxus (Soubra 2005). The doctor does all these physical examinations because the presence or absence of any of these determines whether or not the asthmatic attack is severe or not. It also helps in determining the level of severity (Elton 2006).
Taking a brief history of the patient will help in knowing the behavior which could or could not trigger an acute asthmatic attack. Some of the information collected from the brief history and the physical assessment of the patient will require the doctor to perform assisted ventilation on the patient (Barnard 2005). Some symptoms which can mandate the doctor to perform assisted ventilation include; cyanosis, difficult in speaking, respiratory problems, severe agitation or confusion, some indication of a muscle fatigue and absence of wheezing (Soubra 2005). For patients who have developed exacerbations, the doctor should perform frequent physical examinations most especially after a therapeutic procedure. Since the patient is being managed in the HDU, peak expiratory flow rate (PEFR) is the measurement which is appropriate for determining how the patient is responding to treatment and determine the level of airway obstruction. The doctor can also do oxygen saturation or blood gas analysis which is used to indicate if there is hypoxemia. Hypoxemia is a clear indication of an acute severe asthmatic attack. For the patient to be classified as one who is suffering from an acute asthmatic attack, the initial assessment and evaluation should show a PEF 33-50% best or predicted (Soubra 2005). After the initial evaluation and assessment of the severity of the asthmatic attack, the doctor can go ahead depending on the information collected from physical assessment and the brief history.
Initial Management in Acute Asthmatic Attack which does not Require Mechanical Ventilation
The first step in managing acute asthmatic with development of exacerbation is correction of hypoxemia by supplementing oxygen. In most of times supply with additional oxygen should start early enough even before the patient enters HDU but is continued when the patient has already been admitted. The additional oxygen supply should be provided in such a way that oxygen saturation is kept at SaO2 of above 90% (Soubra 2005). This is supposed to be higher at above 95% for pregnant patients and patients suffering from another heart disease. As this additional supply of oxygen is given, the one undertaking the activity should keep checking the oxygen saturation just to ensure that a response to bronchodilator therapy happens.
Inhaled Bronchodilator Therapy
These are various medicines which are used for inhaling. They of various types including;
SABAs used to inhale have been highly promoted to be used in patients who have acute asthmatic attack especially if they develop exacerbations (White 2005). The mostly used SABAs are the beta 2 selective type which include; albuterol, bitolteral and pirbuterol (Soubra 2005). These types are mostly used because they come with reduced probability of developing cardiotoxicity even if administered at high doses. This is in comparison with other non selective types (Jevon 2010). According to studies done comparing the effective of intermittent and continuous admission of these drugs, continuous admission has shown reduction in the number of times for hospitalization. Patients who suffer from severe highway obstruction have been found to improve a lot if betas 2 selective SABAs are administered continuously (Soubra 2005). Especially in the patients who are being managed in HDU have shown a positive response to treatment when these kind of drugs are used. There two methods which can be used to give inhaled SABA. The first one is meter dose and the second one is spacer device or a nebulizer. Whether the patient gets the inhaled SABA by either of the two methods, the response is the same. For patients with severe acute asthmatic attack in HDU, they may not be able to inhale the medicine when using meter dose. However, these patients use nebulizer. For instance, in 2.5 mg nebulized albuterol which is equivalent to 6-12 puffs is required for a successful response and attainment of bronchodilation (Soubra 2005).
When we consider racemic albuterol which is used to manage patients with acute asthmatic attack, we can see that it is available as R-albuterol and S-albuterol. These two have been found to differ especially in their pharmacologic properties. R-albuterol has been found to show bronchodilator properties while S-albuterol has been found to be effective as it leads to improvements in airway responsiveness. The type of R-albuterol which has been recommended for use in clinical conditions is known as Levalbuterol or can be termed as R-stereoisomer of albuterol (Soubra 2005). Studies done on Levalbuterol have proved that it is more appropriate in treating acute asthma as compared to racemic types of albuterol. It is more appropriate when we compare changes which occur in terms of duration taken when in emergency care, number of times one is hospitalized and physiological changes on the patient (Arshad 2002). Levalbuterol have shown positive change in all these parameters. For patients who are put on Levalbuterol their spirometric response is far more better as compared to patients ho use other types of albuterol (Soubra 2005). Levalbuterol is a very expensive drug and therefore, further studies need to be done to determine the role which it plays in treating acute asthma.
β2-agonists have been the mostly used as the first line bronchodilating agent in management and treatment of acute asthmatic attacks. However, there have been suggestions that ipratropium bromide to be used as an additive treatment (Soubra 2005). According to the study on the effect of β2-agonists and ipratropium bromide combined together in the treatment of acute asthmatic attack, it showed a lot of improvements pertaining airflow obstruction (Milner 1993). However, children have shown better improvements after the combined dose as compared to the response shown in adults. When ipratropium bromide and albuterol are used together, the side effects were reduced specifically because of the ipratropium bromide (Soubra 2005). This is due to the fact that ipratropium bromide has shown a positive response in patients with acute asthma in terms of improving bronchodilation and it comes with no side effects on the patient. Therefore, it is advisable that the combination be used in treatment and management of acute asthmatic attacks especially where exacerbations develop.
Especially for patients with exacerbations due to acute asthma, systemic corticosteroids can be effective. The important thing about systemic corticosteroids is that it leads to increased improvements in terms of airflow obstruction, reduce the number of times one is hospitalized and reduces the rate of relapse after treatment. However studies on the doses of corticosteroids have produced different results (Soubra 2005). Even low doses have shown an increased positive response. The most preferred way to give a corticosteroid dose is oral means since it has proved to be more effective as compared to intravenous route. Apart from oral corticosteroid, inhaled corticosteroid has also proved to be effective in that it reduces the number of times one is admitted in the hospital. Inhaled corticosteroid has leads to improvements in peak expiratory flow rate as well as PEV1 (Soubra 2005). Treatment and management of acute asthma with it has been very successful and there were very few side effects identified.
Methylxanthines is not recommended in the management of acute asthma especially the one which leads to development of exacerbations. The study done on children with acute severe asthma in HDU showed that the level of response was very low when Methylxanthines was used for treatment and management (Soubra 2005). However the same study proved that if aminophylline was combined with Methylxanthines, FEV1 and PEF improve but other factors like time spend in the hospital, symptoms and mechanical ventilation rates never had any positive change (Soubra 2005). It has been found to bring with it adverse side effects like vomiting, hypokalemia, headaches and even death. Care should be taken when using Methylxanthines and close monitoring should be done on serum levels to avoid any serious complications.
Magnesium sulfate has been used frequently in patients with acute asthmatic attack. However, it has been found to lead to bronchodilation as they are antagonists with calcium a process which leads to muscle contraction (Soubra 2005). Studies done on the effectiveness of magnesium in treatment and management of acute asthma has shown that it reduces admission for severe cases. It has also been found to improve peak flow rate and FEV1 in patients with acute asthma who develop exacerbations (Soubra 2005). Although it produces similar side effects like other medicines, it has been associated with hypotension. It is not recommended to be frequently used by patients with acute asthma. However, inhaled magnesium has been studied severally but it has produced different results. The results shows that use of magnesium sulfate did well on severe cases (Kathol 2003).
This is used in conditions where helium is used as a carrier gas for oxygen. The combination of helium and oxygen were used by Barach in treatment and management of acute asthma developing exacerbations (Soubra 2005). Helium was used due to its low density which improved the flow of oxygen in the airways even when resistance is high. However according to the study done by Rodrigo and his colleagues on the use of Heliox in treatment and management of acute asthma, showed that used of Heliox did not reduce the number of times one is hospitalized (Soubra 2005). Helium should be used carefully in patients under mechanical ventilation since it affects measurements of volume and pressure. Studies done on using Heliox as the gas to deliver bronchodilator have proved to improve FEV1.
Noninvasive ventilation is used in treating conditions like hypercapneic respiratory failure which results from exacerbations developing due to acute asthmatic attack. According to the study done by Soroksky and colleagues patients with acute asthma managed with noninvasive ventilation showed some improvements in FEV1 and the number of admissions reduced significantly (Soubra 2005). However, despite the fact that noninvasive ventilation has been found to work well for patients with acute exacerbation asthma, further studies need to be done since it has its limitations. It is not advisable to use it in patients who need airway protection, repeated suctioning or patients with facial trauma (Soubra 2005).
Invasive Mechanical Ventilation
There are some signs in a patient with acute asthma which show the need for mechanical ventilation. Some of the indications for mechanical ventilation include; hypercapnia, obtundation, and cardiopulmonary collapse (Soubra 2005). Proper assessment should be done to make sure that there is a genuine need for mechanical ventilation since it is not a much desired procedure.
If a patient with acute asthmatic attack needs intubation and mechanical ventilation, it should be done as fast as possible (Makino 2005). This should be administered by very qualified personnel and should be done under controlled conditions in order to ensure that bronchospasm does not occur. Bronchospasm can be adequately prevented by first administering inhaled albuterol (Soubra 2005). Oral route is preferred since it allows the use of large size endotracheal tubes which can reduce resistance in the airway allowing a through intervention on the patient. This procedure is recommended on patients who are conscious and cooperative.
Sedation and Paralysis
Sedation and paralysis are important for patients undergoing mechanical ventilation. The main reason for this is to reduce pain and discomfort which the patient feel during this procedure. These can be achieved using a number of products (Harkreader & Hogan 2004). Morphine is one of the cheap products which can be used for this purpose (Soubra 2005). However, it has been associated with a lot of risk factors. Some of the risk factors associated with it include; rigidity in the chest walls and increased probability of developing bronchospasm (Soubra 2005). The recommended product to be used product to be used in sedation is propofol since it acts very fast.
For patients with acute asthmatic attack, they have pathophysiologic features like airflow difficulties and dynamic hyperinflation (Behera 2010). The aim of using mechanical ventilation on these patients is to aid in their respiration. Some of the pathophysiologic features of acute asthma like hyperinflation occur due to increased need for respiration (Soubra 2005). This in turn occur when airflow is obstructed which makes the mucus to block the airway making breathing difficult. It is advisable to come up with the right strategies for delivering mechanical ventilation. There are many strategies to choose from depending on the condition of the patient (Soubra 2005). The two common strategies are volume controlled ventilation and pressure controlled ventilation.
Complications of Mechanical Ventilation
The mostly experienced complications due to mechanical complication include; hypotension and barotraumas (Soubra 2005). The reason as to why hypotension occurs is due to hyperinflation. For barotraumas, it should be expected if the patient develops hypotension, or hypoxia (Soubra 2005).
Acute asthmatic attack is very threatening condition. It is a condition which can be adequately managed if a qualified practitioner is involved. In managing patients with acute asthmatic attack, it is important to do it step by step for adequate provision of care (Siviter 2004). Brief history is very important before management procedures are begun. There so many procedures which can be used to manage these patients depending on the results of initial assessment.
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