Asthma

Conference Lecture

9/23/2015
Presenter: Dr. Eddie Irizarry, Montefiore Medical Center
Asthma
Synopsis: An engaging Q&A-based talk that went over the finer points of ED asthma management with some surprising factoids. 

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Questions

1. Which of the following is involved in the pathophysiology of an acute asthma exacerbation?
   1. Muscle constriction
   2. Inflammation
   3. Excess mucus production
   4. a and b
   5. a and c
   6. All of the above
2. 25 M with h/o asthma p/w SOB/wheeze/tachypnea for a few hours. You suspect asthma. What is the first medication that should be administered?
   1. Albuterol
   2. Solumedrol
   3. Atrovent
   4. Prednisone
3. IV beta agonists can be advantageous in some cases.
   1. True
   2. False
4. After one treatment, the previous patient is feeling much better. His vital signs are normal. He has a slight wheeze and mild tachypnea. What would you do next?
   1. Give steroids
   2. Give magnesium
   3. Discharge
   4. Observe
5. You decide to observe, patient goes out to smoke a cigarette and comes back significantly short of breath and using accessory respiratory muscles. The RN has started a combo-neb. She asks do you want solumedrol. You respond?
   1. Yes, give solumedrol
   2. No, give prednisone
   3. No, give decadron
   4. No steroids for now
6. The route (PO/IV/IM) of steroid administration correlates with clinical efficacy.
   1. True
   2. False
7. Patient has a peanut allergy. He should not have received nebulized ipratropium as this can cause anaphylaxis
   1. True
   2. False
8. While debating whether to give epi, RT walks by and asks if you want BiPAP. He should you answer?
   1. Yes! ASAP
   2. No, the EBM for this intervention is not strong
   3. No, the patient may get worse
   4. No, get the vent ready instead
9. What is the best way of monitoring this patient’s respiratory status?
   1. Serial peak flows
   2. Serial ABGs
   3. Pulse oximetry
   4. End tidal CO2
   5. Clinically
10. You decide the patient needs to be intubated. Is there a rapid sequence intubation medication that may directly help treat asthma?
    1. Etomidate
    2. Versed
    3. Propofol
    4. Ketamine
    5. Two of these
    6. None
11. After using ketamine to intubate the patient, RT asks what setting s you want on the vent. You say:
    1. “Whatever you think”
    2. low PEEP and low RR
    3. low PEEP and high RR
    4. high PEEP and low RR
    5. high PEEP and high RR
12. Patient is uncomfortable on the vent. RN offers to give morphine she has ready in hand. What should you say?
    1. Yes
    2. No
13. You end up giving a fentanyl bolus and starting the patient on a ketamine gtt. The patient is now hypoxic (80% on FiO2 100). What is the next step?
    1. DOPE
    2. Expectant management
    3. Call RT
    4. Start continuous albuterol
14. You can find no obvious reason for hypoxia. What should you do?
    1. STAT CTA for PE
    2. Start lovenox
    3. Call CTS for lung transplant
    4. Call CTS for ECMO
    5. Reintubate patient with larger ETT
    6. Reintubate patient with ETT for each lung
15. For PGY-1’s: 36 F (2 ETT for asthma in past) p/w worsening SOB x 3d. MDI of albuterol and advair not providing much relief. With 2 albuterol news, she feels much better. If she can be discharged, what would you send her home on?
    1. Prednisone taper over 2 weeks
    2. Increased advair dose
    3. Prednisone “pulse” for 5 days
    4. No steroids. She got better quickly in ED
16. For PGY-2’s: Antibiotics are indicated for severe asthma exacerbations.
    1. True
    2. False
17. For PGY-3’s: You have a 28 F pregnant with asthma exacerbation, O2 sat is 86% on RA. What is the recommended O2 sat goal?
    1. >88%
    2. >91%
    3. >95%
    4. 100%
18. For PGY-4’s/attendings: Which is true concerning lidocaine?
    1. There is no role in asthma
    2. Premedication before RSI improves outcomes
    3. Premedication before RSI worsens outcomes
    4. May reduce intubation mediated bronchospasm
    5. Should be given in select cases to avoid intubation

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Answers & Explanations

1. Which of the following is involved in the pathophysiology of an acute asthma exacerbation?
   1. Muscle constriction
   2. Inflammation
   3. Excess mucus production
   4. a and b
   5. a and c
   6. All of the above
      1. Multiple factors contributing to an exacerbation: Muscle constriction and remodeling of airway + inflammation leading to airway wall thickening from edema + plugging from excess mucus production.
2. 25 M with h/o asthma p/w SOB/wheeze/tachypnea for a few hours. You suspect asthma. What is the first medication that should be administered?
   1. Albuterol 
      1. Albuterol is fastest acting of listed medications. Atrovent onset is ~15 mins (peak 1-2 hours) and there is some question in the literature as to whether albuterol + atrovent is superior to albuterol alone. Regarding steroids, peak effect at 2 hours and optimal dose is unknown.
   2. Solumedrol
   3. Atrovent
   4. Prednisone
3. IV beta agonists can be advantageous in some cases.
   1. True
   2. False
      1. Inhaled beta agonists are more effective and have less side effects than parenteral beta agonists. 
4. After one treatment, the previous patient is feeling much better. His vital signs are normal. He has a slight wheeze and mild tachypnea. What would you do next?
   1. Give steroids
   2. Give magnesium
   3. Discharge
   4. Observe
5. You decide to observe, patient goes out to smoke a cigarette and comes back significantly short of breath and using accessory respiratory muscles. The RN has started a combo-neb. She asks do you want solumedrol. You respond?
   1. Yes, give solumedrol
      1. As stated above, optimal dose is unknown. Decadron is most potent, followed by solumedrol, then prednisone.  Decadron has longest duration of action (36-72h). The above patient is in respiratory distress and should receive IV steroids if unable to tolerate PO.
   2. No, give prednisone
   3. No, give decadron
   4. No steroids for now
6. The route (PO/IV/IM) of steroid administration correlates with clinical efficacy.
   1. True
   2. False 
      1. Onset of action and efficacy via PO route effectively identical to IV/IM. 
7. Patient has a peanut allergy. He should not have received nebulized ipratropium as this can cause anaphylaxis
   1. True
   2. False
      1. This was an issue with propellant used in MDI but not with nebulized ipratropium.
8. While debating whether to give epi, RT walks by and asks if you want BiPAP. He should you answer?
   1. Yes! ASAP
      1. No quality studies supporting BiPAP in asthma exacerbation as of yet, but theoretical benefits justify trial of NIV. BiPAP improves oxygenation, gas exchange and decreases work of breathing. Initial target settings: PEEP = 3-5 cm H2O (low), iPAP = 7-15 cm H2O, RR <25 /min, lower I:E (1:5), ↑ inspiratory flow rate, prolonged expiratory time.
   2. No, the EBM for this intervention is not strong
   3. No, the patient may get worse
   4. No, get the vent ready instead
9. What is the best way of monitoring this patient’s respiratory status?
   1. Serial peak flows
   2. Serial ABGs
   3. Pulse oximetry
   4. End tidal CO2
      1. High pCO2 does not absolutely need ETT.
   5. Clinically 
10. You decide the patient needs to be intubated. Is there a rapid sequence intubation medication that may directly help treat asthma?
    1. Etomidate
    2. Versed
    3. Propofol 
    4. Ketamine 
    5. Two of these
       1. Ketamine and propofol cause smooth bronchial muscle relaxation. Ketamine preferable because helps maintain BP.
    6. None
11. After using ketamine to intubate the patient, RT asks what settings you want on the vent. You say:
    1. “Whatever you think”
    2. low PEEP and low RR
       1. The patient should be started with low PEEP (<5 cm H20), RR 8-12 bpm, titrate FiO2, tidal volume 6-8 cc/kg (ideal BW), inspiratory flow rate 60-80 L/min.
    3. low PEEP and high RR
    4. high PEEP and low RR
    5. high PEEP and high RR
12. Patient is uncomfortable on the vent. RN offers to give morphine she has ready in hand. What should you say?
    1. Yes
    2. No
       1. Fentanyl may be better because it is associated with less histamine release than is morphine.
13. You end up giving a fentanyl bolus and starting the patient on a ketamine gtt. The patient is now hypoxic (80% on FiO2 100). What is the next step?
    1. DOPE
       1. Pneumonic to remember most common causes of post-intubation hypoxia/deterioration. 
          1. Displacement: Check ETT for displacement (R mainstem) or dislodgment 
          2. Obstruction: Check ETT for obstruction (mucous plug, kink)
          3. Pneumothorax: Obtain Xray or U/S
          4. Equipment failure (rare): Disconnect patient from vent and bag manually 
    2. Expectant management
    3. Call RT
    4. Start continuous albuterol
14. You can find no obvious reason for hypoxia. What should you do?
    1. STAT CTA for PE
    2. Start lovenox
    3. Call CTS for lung transplant
    4. Call CTS for ECMO
       1. Should be considered as an adjunct when unable to maintain adequate oxygenation with mechanical ventilation + medical therapy.
    5. Reintubate patient with larger ETT
    6. Reintubate patient with ETT for each lung
15. For PGY-1’s: 36 F (2 ETT for asthma in past) p/w worsening SOB x 3d. MDI of albuterol and advair not providing much relief. With 2 albuterol news, she feels much better. If she can be discharged, what would you send her home on?
    1. Prednisone taper over 2 weeks
    2. Increased advair dose
    3. Prednisone “pulse” for 5 days
    4. No steroids. She got better quickly in ED
16. For PGY-2’s: Antibiotics are indicated for severe asthma exacerbations.
    1. True
    2. False
17. For PGY-3’s: You have a 28 F pregnant with asthma exacerbation, O2 sat is 86% on RA. What is the recommended O2 sat goal?
    1. >88%
    2. >91%
    3. >95%
    4. 100%
18. For PGY-4’s/attendings: Which is true concerning lidocaine?
    1. There is no role in asthma
    2. Premedication before RSI improves outcomes
    3. Premedication before RSI worsens outcomes
    4. May reduce intubation mediated bronchospasm
       1. Evidence suggests that lidocaine may reduce intubation mediated bronchoconstriction when used as an induction agent; however, lidocaine has also been shown to increase baseline airway tone.
    5. Should be given in select cases to avoid intubation

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FOAM Resources

1. http://emcrit.org/podcasts/severe-asthmatic/
2. http://coreem.net/podcast/episode-17-0-asthma-and-copd/
3. http://rebelem.com/rebelcast-crashing-asthmatic/