Ridwan M.

Daulay
Wisman Dalimunthe
Rini S. Daulay
 Cough and/or wheezing that:
• Episodic

• Hyperreactivity
• Nocturnal (variability)
• Reversibility
• With atopic family”
 desquamation of epithelium

Mucosal gland Mucus plug

hyperplasia

Basal membrane
thickening

Oedema
Netrophil and
Smooth muscle eosinophil infiltrations
constriction and hypertrophy
Barnes PJ 3
 Trigger

Bronchocontriction, Mucosal edema, Excessive secretion

Airway obstruction

nonuniform hyperinflation
ventilation
atelectasis mismatching of decreased
ventilation and perfution compliance
decreased
surfaktant alveolar hypoventilation increased work
acidosis of breathing

pulmonary
vasoconstriction  PaCO2

 PaO2 4
 Severity of attacks  Class of disease
(Acute) (Chronic)
 Mild  Infrequent episodic
 Moderate asthma
 Severe  Frequent episodic
 Respiratory arrest
asthma
imminent  Persistent asthma

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6
 Asthma
Triggers

• House dust mite

Longterm (HDM)
management • Smoke (polution)
failure • Food
• Infection

Attack

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 Severity of Asthma Attacks

Mild

Moderate
3.9%
11.7% Severe

84.4%
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 Estimation of severity of asthma attacks
Sign/ Mild Moderate Severe Imminent
Symptom respiratory
arrest
Activities Walking Talking Rest
(infant) (loudly cried) (weak cried) (stop eating)

Talking Complete Phrasesor or Single words

sentences partial or short
sentences phrases
Position Can lie Prefer to seat Tripod-like
down sitting
positions
Alertness Maybe agitated Usually Usually Confused
agitated agitated
Cyanotic Absent Absent Present

Wheezing Moderate, Loud, eksp. + Audible Difficult/ can’t

end of eksp. insp. be heard
Breathing Minimal Moderate Severe
difficulties
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Acessory Usually not Usually yes Yes Paradoxical
Muscle of movement
respiration
Retraction No intercostal Moderate +, Deep +, +, Decrease/
to mild tracheosterna nassal flaring none
retraction l retraction
Respiratory Tachypnea Tachypnea Tachypnea Decreasing
rate
Pulse rate Normal Tachycardia Tachycardia Bradicardia

Pulsus Absent Present Present absent

paradoxus (<10 mmHg) 10-20 mmHg >20 mmHg (Fatique resp.
muscle)
PEF / FEV1 (% predictive- value/ % good -value)
- pre-b.dilat. >60% 40-60% <40%
- post-b.dilat >80% 60-80% <60%
SaO2 >95% 91-95% <90%

PaO2 Normal >60 mmHg <60 mmHg

PaCO2 <45 mmHg <45 mmHg >45 mmHg

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Features of Severe Airway
Obstruction
Symptoms and signs:
-Inability or difficulty in speech or feeding
-Exhaustion, agitation or reduced level of consciousness
-Progressive tachycardia and/or tachypnoea
-Use of accessory muscles
-Poor chest movement and quite breath sound

Lung function:
-PEF <30% expected

Response:
-Deterioration despite recent use of appropriate rescue medication
-Transient (<2 h) or partial response to bronchodilator by nebulizer
Referral to Hospital/Emergency
Department
 Short attack with rapid deterioration
 Limited or brief response to bronchodilator
therapy
 Drowsiness or altered state of consciousness
 Evidence of dehydration
 Inability of child to drink or talk
 Inability of parents to cope
 Relieve the symptoms quickly and
precisely
 Reduce hypoxemia
 Lung function, back (near) normal
 After attack: reevaluation

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 Algorithms Asthma Attack
Clinic/ ER
Rate attack severity

First management
• 2-agonist nebulization (neb) 3x, 20’ interval
• 3rd neb + anticholinergic

Severe attack
Mild attack Moderate attack (neb 3x,
(neb 1x, (neb 2-3x, bad/ no response)
good response partially response) • O2 since beginning
• hold out 1-2 hours, • give O2 • IV line
may go home • reevaluate  moderate • chest X ray
• attack reappear   One day care (ODC) • reevaluate→severe
• IV line →hospitalized
moderate attack

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 May go home One Day Care (ODC) Hospital Room
• give 2-agonist • O2 continued • O2 continued
(inhalation / oral) • give oral steroid • overcome dehidration
• patient with • neb every 2 hrs and acidosis
controller, continued • improve in 8-12 hrs, • IV steroid every
• Viral ARI as trigger stable may go home 6-8 hrs
steroid oral may given • no improve within 12 hrs, • neb every 1-2 hrs
• visit outpatient clinic • IV aminophylline, initial-
hospitalized
in 24 hours maintenance
• improve neb every 4-6hrs
• stable within 24 hrs,
may go home
• no improvement,
Catatan: impending resp failure -
• severe attack from beginning, directly neb with PICU
ipratropium
• neb can be replaced by adrenalin sc 0.01 ml/kgBw/x,
max 0.3ml/x
• O2 2-4L/mnt from the start, including during neb

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 Must be given in severe attack

 In severe attack, hypoxemic

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 β2 agonist and ipratropium bromide Vs
β2 agonist alone: better result:
 Decreased of hospitalization rate
 Decreased of symptoms scoring
 Improve lung functions
 Drugs duration of action, longer

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 Rehydration
 Drink less due to breathing difficulties
 vomiting
 Acid-base and electrolyte correction
 Give parenteral medication

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 Intravenous or oral
 Antiinflamation
 Controversy: the use of nebulizer

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 Initial, 6-8 mg/kgBW/IV for 10-20 minutes
 Maintenance, 0,5-1 mg/kgBW/hours
 Need aminophylline plasma level
monitoring
 Be careful, narrow margin of safety

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 Adrenaline, there is maximal dose,
effect on  and 
 Salbutamol SC, have to be careful
 MgSO4, no signiffican
 Steroid inhaler, very high dose
(1600-2000 mg)
 Antibiotic, not use
 Mucolitic, not suggest for severe
attack
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 No/ bad response after nebulization
 Oxygen
 Parenteral, rehidration, acidosis
correction
 Steroid IV
 lnitial Aminophylline IV,
then the maintenance
 Nebulization
 Chest X-ray
 Good: May Go Home
 No/ bad response: Intensive Care

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 Dehidration
 Metabolic acidosis
 Atelectasis

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 Previous life threatening episode, requiring
ICU admission or mechanical ventilator
 Recent hospitalization or multiple ED visits for
Asthma
 Depency on multiple medication
 Previous Pneumothorax associated with
Asthma
 Excessive use of short acting β2 agonist,
especially in the absence of inhaled
corticosteroid
Indication of early transfer to
ICU
 History of previous attack resulting in ICU
admission
 PCO2 >45 mmHg
 PEF/FEV1 <33%
 PO2 <60 mmHg
 Depressed conscious level
 Bradicardi
 Bradypnoea
 Metabolic acidosis
 Pneumothorax or Pneumomediatinum
Treatment in ICU

 Intubation
 Ventilatory strategy
 Sedation
Intubation

 Mechanical ventilation: rare

 No absolute indication, usually:
 Pharmacological treatment failed to reliev
respiratory distress
 Respiratory failure imminent
 Choose largest ETT to reduce tube resistance
Ventilatory strategy
 Volume controlled ventilation is preferred
 Initially with low respiratory rate (half the
normal RR for the child’s age)
 Short inspiratory time, I:E=1:3 to 1:6 to
faccilitate passive expiration and reduced risk of
lung hyperinflation
 TV 6-10ml/kgBW to limit inspiratory pressure
and avoid barotrauma
 Low PEEP (0-3 cmH2O) to avoid lung
hyperinflation
 Initial ventilator setting:
 Max peak inspiratory pressure 35-40 cmH2O
 PEEP 0-3 cmH2O
 Respiratory rate 10-15 bpm
Sedation

 Initial phase of ventilation: sedated and

muscle relaxant  allow rest and prevent
patient/ventilator asynchrony
 Sedation:
 Benzodiazepines (midazolam, lorazepam)
 Ketamine
 Morphine (avoid) risk bronchospasm by
histamine release
 Muscle relaxant: vecuronium
Risks of Intubation

 Cardiovascular instability, combination

worsening lung hyperinflation, relative
hypoxemia and sedation 
 Affect venous return
 Left ventricular filling pressure
 Management: CV support:
 Fluid boluses
 Inotropic agent