Presented during the 1st Malaysian National Emergency Critical Care Symposium in Ipoh, Perak, Malaysia, Nov 2013.

1. Updates
on
Asthma
and
COPD
Keng
Sheng
Chew
School
of
Medical
Sciences
Universi6
Sains
Malaysia
1

2. Conflict
of
Interest
• I
declare
I
have
received
educa6onal
grants
from
Astra-­‐Zeneca
(M)
Sdn
Bhd
2

3. Outlines
•
•
•
•
•
•
•
•
In
asthma:
Con6nuous
neb?
IV
B2-­‐agonist?
IV
steroids?
An6cholinergics?
Magnesium
sulphate?
NIPPV?
When
intubate?
What
to
look
for?
3

4. Outlines
•
•
•
•
•
•
In
COPD:
Recent
concepts
B2-­‐agonists
vs
an6cholinergics?
NIPPV?
Issues
of
mechanical
ven6la6on
Hypoxic
drive
–how
true
is
this
fear?
4

5. Updates
on
Asthma
5

6. Pathophysiology
of
Asthma
6

7. Pathological
changes
7

8. “Rules
of
2”
in
asthma
• AXacks
>2
6mes
per
week
or
• Needs
rescuer
inhaler
>2
6mes
per
week
• Awakening
due
to
nocturnal
symptoms
>2
6mes
per
month
• Use
>2
canisters
of
relievers
per
year
• If
yes
to
any
=
uncontrolled,
needs
steroids
• (Adapted
from
GINA
guideline)
8

9. Con@nuous
neb
vs
intermiCent
neb?
• “Con6nuous”
neb
=
con6nuous
aerosol
delivery
or
sufficient
frequency
of
at
least
1
neb
q15
min
or
>
4
neb/hour
• In
a
Cochrane
systema6c
review,
Camargo
et
al
(2009),
8
trials,
n
=
461
• Con@nuous
neb
– Benefits
in
severe
disease
– Significant
lung
improvement
at
2
–
3
hours
– Similar
side
effects
(tremors,
increased
K+,
HR)
– Well
tolerated
9

10. IV
Beta-­‐2
agonists
vs
inhaled
Beta-­‐2
agonists?
• Travers
et
al
(2001),
in
a
Cochrane
systema6c
review,
15
trials,
n
=
583
• IV
beta
agonists
offer
no
therapeu6c
advantage
over
inhaled
forms
of
the
drugs.
• However,
no
difference
in
autonomic
side
effects
10

11. Early
IV
steroids
use?
• Rowe
et
al
(2009),
Cochrane
systema6c
review,
12
trials,
n
=
863
• IV
steroids
given
within
1
hour:
• significantly
reduced
admission
rates
(OR
=
0.40,
95%
CI:
0.21
to
0.78)
• Benefits
most
pronounced
among
those
with
severe
asthma
and
in
those
who
have
not
yet
been
on
systemic
steroids
prior
to
ED
presenta6on
11

12. An@cholinergics
• An6cholinergics
–
not
to
be
used
alone
• Teoh
et
al
(2012),
in
a
Cochrane
review,
4
trials,
n
=
171
– An6cholinergics
alone
less
efficacious
and
more
likely
to
fail
• An6cholinergics
combined
with
SABA?
– Griffiths
et
al
(2013),
in
a
systema6c
review,
15
trials,
n
=
2497
(pediatrics),
found
– combining
an6cholinergic
and
SABA
significantly
reduces
the
risk
for
hospital
admission
12

13. Magnesium
sulphate
• Blocks
calcium
channel
• Relaxes
bronchial
smooth
muscle
• Inhibits
contrac6le
response
to
endogenous
bronchoconstrictors
• Rowe
et
al
(2009):
• 7
trials,
n
=
665
• Overall
no
improvement
in
lung
func6on,
no
improvement
in
adm
rate
• BUT
reduce
admission
rate
in
severe
asthma
subgroup
13

14. NIPPV
in
Asthma?
• Lim
et
al
(2012)
in
a
Cochrane
review,
5
trials,
n
=
206,
preliminary
results
show
NIPPV
has
benefit
of
– Reduced
hospitaliza6on
rate
– Reduced
6me
to
discharge
from
ED
– Improves
lung
func6on
• But
s6ll
lack
of
good
evidence,
remains
controversial;
NOT
for
rou6ne
use
• Two
of
the
studies:
2
intuba6ons
needed
in
45
par6cipants
on
NPPV
vs
no
intuba6ons
in
41
control
pa6ents
(risk
ra6o
4.48;
95%
CI
0.23
to
89.13)
14

15. Mechanical
ven@la@on
• 4
indica6ons
for
intuba6on
(Brenner
et
al,
2009
in
Proceedings
of
the
ATS)
– cardiac
arrest
– respiratory
arrest
or
profound
bradypnea
– physical
exhaus6on
– AMS
(agitated
pa6ent,
interfering
with
oxygen
delivery)
• Hypercapnia
per
se
without
evidence
of
physical
exhaus6on
or
mental
changes
IS
NOT
an
indica6on
• Persistent
hypercapnia
despite
treatment
+/-­‐
AMS
is
an
indica6on
(PaCO2
increase
~
5mmHg/Hr
or
more
than
55
–
70
mmHg)
15

16. Mechanical
ven@la@on
• Permissive
hypercapnia
-­‐
minimize
risk
of
increased
intrathoracic
pressure.
Ini6al
sepng:
– TV
6
ml/kg
– Rate
6/min
– I:E
up
to
1:4
• Try
keep
Plateau
pressure
below
30
cm
H20.
• Pplat
(or
lung
distension
pressure)
gives
an
es6mate
of
average
of
end-­‐insp
alveolar
P
(Brenner
et
al,
2009)
16

17. Induc@on
Agents
Ketamine
releases
of
catecholamines
bronchial
smooth
muscle
relaxa6on
Side
effects
–
hypersecre6on,
hypertension,
arrhythmias,
and
hallucina6ons
• rela6vely
contraindicated
in
pa6ents
with
ischemic
heart
disease,
hypertension,
increased
intracranial
pressure.
•
•
•
•
17

18. Updates
on
COPD
18

19. Reversible
Irreversible
Source: Peter J. Barnes, MD

20. Basics
• COPD
is
a
systemic
disease,
not
just
pulmomary
(Agus6,
2005)
– systemic
inflamma6on,
systemic
oxida6ve
stress,
ac6va6on
of
circula6ng
inflammatory
cells,
e.g.
neutrophils,
macrphages,
and
augmented
levels
of
pro-­‐
inflammatory
cytokines
• Extrapulmonary
associa6ons:
IHD,
osteopenia,
cachexia,
malnutri6on,
skeletal
was6ng
20

21. Bronchodilators
• Cochrane
systema6c
review
by
McCrory
et
al
(2005)
– No
significant
difference
in
changes
in
FEV1
between
b2-­‐agonists
and
the
an6cholinergic
ipratropium
at
90
minutes
and
24
hours
and
– no
advantage
combining
• An6cholinergics
–
slower
onset
(15
min,
peak
60
to
90
min,
and
longer
6
to
8
hrs).
• General
consensus
(GOLD)
–
SABA
first,
then
an6cholinergics
21

22. NIPPV
in
COPD
• Ram
FSF
et
al
(2004)
in
a
Cochrane
systema6c
review,
14
trials
involving
n
=
622
(outcomes
of
treatment
failure),
n
=
541
(mortality)
• NIPPV
resulted
in
• decreased
mortality
• decreased
need
for
intuba6on
• reduc6on
in
treatment
failure
22

23. Mechanical
ven@la@ons
• Issues
with
mechanical
ven6la6on
in
COPD
(BruloXe
et
al,
2012):
• poorer
prognosis
(mortality
rates
between
20%
and
73%)
• a
mean
life
expectancy
of
1
year
• Barotrauma,
infec6ons
• Discuss
with
family
regarding
pros
and
cons
23

24. Hypoxic
Drive
in
COPD?
• How
real
is
this
fear?
• Started
off
with
a
paper
by
E.J.M
Campbell
in
1960
• Really
no
science
behind
it!
Consensus
opinion
• A
Cochrane
review
by
Aus6n
Wood-­‐Baker
(2009)
– “No
relevant
trials
have
been
published
to
date,
so
there
is
no
evidence
to
indicate
whether
different
oxygen
therapies
in
the
pre-­‐
hospital
se@ng
have
an
effect
on
outcome
for
people
with
acute
exacerbaBons
of
COPD”
24

25. Hypoxic
Drive
in
COPD?
• Plant
et
al
(2000)
shows
an
associa6on
between
increased
oxygen
with
hypercapnea,
respiratory
acidosis,
and
ICU
admission
but
this
does
not
occur
in
every
pa6ent
given
increased
FiO2.
• May
happen
• Careful
observa6on
of
this
pa6ent
• BUT
remember:
the
risks
of
withholding
oxygen
are
much
greater
than
giving
them
too
much!
25

26. Summary
•
•
•
•
•
•
•
•
In
asthma:
Con6nuous
neb?
IV
B2-­‐agonist?
IV
steroids?
An6cholinergics?
Magnesium
sulphate?
NIPPV?
When
intubate?
What
to
look
for?
26

27. Summary
•
•
•
•
•
•
In
COPD:
Recent
concepts
B2-­‐agonists
vs
an6cholinergics?
NIPPV?
Issues
of
mechanical
ven6la6on
Hypoxic
drive
-­‐
controversials
27

28. References
• Camargo
Jr
CA,
Spooner
C,
Rowe
BH.
Con6nuous
versus
intermiXent
beta-­‐agonists
for
acute
asthma.
Cochrane
Database
of
Systema6c
Reviews
2003,
Issue
4.
Art.
No.:
CD001115.
DOI:
10.1002/14651858.CD001115
• Travers
A,
Jones
AP,
Kelly
K,
Barker
SJ,
Camargo
CA,
Rowe
BH.
Intravenous
beta2-­‐agonists
for
acute
asthma
in
the
emergency
department.
Cochrane
Database
Syst
Rev.2001;(2)
:CD002988
• Rowe
BH,
Spooner
C,Ducharme
F,
Bretzlaff
J,
BotaG.
Early
emergency
department
treatment
of
acute
asthma
with
systemic
cor6costeroids.
Cochrane
Database
of
Systema6c
Reviews
2001,
Issue
1.
Art.
No.:
CD002178.
DOI:
10.1002/14651858.CD002178.
28

29. References
• Griffiths
B,
Ducharme
FM.
Combined
inhaled
an6cholinergics
and
short-­‐ac6ng
beta2-­‐agonists
for
ini6al
treatment
of
acute
asthma
in
children.
Cochrane
Database
of
Systema6c
Reviews
2013,
Issue
8.
Art.
No.:
CD000060.
DOI:
10.1002/14651858.CD000060.pub2.
• Lim
WJ,
Mohammed
Akram
R,
Carson
KV,
Mysore
S,
Labiszewski
NA,
Wedzicha
JA,
Rowe
BH,
Smith
BJ.
Non-­‐invasive
posi6ve
pressure
ven6la6on
for
treatment
of
respiratory
failure
due
to
severe
acute
exacerba6ons
of
asthma.
Cochrane
Database
of
Systema6c
Reviews
2012,
Issue
12.
Art.
No.:
CD004360.
DOI
10.1002/14651858.CD004360.pub4.
29

30. References
• Barry
Brenner,
Thomas
Corbridge,
and
Antoine
Kazzi
"Intuba6on
and
Mechanical
Ven6la6on
of
the
Asthma6c
Pa6ent
in
Respiratory
Failure",
Proceedings
of
the
American
Thoracic
Society,
Vol.
6,
No.
4
(2009),
pp.
371-­‐379.
• McCrory
DC,
Brown
CD.
An6cholinergic
bronchodilators
versus
beta2-­‐
sympathomime6c
agents
for
acute
exacerba6ons
of
chronic
obstruc6ve
pulmonary
disease.
Cochrane
Database
of
Systema6c
Reviews
2003,
Issue
1.
Art.
No.:
CD003900.
DOI:
10.1002/14651858.CD003900.
30

31. References
• Agus6
AG.
Systemic
effects
of
chronic
obstruc6ve
pulmonary
disease.
Proc
Am
Thorac
Soc
2005;
2
(4):367-­‐70;
discussion
71-­‐2.
• Ram
FSF,
Picot
J,
Lightowler
J,
Wedzicha
JA.
Non-­‐invasive
posi6ve
pressure
ven6la6on
for
treatment
of
respiratory
failure
due
to
exacerba6ons
of
chronic
obstruc6ve
pulmonary
disease.
Cochrane
Database
of
Systema6c
Reviews
2004,
Issue
3.
Art.
No.:
CD004104.
DOI:
10.1002/14651858.CD004104.pub3.
• BruloXe
CA,
Lang
ES.
Acute
exacerba6ons
of
chronic
obstruc6ve
pulmonary
disease
in
the
emergency
department.
Emerg
Med
Clin
North
Am.
2012;
May;30(2):223-­‐47,
vii.
31

32. References
• Teoh
L,
Cates
CJ,
et
al.
An6cholinergic
therapy
for
acute
asthma
in
children.
Cochrane
Database
Syst
Rev
2012,
Issue
4:
CD003797.
• Plant
PK,
Owen
JL,
Elliot
MW.
One
year
period
prevalence
study
of
respiratory
acidosis
in
acute
exacerba6ons
of
COPD:
implica6ons
for
the
provision
of
noninvasive
ven6la6on
and
oxygen
administra6on.
Thorax
2000;55:550–4.
32

33. 33