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Exacerbation of Asthma 대한내과학회지 : 제73권 부록 2 호 2007 □ 임상강좌 □ Exacerbation of Asthma 성균관대학교 의과대학 내과학교실 최 동 철 2007년내과학회임상강좌 2007년내과학회임상강좌 Exacerbation of Asthma Exacerbation of Asthma Key Points -천식의 악화란 호흡곤란, 기침, 천명,흉부 압박감 등의 증상 중 Inducers 한가지 이상이 나타나는 것을 가리킨다. Respiratory -천식이 악화되면 숨을 내쉬기 어려워 지고 Allergens viral infections Occupational 폐기능검사에서 최대호기유속이나 1초간 노력성 호기량이 감소한다. agents -주요한 치료는 기관지 확장제, 스테로이드 및 산소 투여이다. Asthma flare -치료 목표는 환기 장애와 저산소증을 개선하고 재발을 방지하는 것이다. Aspirin -심한 천식 발작은 응급 상황이며 적절한 시설이 있는 곳에서 치료해야 하고 전문가의 감독이 필요하다. Exercise Irritants Respiratory viral infections -가벼운천식발작(최대호기유속의 감소가 20% 미만)은 지역의료기관에서 치료할 수 있다 Provokers Trends in Prevalence of Asthma Death Rates for Asthma By Age, U.S., 1985-1996 By Race, Sex, U.S., 1980-1998 80 Rate/1,000 Persons Age (years) Rate/100,000 Persons 70 5 <18 Black Female 60 18-44 4 Black Male 45-64 50 65+ 3 White Female 40 Total (All Ages) 2 30 White Male 1 20 85 86 87 88 89 90 91 92 93 94 95 96 0 1980 Year 1985 1990 1995 2000 Year － S 737 － － 대한내과학회지 : 제73권 부록 2 호 2007 － 2007년내과학회임상강좌 2007년내과학회임상강좌 Exacerbation of Asthma Histrory (1) A. Timing of dyspnea Acute onset Insiduous onset anxiety, hyperventilation COPD Q1: 환자의 호흡곤란이 천식 발작인가? asthma, pulmonary edema interstitial fibrosis pulmonary embolism, sarcoidosis chest trauma diseases of chest wall (pneumothorax, rib fracture, or diaphragm contusion) spontaneous pneumothorax 2007년내과학회임상강좌 2007년내과학회임상강좌 Exacerbation of Asthma Exacerbation of Asthma Histrory (2) Histrory (3) B. Relationship to physical activity Nocturnal dyspnea ATS Shortness of Breath scale Asthma, CHF, GE reflux Grade 0 (none) Orthopnea Not troubled by shortness of breath when hurrying on the level or walking up a slight hill Grade 1 (mild) CHF, massive ascites or pregnancy Troubled by shortness of breath when hurrying on the level or walking up a slight hill Bilateral phrenic nerve paralysis, severe COPD Grade 2 (moderate) Platypnea(Difficulty in breathing when erect, relieved by lying down) Walks slower than the people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace in the level AV malformation in lung, interatrial shunt Grade 3 (severe) Trepopnea(dyspnoea in one lateral position) Stops for breath after walking about 100 yards or after a few minutes on the level Heart disease, VQ mismatch Grade 4 (very severe) Too breathlessness to leave the house, or breathless on dressing or undressing 2007년내과학회임상강좌 2007년내과학회임상강좌 Exacerbation of Asthma Exacerbation of Asthma Histrory (4) Physical Exam (1) High Risk patients - 치료의 시작과 동시에 문진 및 진찰을 실시한다. -기도삽관및인공호흡기사용의병력 - 관찰할 사항: 말을잘하나? - 지난해에 천식 발작으로 응급실을 방문하거나 입원하였던 환자 호흡 및 맥박수, 보조호흡근의 사용, 비정상적인 호흡음 - 최근에 경구 스테로이드를 사용하였거나 사용 중인 환자 - 진찰만으로는 - 흡입 스테로이드를 규칙적으로 사용하지 않는 환자 천식 발작 및 저산소증의 중증도를 객관적으로 평가할 수 없음 -흡입기관지확장제를한달에1개이상사용하는환자 - 폐기능의 측정이 매우 중요 - 천식 치료계획에 순응도가 낮은 환자 - 치료에 지장이 없도록 신속히 폐기능을 측정하고 치료를 시작한다. － S 738 － －최동철 : Exacerbation of Asthma － 2007년내과학회임상강좌 2007년내과학회임상강좌 Physical Exam (2) Physical Exam (3) Inspection, Percussion, Palpation Mechanism of production of wheezing - Vital signs including respiration rate - Body habitus: obese or cachectic 1. Normal airway - Position: leaning foward in COPD - Expansion of chest wall: symmetricity - Use of accessory muscles: ICS or suprclavicular fossa 2. Slight narrowing retraction - Cyanosis or clubbing alternation of 2 & 3 produces continuous sound - Extended jugular vein or hepatojugular reflux 3. Greater narrowing - Unilateral vs bilateral L/E edema 2007년내과학회임상강좌 2007년내과학회임상강좌 Labaratory test (1) Labaratory test (2) Screening tests in dypnea (1) Screening tests in dypnea (2) General Principle A. Plain chest radiography " The labaratory test is occasionally of help in the diagnosis of - diagnosis: pneumothorax, pleural effusion, pneumonia, TB, dyspnea" emphysema, lung cancer, interstitial lung disease (Stulbarg MS, Adams L: Dyspnea. In Textbook of respiartory diseases p521) - helpful: cardiomegaly, chest wall deformity, pulmonary vascular abnormality Screening tests to be performed - In asthma: hyperinflation, pneumothorax Most helpful : Chest PA, ECG, Spirometry, ABGA B. 12 lead ECG Occasionally helpful: CBC, TFT* - does not establish diagnosis directly - provides indirect evidence for causative diseases of dyspnea * variable depending on authors (arrhythmia, myocardial ischemia, chamber enlargement etc) 2007년내과학회임상강좌 2007년내과학회임상강좌 Labaratory test (3) Labaratory test (4) Screening tests in dypnea (3) Screening tests in dypnea (4) D. Arterial Blood Gas Analysis (ABGA) C. Pulmonary function test - measures amount of dissolved O2 & CO2 in arterial blood A. Spirometry cf. Oximetry: measures fraction of O2 carried in hemoglobin Peak Expiratory Flow Rate (PEFR) - provides best measure for delivery of oxygen from atmosphere Forced Vital Capacity (FVC) to blood - minor change in ventilation affect Forced expiratory volune in 1 second (FEV1) PaCO2 level more significantly than PaO2 level * Changes of spirometry in pulmonary disease - Normal value in adult: 80-103 mmHg at room air FEV1 FVC FEV1/FVC PEFR PaO2 = 5 x FiO2 Obstructive lung disease - In any patient with dyspnea, Restrictive lung disease presence of hypoxemia is worrisome. － S 739 － － 대한내과학회지 : 제73권 부록 2 호 2007 － 2007년내과학회임상강좌 2007년내과학회임상강좌 Labaratory test (5) Screening tests in dypnea (5) " Cross Over " in severe asthma pH PaCO A-a DO2 (Alveolar arterial oxygen tension difference) 2 Formula 1 7.50 60 A-a DO2 = PAO2 -PaO2 50 = PIO2 - (PaCO2 x 1.2) - PaO2 = (760 - PB) x FiO2 -(PaCO2 x 1.2) - PaO2 7.40 40 PaO2 without O2 Formula 2 Normal A-a DO2 : 4 + age/4 30 7.30 20 - In patients with dyspnea, calculation of A-a DO2 may give additional diagnostic clue. Day 1 Day 2 Day 3 Day 4 Day 5 (modified from Weiss EB, Stein M: Bronchial asthma, 3rd ed, 1993) - If A-a DO2 <20, little possibility for parenchymal lung disease 2007년내과학회임상강좌 2007년내과학회임상강좌 Five major causes of hypoxemia Causes A-a DO2 Examples Comments Alveolar O2 High altitude, CO poisoning tension Ventilation CNS disorders(IICP), drugs, PaCO2 compensation for metabolic alkalosis, Q2: 얼마나심한천식발작인가? COPD or severe asthma Diffusion Interstital lung disease rare resting hypoxema V/Q mismatch Pneumonia, pneumothorax, improves CHF, ARDS, pulmonary embolism with O2 asthma, COPD Shunt ASD, VSD, AV malformation does no improve with 100% O2 2007년내과학회임상강좌 2007년내과학회임상강좌 2006 Severity of Asthma Exacerbations (1) Severity of Asthma Exacerbations (2) － S 740 － －최동철 : Exacerbation of Asthma － 2007년내과학회임상강좌 2007년내과학회임상강좌 Management of Asthma Exacerbations Community settings - 최대호기유속의 감소가 20 % 미만인 가벼운 천식 발작은 Q3: 어디서 치료하나 ? 지역의료기관에서 치료 가능 - 속효성 기관지확장제를 몇 차례 흡입 후 1시간이내에 상태가 호전되면 굳이 응급실로 보낼 필요 없음 - 호전될 때 까지 전신 스테로이드의 처방을 고려 2007년내과학회임상강좌 Q4: 어떤 치료제를 사용하나 ? － S 741 － － 대한내과학회지 : 제73권 부록 2 호 2007 － 2007년내과학회임상강좌 2007년내과학회임상강좌 GINA 2006 update GINA 2006 update Management of asthma exacerbations Management of asthma exacerbations in acute care setting in acute care setting 2005 update 2006 revision Treatment for Moderate Episode Treatment for Moderate Episode 2005 update 2006 revision Initial Treatment Initial Treatment Oxygen Inhaled β2-agonist and inhaled Inhaled β2-agonist and inhaled Inhaled rapid-acting β2-agonist, usually by Inhaled rapid-acting β2-agonist continuously for anticholinergic every 60 minutes anticholinergic every 60 min nebulization, one dose every 20 minutes for one one hour. Consider glucocorticosteroids Oral glucocorticosteroids hour. Continue treatment 1-3 hours, provided Continue treatment for 1-3 hours, provided there is improvement there is improvement GINA 2006 update 2007년내과학회임상강좌 2007년내과학회임상강좌 Drugs in Emergency Tx (1) Management of asthma exacerbations Sympathomimetic agents in acute care setting 2005 update 2006 revision - Mechanism: activation of adenyl cyclase on airway smooth muscle Criteria for Severe Episode Criteria for Severe Episode - Do not inhibit late asthmatic reactions • Hx: high-risk patient • History of risk factors for near fatal asthma - Beta-2 selective agents preferred • PEF < 60% predicted/personal best • PEF < 60% predicted/personal best - MDI with spacer or Nebulizer vs Oral or IV,SQ route • Physical exam: severe symptoms at rest, • Physical exam: severe symptoms at rest, chest retraction chest retraction - Advantage: Rapid onset of action • No improvement after initial treatment • No improvement after initial treatment Good patient acceptance Treatment: Treatment: Effective bronchodilation with little tachycardia •Oxygen • Oxygen Wide therapeutic range • Inhaled β2-agonist and inhaled • Inhaled β2-agonist and inhaled anticholinergic anticholinergic - Proper technique is required for maximal effect • Systemic glucocorticosteroid • Systemic glucocorticosteroids • Consider intravenous magnesium • Intravenous magnesium Open vs Closed mouth technique • Consider subcutaneous, intramuscular, or MDI with spacer vs Nebulizer intravenous β 2-agonist • Consider intravenous methylxanthines 2007년내과학회임상강좌 2007년내과학회임상강좌 Bronchodilatory effect of β-agonist & anticholinergics β2-adrenergic agonist 800 salbutamol Dosages for inhaled β2-adrenergic agonist for acute asthma in adults 600 ipratropium Drug available form dosage comments 400 salbutamol MDI:100 µg/puff 2-4 puffs or 0.5~1ml safe for Pt without (=ventolin) solution: 5mg/ml every 20min x 3, cardiovascular disease 200 then every hour Increase terbutaline DPI:500µg/puff no MDI in Korea UDV: 5mg/vial 0.5-1ml 0 0 30 60 90 120 180 240 300 360 420 480 fenoterol MDI:400µg/puff ? not FDA approved Time(min) ( NIH Guidelines for the diagnosis and management of asthma, 1991) Responses
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