Asthma is defined as a chronic inflammatory disease of the airways associated with bronchial hyper-reactivity responsible for recurrent episodes of wheezing, breathlessness, chest tightness and coughing. Generally these symptoms are accompanied by bronchial obstruction, usually reversible spontaneously or with treatment.
The factors triggering / aggravating asthma are numerous: allergens, infections, exercise, certain medications (aspirin), tobacco, etc.
In young children, most of the early asthmatic episodes are associated with a respiratory infection without symptoms between episodes of infection. Piping episodes become less frequent over time; most children do not develop asthma.
Asthma attack (acute asthma)
The asthma attack is a paroxysmal access symptoms. Duration and severity are variable and unpredictable.
Assessing the severity of an asthma attack:
quickly determine the severity of the crisis based on the following clinical criteria. All the signs are not necessarily present.
Treatment:
The management depends on the severity of the crisis and the response to treatment:
Mild to moderate crisis:
– Reassure the patient and install half-sitting position.
– Administer:
• salbutamol (aerosol): 2 to 4 puffs every 20 to 30 minutes, up to 10 puffs if necessary during the 1st hour. In children, use a spacer
“In the absence of a spacer, use a plastic bottle of 500 ml: the mouthpiece of the inhaler into an opening in the bottom of the bottle (the container should be as airtight as possible).
The child breathes through the mouth, in the same way as a spacer. The use of a plastic cup of a spacer substitute is not sufficiently effective to be recommended. “To facilitate the administration (with a face mask in children under 3 years). Each puff administered, let breathe 4 to 5 times the content of the inhalation chamber and repeat.
• prednisolone PO: 1 to 2 mg / kg once daily
– If clinical improvement is complete: keep the patient under observation for an hour (4 hours if he lives far away) and then continue home treatment: salbutamol for 24 to 48 hours (2 to 4 puffs every 4 to 6 hours according to clinical response) and prednisolone PO (1 to 2 mg / kg / once daily) to complete 3 days of treatment.
– If the improvement is incomplete: continue with 2-4 puffs of salbutamol every 3 or 4 hours in cases of mild crisis; 6 puffs every 1 to 2 hours in moderate crisis, until the resolution of symptoms and when clinical improvement is complete, proceed as above.
– In the absence of improvement or if damaged, treat as a serious crisis.
Serious crisis:
– Admit the patient, install half-sitting position.
– Administer:
• oxygen continuously, at minimum flow of 5 liters / minute or maintain O2 saturation between 94 and 98%.
• salbutamol (aerosol): 2 to 4 puffs every 20 to 30 minutes, up to 10 puffs if necessary in children under 5 years, up to 20 flashes in children over 5 years and ‘adult. Whatever the age of the patient, use a spacer to improve the effectiveness of treatment.
or salbutamol (solution for nebulization).
• prednisolone PO: 1 to 2 mg / kg once daily
If vomiting occurs, use hydrocortisone IV every 6 hours (children: 5 mg / kg / injection, adults: 100 mg / injection) until the patient can tolerate oral prednisolone.
– If the improvement is complete, keep the patient under observation for at least 4 hours. Continue treatment with salbutamol for 24 to 48 hours (2 to 4 puffs every 4 hours) and prednisolone PO (1 to 2 mg / kg / once daily) to complete 3 days of treatment.
Reassess after 10 days: consider a basic treatment if asthma was persistent in recent months. If the patient is already receiving background therapy, check that the treatment is properly followed, reassess the severity of asthma and adjust treatment as needed.
– In the absence of improvement or for any damage, see crisis-life-threatening.
Crisis involving life-threatening (ICU):
– Insert an IV line
– Administer:
• oxygen continuously, at minimum flow of 5 liters / minute or maintain O2 saturation between 94 and 98%.
• salbutamol (solution for nebulization)
Children under 5 years or under 15 kg: 2.5 mg / nebulization, to be repeated every 20 to 30 minutes if necessary until clinical improvement; switch to salbutamol aerosol soon as possible (use a spacer).
Children over 5 years and adults: 2.5 to 5 mg / nebulization, to be repeated every 20 to 30 minutes if necessary until clinical improvement; switch to salbutamol aerosol soon as possible.
Oxygen must be used as a nebulizing vector.
• hydrocortisone IV repeated every 6 hours (children: 5 mg / kg / injection, adults: 100 mg / injection).
– In patients not rapidly respondent salbutamol nebulized:
• In adults, a single dose of magnesium sulfate (1 to 2 g in 20 minutes infusion in sodium chloride 0.9%).
• In children, nebulized salbutamol continuously rather than intermittently.
remarks:
– In pregnant women, treatment of asthma attack is identical. In cases of mild to moderate crisis, oxygen therapy reduces the risk of fetal hypoxia.
– For any patient, regardless of the intensity of the crisis, look for a chest infection and the underlying process.
Chronic asthma
Clinical signs:
– Asthma should be suspected in a patient complaining of respiratory symptoms (wheezing, breathlessness, chest tightness and / or coughing)
occurring by episodes including the frequency, severity and duration vary, waking him at night and forcing him to sit to breathe. These symptoms may also occur during or after physical exertion.
– Pulmonary auscultation may be normal or find diffuse wheezing.
– The presence of signs or personal or family history of atopy (eczema, allergic rhinitis / conjunctivitis) or family history of asthma reinforces the presumption but their absence does not rule out the diagnosis.
Patients both with signs and a history suggestive of asthma are considered asthma after exclusion of other diagnoses.
The evaluation of the permanence of the symptoms, their frequency during the day and night and their impact on the patient’s physical activity to determine if asthma is intermittent or is persistent.
Treatment:
Only persistent asthma requires long-term treatment. Background therapy (inhaled corticosteroids) depends on the initial severity of asthma. It is set to effective alleged landing and re-evaluated and adapted to the symptoms of control.The goal is to get no symptoms with the lowest dose of inhaled corticosteroids. The occurrence of severe exacerbation or loss of control requires a consultation to reassess treatment.
DMARD does not mean lifelong treatment. Periods when crises occur can last from several months to years, interspersed with asymptomatic periods where the basic treatment loses its appeal.
Inhaled corticosteroids: beclomethasone dosage depends on the severity.
We must seek the lowest effective dose for both control symptoms and prevent systemic and local side effects:
Children: 50 to 100 micrograms 2 times / day depending on the severity. Increase to 200 micrograms 2 times / day if symptoms are not controlled. In patients with severe persistent asthma, the doses can reach 800 micrograms / day.
Adults: start with 250 to 500 micrograms 2 times / day depending on the severity. If the total dose of 1000 micrograms / day (divided in 2 doses) is insufficient, it is possible to increase the dose to 1500 micrograms / day but the benefit is limited.
Puff count depends on the concentrations of beclomethasone in the inhaled suspension: 50, 100 or 250 micrograms / puff.
To prevent incorrect dosing on administration, use the inhalers of 50 or 100 micrograms / puff in children. Book puffers 250 micrograms / puff for adults.
Physical activities are not against-indicated; if the stress induced symptoms, inhaling one or two puffs of salbutamol is recommended 10 minutes before exercise.
In pregnant women, the poorly controlled asthma increases the risk of preeclampsia, eclampsia, hemorrhage, in utero growth retardation, prematurity, neonatal hypoxia, perinatal mortality. The basic treatment is based on salbutamol and beclomethasone inhaled at usual doses in adults. Avoid as much as possible oral corticosteroids.
When symptoms are not continuously monitored for at least 3 months, check the inhalation technique and compliance before moving to the next level.
When symptoms are controlled continuously, ie d. the patient is asymptomatic or asthma has become intermittent for at least 3 months: reduce inhaled beclomethasone and albuterol, and if it appears possible, discontinue the background.
In all cases with a salbutamol patient inhaler for éventuelles.Évaluer crises after 2 weeks. If the result is satisfactory, continue for 3 months and reassess. If asthma becomes persistent, resume background processing at appropriate level, etc.
