Asthma attack treatment in hospital

Asthma attack treatment in hospital UK


Asthma attack treatment in hospital


Asthma attack treatment in hospital Okay wasn't another make cram lecture will talk about a case today some action you go down to the emergency room to get called and there's a 25-year-olds. Asthma attack treatment in hospital Occasion female who is about 4 months postpartum. And she's having a hard time breathing so she's got shortness of breath it's been going on for about a week and it's progressive. And she has a history of asthma but she has been remiss in using her inhaler. And on physical examination, you notice that she's got a bilateral expert Tory wheezing. And her respiratory rate is in her twenties and she certainly is looking anxious she's got a history of anxiety disorders well. Vital signs she's a Febbraio her blood pressure is 150 over 70 pulse is already in the 1 twenties and that's because she's already received an albuterol and Atrovent nebulizer. She saturating in the low nineties about 92 percent and as we said her respiratory rate is in the twenties. You do a blood gas and her PH looks like something like 7 points 35 PCO 2 is in the high forties PO 2 is in the eighties and by carbs 24. 

So you give a nebulizer treatment again and you start steroids nebulizers. You're a little bit of oxygen but she doesn't get better she continues to have issues so you start her on some bi-pap because she looks like she's using some accessory muscle use and you start her on regular settings about 10 over 5 when you increase that to 12 over 6 and you draw another blood gas and instead of 7.35 after about 2 or 3:00 hours of battling with her and everybody else in the emergency room, you now get a PH of 7.206475 and 24 and that's on bi-pap she is awake alert oriented but she's a little bit more lethargic than she was initially okay let's stop there and talk a little a bit about what's going on with her and the diagnosis. So most likely this lady has an asthma exacerbation. I remember with asthma you've got a bronchus and you've got a smooth muscle that's going throughout this. Asthma attack treatment in hospital

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And because of information that is occurring in this area so inflammation causes contraction of this down to a small hole and as a result of that the air has a hard time getting out and that's the keyword there is out so air can come in but the air has a very hard time coming out and you have a problem therefore on exhalation. If you were to look at a flow-volume loop you would see a normal flow volume look looks like this you have a lot of air coming out initially and then you get to the small Airways and you take a deep breath then so that's what a flow volume local looks like with flow here on the. axis and volume on the. axis in small Airways disease either in COPD or when you have asthma flare you are going to look very similar on inhalation of stock it effectively out of here they can go into the lawn but what you'll see on exhalation is no issue with the larger ways but you'll notice that the small Airways are decreased and so you can see her flow rates on exhalation are incredibly


Asthma attack treatment in hospital


Asthma attack symptoms

reduced and again that's primarily because the small muscles here in the Airways in the small Airways particularly are contracted now there are 2 receptors that you've got to be aware of on here there is a muscarinic receptor and there is a beta-receptor the beta receptor actually causes muscular relaxation and so you want to activate this receptor with beta-agonists. However the muscarinic receptors you want to block with a muscarinic antagonist. And so those are just about all of the medications that and then I Teo trope ram ipratropium you medically dating him all of those anticholinergic medications were as these beta-agonists are the ones in and then L. that would be like albuterol some meter all 4 models so the are you Ms again are the muscarinic antagonists there is one that does not end with a and that is like pi relates so that's the one exception to this but the I are the muscarinic antagonist the oils are the beta-agonists and what that's going to do is it's

going to open up those Airways which is what you need to get the air out and so that's the real problem here air cannot get out of course it goes without saying that there must come out during the exhalation phase and see what the exhalation phase of breathing to be as long as possible well that's hard to do when the patient's breathing fast because that gives a short amount of time for both inhalations and exhalation so that is the issue with asthma and that's the issue with this patient that's come into the hospital. Okay so let's continue as it goes our the patient continues to get worse. And now she's becoming more confusing so the decision is made into the paper before the patient gets that intubation there's another blood gas that's gotten on this patient and clearly shows a worsening acute respiratory acidosis this time 7.108070 and 24 remember now that the bicarb has not changed the PO 2 is a little bit less the PCO 2 has greatly increased and that's because the PH to drop pretty precipitously so the patient's intubated with an endotracheal tube and put on the ventilator and initial settings for the patient of 20 a total volume of 500 of 5 and 2 of 100 percent so this means that the patients could get a breath at least 20 times per minute more


Asthma attack treatment in hospital


Asthma emergency treatment

if the patient demands that the total volume of each brought this could be 500 ML is our house leader the amount of pressure left in the circuit is gonna be 5 at the end of escalation and the patients could be breathing in 100 percent oxygen so after a while the patient is on the ventilator and X. rays are taken it shows that the patient has clear lung fields there's a heart but that the Hemi diaphragms are very flattened and the rest of the lungs are consistent with the hyper expansion the patient's blood pressure starts to drop slightly which could be because of the fact that the patient was sedated and helped and intubated and sedated for that or it could be because of hyperinflation and so what we are concerned about is the patients having something called dynamic hyperinflation on theme explain to you what this is what happens here is that the air goes into the lines.

As the air goes into the lungs inflates the lines in this case we're giving 500 of air but because the airwaves are so obstructed that it takes such a long time for the air to come out that let's say only 450 M. L.'s of the air come out before the next breath which is either the term and by a time constant or when the patient takes another breath another 500 goes in when only 450 came out and so what happens is with that next breath you're gonna get a little bit more hyperinflated and with the next press a little bit more hyperinflated and so that's called dynamic because this happens over period hyperinflation so what happens there is that the intrapartum pressure starts to increase and that can prevent venous return that can also increase your plateau pressures can also cause issues.


Asthma attack treatment in hospital


pressures and so the compliance of the loan becomes less and less and less and with the less venous return you're gonna get less cardiac output and a decrease in blood pressure and so really the crux here is that when patients have severe asthma exacerbations and the put on the ventilator and they start to dynamically hyperinflate the real key here is that there is not enough time for exhalation. Exclamation point triple underline that could be potentially a serious fatal situation where the patient could die because there's not enough time for exhalation if you ever see a situation like this where the patient is dynamically hyperinflated and they can't trigger the ventilator because there's so much positive pressure inside their lawns and their blood pressure's

going down in their heart rates going up you should detach them from the ventilator and allow a man of time for all of the air to come out of their lungs so that blood can come back to the heart and they can get a blood pressure. Short of that how would you prevent a patient from getting in the situation well join us for our next video where we talk about ventilator management issues and things that you can do to prevent specifically patients with obstructive lung disease asthma or COPD to ventilate without running into these situations but again the fail-safe ways to disconnect read more 

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