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[Music] good afternoon everyone this is dr vishali and i welcome behalf of netflix first of all a very happy independence day to all of you thank you so much for joining today for this session so for today's session the session is very important when it comes to the emergency management so it's the emergency management of asthma and casualty for that we have with us our netflix select superstar creator dr salil benray he's a pulmonologist and a transplant physician at nana at the max hospital global hospital and massena hospital mumbai so we are delighted to have you or happy independence day to you as well and i would hand it over to you now thank you thank you thank you very much and as as everyone is should be celebrating today happy 75th independence day for everyone it's really a fantastic occasion and as usual we are back on this particular session on uh asthma so it is as everyone knows a very very common disease and i am sure everyone of the clinician doctors who have been practicing have seen patients of asthma prevalence of asthma is very high we very well know that asthma actually goes across all age barriers right from children to the middle east to the elderly so there is no age barrier where we can say that asthma is more common in this age or that the other age and as we can see these days with the seasonal change the monsoon and the havoc created by the flu infections asthma triggers have increased and obviously you all will be seeing patients of asthma in a large number so today's topic is going to be asthma and casualty or as mining emergency situation as we can talk about even asthma where a patient is having severe attack of asthma and he comes to your clinic in the opd or if you have a daycare center what to do and how to approach that patient so let's start with the practical scenario i'm not going to show many slides there will be few five to seven basic slides only it will be more of uh what should be the practical practical approach to asthma patients so when you have a patient who comes to you and he obviously we are talking of acute asthma so he's very breathless he's having a respiratory rate very high the symptoms either he comes himself and is able to speak well and good but most of the patients when we say acute severe asthma they are unable to speak and someone gets the patient to your opd or to the casualty with a patient being saying that since about few hours the breathlessness has increased or it has worsened or that he has been on inhalers for last two days but since last few hours the breathlessness has become out of control and we have got him to you to the casualty so that is the usual scenario very less often you will find patients without any past history no history of asthma not being on inhalers and first time he comes with a sudden attack or sudden onset asthma uh where he has come to you in that situation the first thing you're going to take is going to be the pulse oximeter that's going to be the first thing which you need to do any patient who is breathless when the history started what was the onset of this is very important but it's very crucial to first see whether the patient is having hypoxia whether it's sinus so the first thing in a breathless patient you are going to check is the respiratory weight because it will be very high he could be using the accessory muscles of respiration there would be dilatation of the alienasia there will be more involvement of the diaphragmatic muscle with muscles as well as the neck muscles so there would be obvious signs where the patient is the clinical assessment tells you that he's in respiratory distress so first and foremost pulse oximeter saturation is what matters because that will change the line of your treatment if the saturation is going below 90 percent you have seen the patient he's in the casualty he's tacky at times you may actually hear the wrong kind which we call as audible vs okay we may be able to hear the expiratory sounds which could be audible vs and when you check the saturation it could be as low as 76 or even 84. so there could be a drop in the saturation right at the time the patient has been brought to the casualty right at that time now the patient may tell you or the relative may tell you his breathless since a few hours and you need to starting one of them that's the first thing you need to do even before you really start investigating him further are starting to tell the nerves or you start giving an intravenous or intramuscular injection first thing is you need to secure the airway and the breathing you need to start the patient on nasal oxygen what i mean to say here is that in case you find that in your clinic itself you have a patient who comes to you saying i have got an acute attack of asthma and you find that the saturation is going below 90 his respiratory it is going about 30 it would not be very appropriate to actually start treating him in a clinic where you don't have oxygen oxygen facility you need to give the patient oxygen whatever treatment you give may be form of nebulizer may be in the form of injections will have some duration for its onset okay so you need to have that kind of a backup and the topic today is actually asthma and casualty so if we are talking of casualty we are well-versed with that that there would be an oxygen backup to be given to the patient so the oxygen is started oxygen is started and now is the time where you need to think should i treat him as asthma or should i treat him as a mimic of asthma so there are certain clinical presentations which may look like asthma but may not be always asthma all right when we say asthma as a disease we mean to say that the airways have gone into a spasm they have there is a smooth muscle contraction and that has caused the narrowing and it is leading to the breathlessness there is a similar mimic where the patient present with sudden onset breathlessness there would be wheezing also there would be hypoxia also and that is what certain books call it as cardiac asthma what is cardiac asthma it is actually cardiac failure and pulmonary edema so there could be a mimic of asthma which is not asthma but we are seeing a patient who has cardiac asthma or who has pulmonary edema and this patient will also come with breathlessness you will be able to hear wheezing his saturation will be low you would be sweating now please mark that there is a little difference in these patients with cardiac asthma or pulmonary edema usually they have a background history of a cardiac disease or a comorbidity which could be a known hypertensive a elderly person a diabetic or an obese person patient who has already had a ischemic heart disease who is on vasodilators or on blood thinners who has undergone an angioplasty earlier so there would be certain clues which may help you find out that this is may not be the treatment way to go ahead with giving only and only nebulizer you need to do something more and that something more is diuresis is lasik is infusion with prosemite so you need to please understand that every patient who comes to you and who is wheezing need not be asthma so everything which visas is not asthma that is very very true and in the initial phase of pulmonary edema before they get pink for the sputum as very typical and classical presentation in fact they will have bilateral wheezing so you may come across a middle aged to elderly patient who got into the wheelchair and is brought into the casualty and his breathless respiratory is on 36 saturation is 82 he is psychic he is sweating bilateral you put the stethoscope and there is wheezing her and you may feel that oh this could be acute attack of asthma but please remember you need to understand it could be also a cardiac ailment if he could be infecting it could be actually having a myocardial infarction he may bring pulmonary edema so you need to be sure about that but the bottom line as i was saying in the beginning is you need to give oxygen start oxygen because giving oxygen helps even the myocardial supply of oxygen is held plus the respiratory muscles get oxygen so definitely the first line of treatment in a patient with hypoxic and breathless will be to give him oxygen so it matters to know that whether it is life threatening whether it is severe whether it is mild to moderate so one of the mimics is of course cardiac asthma there could be another mimic there could be a patient with foreign body aspiration and asphyxia which may come with sudden onset breathlessness so there is a while having lunch or dinner he suddenly had a bout of cough and suddenly the patient becomes starts choking he starts wheezing he's brought to the casualty with a history that since a couple of hours suddenly he's become breathless saturation is gone to 80. so you need to also keep in mind there could be a foreign body aspiration which could be partially obstructing one of the airways and giving rise to a wheezing sound and it is certain onset so there is breathlessness as well there could be vocal cord abnormalities which may present in the form of abnormal sound and there could be wheezing there could be breathlessness not very common but tracheomalacia where the trachea collapses when the patient is breathing in there is a sudden collapsing of the trachea it may also present with wheezing and hypoxia but as we all know the commoner one would be in terms of bronchial asthma so we come back to the situation where we are in the casualty or the emergency department you are sitting there a patient is wielding is bilaterally wheezing saturation is low you started the patient on oxygen what are you going to do next of course we are going to tell the nurse or the sister whoever is there to place secure iv line intravenous line you need to do that because whether it is elastics whether it is any other injectable bronchodilators you need to have a intravenous line along while the sister is doing that you are going to do two things one is take the blood pressure you need to also take a cardiogram or ecg very important to do a ecg to check whether the patient is having a myocardial perfusion injury there is a problem with the heart there is arrhythmia for that matter so a cardioscope will also pick up an arrhythmia so you may put the ecg leads start the cardioscope and you can make out the changes in the cardiac monitor if there is only sinus tachycardia the heart rate is 130 140 but no changes then you may understand it is more of a respiratory distress which is giving rise to the tachycardia but please do not forget arrhythmias and cardiac ecg changes to be always considered when the patient is having breathlessness even if it is an asthmatic so a asthmatic patient may develop cardiac problem and may be brought to the casualty with cardiac failure an asthmatic patient may develop aspiration and could be brought to the casualty with more breathlessness similarly a asthmatic patient may be brought to the casualty with an air anemia and he will have to be managed according to what is the arrhythmia on the cardiac monitor on the ecg at this point of time you need to also do a blood sugar checking at gt because anyway the nurse is going to put iv line it is best to take one drop of the blood and tell the sister or whoever is the other attendant to do a blood sugar testing because you are going to treat many things simultaneously you would be probably pushing the patient on iv fluids which may be dextrose you may give the steroids so you need to know one more thing which is how much is the blood sugar at this point of time so these things will more or less come to you automatically it's just about that situation where you are going to start the patient on oxygen you are going to take the blood pressure and iv line is inserted a blood sugar testing is done and the cardiac monitor is switched on once you start the oxygen you will observe that the saturation is improving okay it may be initially 84 82 but on 1 liter or 2 liter it may come up to 88 it is not touch the normal but it is at least improved from what it was now one more test of course we are going to discuss the treatment also but let's just see what will be done in the in the icu now the next thing which happens is here we have in the casualty or nebulizer so we are hearing a patient having wheezing we are hearing that there is a lot of ronki also saturation is low you are going to start the patient to use a nebulizer we will discuss which nebulized medicine to be giving but what i am focusing on is the bronchodilator because bronchodilators will open the airways and they are locally acting so they work very fast in fact salbutamol works within few minutes so the moment you start an acetalin or a salbutamol nebulization the airways may open and it may help the patient to breathe more easily the respiratory distress may settle down so nebulization is something with a mask so we are going to give nasal prongs we are having a nebulizer you may start the patient on a nebulization there would be response rescues means there are liquid solutions which are to be twisted and put in the nebulization chamber and the nebulization is started and once the patient is put on a mask or a mouthpiece so there are two ways to give a nebulizer one is to put a mask and the patient is breathing second is there is a mouthpiece either way you put the put the mouthpiece in the mouth and while he is breathing the medicine is getting inhaled and is going into the airway so one is to put a mask or the mouthpiece so either of them you start the nebulization one of the ways which can be done in case the nebulizer is not handy is you can actually connect the oxygen cannula the the cylinder or the place from where the oxygen is coming that same cannula be connected to the chamber of the nebula that's the hudson's chamber and you can start the nebulization and obviously with the flow of the oxygen the nebulized liquid is made into small fumes or mist and the patients start inhaling that so we are doing two things at the time we are giving him high flow oxygen and we are giving him nebulized medicine as well so both the things are happening if you are giving high flow oxygen and giving nebulization simultaneously okay so let's put one two three four things together so one is that patient is wielding you're going to start him on oxygen pulse oximeter has to be there that's the most important instrument at that point of time oxygen is started how much to start oxygen is a question now there is a flow meter on the oxygen cylinder which will mark one two three four it's up to ten okay it's up to ten now once you start the flow meter to two or three our target is that we want to maintain the oxygen saturation above 90 that is my target it may not come to 98 because he is still wheezing there is still bronchial airway narrowing so i can't expect that saturation will go to 97 or 98 the other medicines will act then the saturation may improve so my focus will be to keep the saturation about 90 why should i keep it above 90 because i need to maintain the myocardial oxygenation the brain oxygenation the renal oxygenation the tissue oxygenation to the muscles and to maintain that i need to maintain a saturation of at least more than 90 so that will be my target so the oxygen is started ecg is taken cardiac monitor is started iv line is inserted the sugar is checked and now we are going to understand what exactly we are going to do is we are going to start the nebulization so role of bronchodilators in cardiac asthma as doctor is asking so in cardiac asthma it is going to help to open the airways no doubt because there would be narrowing the fluid which comes into the septum the interceptor fluid is also causing a narrowing but remember these are bronchodilators so they work better if there is a smooth muscle contraction so there they are more effective obviously when we are treating a patient with bronchial asthma not so not supposedly an active ingredient when we are talking of cardiac asthma so there could be a mixture of both so what i am trying to explain in one way is also that you may have a patient with cardiac disease developing asthma so at that point it may be very difficult to make out whether it is purely cardiac or purely purely respiratory so when we don't have the time to evaluate it you are going to start the patient on nebulization you will have to start the patient on nebulization keeping in mind tachycardia please do not forget this so the beta to add one which we are going to use is salvation okay so that has got a side effect of causing tachycardia it may lead to tachy arrhythmias also so if a patient is having tachycardia and you are giving nebulization please keep a watch about arrhythmia and if the patient is already having a cardiac this is more the reason that you need to be careful you may switch on albutermal to lever salvador levos albutamol is one of the ways because it's a levo isomer of that bittman so the side effect profile is comparatively safer when we think about giving livo salvation so that is one way where we can try to take care of the cardiac arrhythmias another option which at some point if there is a cardiac arrhythmia is to start with ipra trophium ipratropium it's an anticholinergic a protropium is also shown to have tachycardias no doubt but you may try to give a combination of levos albutamol and ipratropium and hair and check whether the wheezing is reducing the position in which the patient should be kept is very important as someone is asking it is about hypotension see now when this patient has come to you with breathlessness hypoxia wheezing if we are talking of tachycardia the heart is beating at almost 140 or 130 beats per minute what is happening is the cardiac output is getting compromised there's cardiac output is getting compromised and as the cardiac output get compromised the pressure the systemic blood pressure will drop got it at the same time if the patient is having a low cardiac ejection fraction it may still precipitate the cardiac output and obviously the hypotension will come into picture so in such a situation you are not going to make the patient sit we are going to keep the patient lie down because then the cardiac output may improve not completely but you have to be careful about that so you have to check i'll every time go back to the basics is first oxygen pulse oximeter ecg cardiac monitoring iv line you need to do the abg arterial blood gas so by this time you started the patient on nebulization and by the time the nebulization is going on you are also going to do a arterial blood gas provided that facility is there in the nursing home and hopefully if it is there then that sample which is used which is collected in a heparinized syringe is sent to the lab to tell us about two important parameters one is about the ph and second is about carbon dioxide so both the parameters become very important when we are thinking about the next few hours of treatment okay so at this till this point i think we have talked about what will happen dr john is asking about buddhist tonight yes dudacion is the inhaled corticosteroid now inhaled corticosteroid takes more than an hour to really show an effect and that is an anti-inflammatory effect so though it is used in casualties in emergency departments when we talk of acute asthma and attack of asthma or very severe asthma what our focus is going to be use albutermal salbutamol okay there has to be nebulized form if you don't have a nebulizer there could be varied situation there there may not be a nebulizer available you would have to use a metered dose inhaler with a spacer so there is a instrument called a spacer and a meter dose inhaler and we can actually put a mask connected to the spacer connect it to a metered dose inhaler and press the meter dose inhaler so it can give the medicine into the mask all right so not necessarily okay i've been abilizing here now what to do you can go in for a metered dose inhaler with a spacer and speed spacer can be connected to a mask so a mask can be put spacer is connected and a meter dosing here so this is the next step which we are going to do is about starting the patient on nebulization preferably salvator mall achievement levos albitamol apratropium is one of the ways by which we can sort of try to manage the arrhythmias in case it happens that the patient is becoming drowsy we have to see the extremes of the patient either the patient will settle down yes we will come to iv magnesium also but before that we are still managing the acute patient in our emergency world is that there are two ways his patient may move about one is he may worsen second is he may improve now if he starts improving the saturation starts improving the tachycardia starts settling down his therefore his sweating stops and he may be able to speak because initially he was so breathless that he was not able to speak at all he may be able to speak the other extreme of this is that the patient may become drowsy he may become cold and comatose he may become unconscious now these things are something which we need to manage by putting the patient on a ventilator we cannot have a patient who is comatose or becoming unconscious and naturally we can't start giving him just a metered dose inhaler or a spacer you need to maintain his airway so you need to maintain his breathing so at this point if at all he worsens he becomes comatose unconscious losing sensorion you need to start immediately resuscitating him he has to be integrated he has to put in a lambo bag and you will have to put him on a ventilator similarly you have to manage the cardiac aspect also so one question about how many puffs we can give through the metadose inhaler so as we know meter dose inhaler contains 200 micrograms 400 micrograms so we have to obviously give two puffs immediately after five minutes you can give another two cups because the dose of salbutamol is up to five milligrams we can give if you go to see the residues that is the nebulized solution it is 2.5 milligram per 2.5 ml whereas in the meter dose inhaler you get in microgram so naturally you can go to a higher dose of meter dose inhalers two parts weight let the patient at least breathe and breathe out if you keep on pressing it it will just keep on accumulating in the spacer so giving a puff is important giving two puffs is also important but at the same time he has to inhale and exhale at least six to eight times so that the medication starts going into his airways and showing some effect immediately if you start pushing more and more and more metered dose inhaler it is not going to be effective and it's not going to reach the lower airways neither the larger airways most of it will just deposit in the mask okay so salvitomol we have talked about oxygen we have talked about now at this point what we have done is very very good management we started the patient on oxygen we started the patient on nebulizer we told the nurse to take a iv line we have told the blood gas to be done sugars came up to be 120 or 140 so it was not in the higher range nor in the hypoglycemic range and now we are in the situation to start the next line of treatment okay so at this point if everyone is clear about how we are managing we are going to start the next line of treatment which will be coming parental or systemic medication now in parental medication there are two medications which are commonly used as someone is mentioning here dr sonam is mentioning we have steroids to be given and second injection which is available is the theophylline amino fiber so these are very common injections which are used or given during an acute attack of breathlessness we will discuss both of them definitely we are going to talk of both of them in all this plan of treatment it is very important for you to keep auscultating if possible there is a facility of a portable x-ray please do a portable x-ray at times this severe airway obstruction has given rise to lot of air trapping and subsequently a pneumothorax so there could be asthma with right-sided pneumothorax or asthma with left-sided pneumothorax or asthma with bilateral pneumothorax so you need to also start planning all these things simultaneously the way you talk to care of an ecg if possible it should be asked for a portable x-ray you he cannot be taken to a x-ray room in the situation right now which we are discussing maybe after stabilization you can definitely take him by this time the sister is asking should we give steroids so we go to the next important point though it's a very uh you know lot of things written on this slide if you people can pinch the slide and zoom you may be able to see that nebulized bronchodilator is the first line and salbutamol 5 milligram with ipratropium 0.5 mg via the oxygen cannula is very good to maintain the oxygen as well as give the delivery of the nebulized medicine coming to the next plan as everyone is asking about steroids so yes there are three forms of steroids one is i think each one is accustomed to it i'm not saying anything new about it hydrocortisone methylprednisolone and so either of them is available uh hydrocortisone um dexamethasone and methylprednisolone the one which acts the fastest is methylprednisolone so methylprednisolone it acts within an hour and the effect is lasting for a few hours so methyl produce alone if you talk about the dosages even if you give point it's up to 0.5 mg per kg 0.5 to 1 mg per kg bolus can be should be given so if you have a 50 kg person a 40 milligram 50 milligram of methyl friendly syllable intravenous will be the will be a good injection to give having a good effect and a long lasting effect if it is not available naturally we are going to think about hydrocortisone there is a difference in the cost so hydrocartesian is definitely easily available probably there in the casualty in one of the instrument boxes for emergency medicines and 100 milligram six to eight hourly will be how we will have to give hydrocortisone so dexamethasone is again very much available in most of the hospitals it can be given intramuscular also however the efficacy becomes slow the onset of action becomes slow if you are going to give an intra muscular injection intravenous is the choice and that's why i said that first thing when the patient is being assessed one of the nurses has to take a iv line it is very important either you may have to give one of these steroids you may have to further give a amino filing also or at some point of time if he goes into an arrhythmia then you may have to give one of the anti-arrhythmic agents as well and it may happen that after about an hour of assessment seeing his reports you may feel that he is also having fluid overload even classics needs to be given intravenous so nebulized bronchodilators very important hydrocortisone methylprednisolone dexamethasone so dexamethasone four milligram twice a day hydrocortisone hundred milligram twice a day methyl protein salon 40 to 80 milligram once a day is more than enough to maintain the anti-inflammatory effect steroids don't have any bronchodilator effect so they are not going to improve the bronchial constriction in 10 minutes or 5 minutes that job is done by the bronchodilators like salbutamol that's why i said that we need to nebulize it you may use continuous nebulization as long as the heart rate is within range or you are there are no techy arrhythmias you can actually nebulize wait for about five minutes again put the next nebulizer and continue the nebulization so we are doing nebulization we are starting the patient on steroids choice methyl methylprednisolone first acts faster of course the common one which is used is hydrocortisone you're going to keep a check on the sugar because steroids are going to pump the sugars to go up by this time the patient comes the nurse reports the blood gas abg because it takes at least some time for the blood gas report to come to you now you are going to analyze the abg report the abg report is showing a ph of 7.14 okay so it's an acidotic ph the carbon dioxide is on the lesser side it is hyperventilating patient is tachypnic so is washing out carbon dioxide so carbon dioxide is around 30 [Music] the lactates have increased acids have increased there is a lot of metabolic acidosis because the muscles have been working faster and faster so the acids have increased and led to metabolic acid acidosis so this could be one of the abg's which may come up in a patient of acute asthma has been brought to you and suddenly you find that there is actually respiratory alkalosis but at the same time the muscles are generating lot of acids and that's why the acids have come down okay so there is a metabolic acid also if at all you see another scenario patient was unwell since day before yesterday or yesterday and he's been for overnight and they have brought the patient the next day to the casualty he may be actually going into respiratory fatigue because he's been breathing fast for a long duration and in that situation you may actually find that the carbon dioxide is getting retained there is retention of carbon dioxide so there could be respiratory acidosis come up in the abg so if the abg is showing a ph of 7.14 carbon dioxide is 76 please be sure that this patient should be put on a bipap or a niv non-invasive mode of ventilation you cannot just stick to giving him nasal oxygen so what are the criteria to put a patient on an niv one and foremost is to check whether the patient's abg is not positive if the ph is above 7.2 you can still hold on but if he is going into acidosis carbon dioxide is rising even for that matter ph of 7.24 7.26 with a carbon dioxide of 55 it would be still appropriate to start the patient on a bipap or a niv what will the nib do it gives a high pressure and helps in more dilatation of the bronchi it helps in the compliance of the diaphragm so it allows the more ventilation to happen and improves the carbon dioxide wash out so you may be actually doing good by giving him a niv and his breathing is supported he doesn't go into further respiratory fatigue so you will have to plan these things so going back to the first time we saw the patient that patient came to our casualty he was taconic breathless sweating saturation low started the patient on oxygen started the patient on neutralization clinically there was bilateral disease that they put the patient on a iv line was inserted sugar was checked the blood gas was done patient blood pressure was checked if he is hypotense tensive you are going to put him on iv fluids also okay you need to put the patient on iv fluid also now see the questions changed to this patient is about has he passed urine in the last few hours because now we are thinking is it cardiac is it pulmonary is it is he having a fluid overload has he passed enough urine is he not passing urine so you may actually tell the nurse to pass up catheter as well a police catheter because we need to monitor the output so if the blood pressure is high patient is not passed during bilateral beazing you are waiting for certain lab reports to come and there is enough indication that he is also having fluid overload you may have to actually diuretize the patient i hope everything is clear till here then we go ahead with one more point which few of you have been making about magnesium sulfate so intravenous magnesium sulfate single infusion of 1.2 to 2 gram over 20 minutes has been used in in acute asthma so that is one of the ways or one of the adjoints of the therapy that is not the primary treatment it is an adjunct with the therapy along with the neutralization along with the steroids or the anti-inflammatory so this is the way we will move on at this point you need to have an x-ray by now you know you need to get an x-ray because we need to see if there is anything else which has come up is there a collapse certain patients because of an aspiration there could be a segmental collapse and that could lead to sudden onset breathlessness and there could be wheezing also so if if we try to check the management of acute asthma attack though it's a very simple one because we are going to go very logically oxygen salbutamol hydrocortisone apriotropium we'll talk about theophyllines magnesium and intubation knowing that we have to rule out cardiac asthma knowing that we have to do a x-ray of the chest knowing that we need to know the output of this patient also so all these things have to be known okay i think magnesium sulfate the dose i have mentioned there in one of this thing single infusion of one to two grams over 20 minutes [Music] frankly speaking i i have not i mean it should not be that what i have done it is recommended but my most of the patients who are asthmatic they respond to oxygen they respond to nebulization and to steroids steroids as i said will not be a magic drug that you give steroids when the the wheezing will go on you know it takes its own time okay so we are going to wait and start using this treatment modality one sample at this point should go for a blood test also means whenever you are putting an iv line preferably put one one sample for blood cultures and hemoglobin and other tests they will be going so that the lab reports come later on by maybe in a few hours you may get the idea about what is the problem now we will go to the next slide so this this is like a short term action each one of you can just note them down we'll talk about amino file in dairy filing because that is one question which uh few of you have asked but meanwhile just go through the names of these so beta stimulants we have talked about salbutamol and turbo talent in fact turbutarian has been used subcutaneous also in acute asthma we don't use it much in that form now with the nebulizations available the effect is very quick and very fast and with methylperitoneus alone and other forms of uh long co-dilators we really don't need to go into subcutaneous very very less less use of turbutalin presently coming to the bronchodilators and the drug uses just a little bit details about that so this is the dosage of salbutamol as i mentioned here 0.15 milligram per kilogram per dose and 0.5 mg per kg per hour now as someone was asking about the inhaler so salbutamol inhaler two puffs wait for at least patient to take in and exhale six to eight breaths then make it two puffs again if you keep on pressing it every every moment every moment it's not going to actually go into the deeper airway apra tropium and the someone who is also asking the dose of steroids so prednisone i have mentioned over here now this dose of friendly salon is important we know the side effects of freddie salon so there would be some special special situations there could be a patient who is having uncontrolled diabetic and he's on his foot on steroids there could be a patient who is having osteoporosis but he needs steroids there could be a patient who is having peptic ulcer disease but he needs steroids you need to be careful and monitor these things the moment you switch to oral steroids there is always a risk of perforation the ulceration to aggravate even gastritis to aggravate so you need to give along with that proton pump inhibitors or maybe new cane gel something to sort of neutralize the effect of the steroids so you don't forget that patients who are going to be on steroid for a longer duration please situate that you have to uh you have to sort of uh give calcium along with it or give vitamin d supplements along with it because many of our patients can actually uh go into osteoporosis on a later date later later uh later time so buddhasonite dose so glutathione comes also as rescues so again we have to either we give salvation all then alternate it with buddhism but the better option is give salvation all till the breathlessness gets controlled then you add buddhisonite buddhisonite would be again putting one rescue and again after another six hours another six hours so beautiful night you need not keep on repeating nudisonite every five minutes every ten minutes okay so uh these practical problems will be faced by all of you right from dosages okay uh can we give steroids in patients with old tb yes because here we are dealing with a life-threatening situation so why are we using steroids is if there is an acute asthma sudden onset asthma extensive wheezing we have to use steroids but it is not only the dose of steroid which matters but the duration of so when we say that now today he's in emergency situation and i have given 40 milligram penny salon or methylpridney salon after two days or three days i would start him on oral steroids now oral steroid going by the books definitely it is going to be for at least two weeks we need to give him a high dose of steroids having said that you need to customize your treatment as i said all the factors diabetes osteoporosis peptic ulcers not even old tb there would be patient with active tb having acute asthma now having active db does not mean now you can't use steroids you have to use steroids for that instance it won't cause immunosuppression one dose to those three doses of steroids will not cause immunosuppression what you are worried about is will immunosuppression happen and tuberculosis will flare up so that is not going to be the case so we can use steroids even in active tb if you are treating the acute emergency okay now this is some dosages about the steroid which which few of you wanted so hydrocortisone dexamethasone prednisone please note them down so that they are helpful to you when so as you can see here it is three to five days three to five days three to five days it is not going to be for a significantly long duration in fact the examiner zone is only going to be one or two days and then we are going to actually switch on to the short acting so there is a short acting steroids intermediate acting steroid and long-acting the dexamethasone being long-acting steroids less preferred methylprednisolone is going to be of course acting very fast green is the short acting so epcorlin or hydrocortisone which we use is the commonest steroid less costly also so that is one of the commonest medications which is used to give in a patient with acute attack of asthma now coming to uh amino firing amino vitamin is something which is used very common now the problem with amino violin is its therapeutic index therapeutic concentration so first let us understand what is the problem with theophile and the problem with aminophylline dairy filing is three four things remember this one is tachycardia they induce tachycardia they can induce seizures convergence okay so they are called they can cause actually even gastritis so these are the three main things which can be something where we limit the use of which can lead to a limitation of its usage and having to be more cautious and judicious when you use amino fiber so there has to be a loading dose there has to be a maintenance dose the loading dose can be given up to 5mg per kg of course these are diluted in even dns and it can be given over a period of a few hours and then we are going to give him an infusion of 0.6 milligram per kilogram over 24 hours as that is mentioned here one two three the fourth point maintenance growth of 500 micrograms per kg per hour in the elderly there is a lesser dose than in the patients who are already on theo filing so those who are already on theophile and they would have a concentration of theophylline in their blood the aminophylline and if you infuse it very fast even for that matter if you give dairy phyllis intravenous it has to be diluted in 20 cc of saline and given over 30 minutes you are not supposed to give dairy file in intravenous as a bonus you are going to dilute it and give it over 30 minutes so dairy filing intramuscular is something which is given compared to iv since it is intramuscular the side effect profile is safer intravenous can cause tachycardia if it is not given in a slow uh slow form if it is given as a bonus it may induce such a bad tachy arrhythmia that it may actually cause cardiac arrest as well okay so there is a specific way to give aminophylline it can be diluted in ns normal saline or in glucose it has to be given as a loading dose and then it has to be given over a period of 24 hours slow infusion correct amino filing now amino filing is a bronchodilator absolutely so theophilics work as bronchodilators but again coming back to what is the safest bet on using bronchodilators is nebulized salvation the next income is the steroid it's not a bronchodilator it's an anti-inflammatory but steroids and third will be amino fiber so these three things will be actually used step by step as per your requirement now if we put all this knowledge together and we have a patient in our casualty who is breathless who is having these you are going to know that you have to rule out cardiac asthma we have to rule out foreign body aspiration we need to do an x-ray to check whether there is a pneumothorax vocal cord dysfunction all these things have been considered patient is put on oxygen patient is nebulized with salbutamol if nebulizer is not available we are going to meter those inhaler with a spacer is going to be used watch for tacky arrhythmias lemo salvatomol is available a combination of devos alberta mall with ipratropium is also available in nebulized form also as well as in the inhaled form so use it secure iv line send a blood gas sample do a blood sugar test start using the help of a blood gas to decide whether you need to put the patient whether there is acidosis whether that's carbon dioxide retention while doing all this if the patient becomes drowsy there could be some patient who is being nebulized and suddenly he starts becoming drowsy or he starts painting then there is no way but to maintain the airway how do we maintain the airway we need to intubate and put the patient on a ventilator however if you find that the patient is arousable okay it's oriented but arousable his ph is acidotic carbon dioxide is increasing please do not wait with only oxygen you need to start the patient on a niv if there is a cpap or a bypass please start with an niv is preferable and that helps the carbon dioxide magnesium sulfate we have already discussed at this point you may give him efcolin or hydrocortisone the dose we have discussed of ethylene or hydrocortisone and it works very fast short acting so you may have to repeat every six to eight hourly methyl friendly salon act for a longer duration of time you can give it as a bonus 40 milligram check the weight of the patient approximately and decide the dose dexamethasone it's a long acting steroid but yes it is it is used intramuscular also if you are switching on if you are giving a minor filing so if at this point of time you feel that the patient is responding i don't think you need to start a minor fight are improving or his clinical assessment shows that his wheezing is less you did not you need not start the patient on a myeloma infusion so i would prefer that amino filing be kept reserved it has its own problems i can't say that it is a very very common problem that everyone faces many patients are given even verified and intramuscular on opid basis there are doctors who give intramuscular dairy filing which safely but you need to be cautious tachycardia seizures gas priorities in fact at times if you do a theorem therapeutic level later on of pure filing you may be having to step down the dosages of the theophile lens or amino filings which you are giving after all this coming to the last five minutes of our discussion today after all this you are going to definitely take a detailed history of what triggered the asthma the story doesn't end just by salvaging the acute attack of asthma it's actually in fact going to what triggered it was it reflux was it a dust allergy was it a food allergy anything which triggers occupational dust changing the weather traveling viral infection viral infections they can itself trigger asthma or aspiration microaspiration so all these things together have to be considered when you are planning to treat this patient tomorrow and day after do not forget most of the medicines steroids aminophylems do cause reflux and gastritis especially gastritis so gastritis may increase asthma you are using theophyllines for asthma you are using steroids for asthma but steroids are increasing the gastritis and gastrointestinal so you have to plan the strategy as to how you are going to work on that now what is the role of physiotherapy in acute asthma i think the physiotherapists are the best people to tell us about that there are physiotherapists who help out in acute asthma but i assume that in respiratory distress where the patient is hypoxic patient is unable to breathe we really can't tell the patient to do a particular set of breathing exercises we need to control the vital parameters first then institute the physiotherapy or the exercises which would be wrong the role in asthma yes definitely role of physiotherapy acute attack of asthma limited so try to maintain the blood pressure the saturation very important heart to be considered make use of a 2d echo when there is always a confusion happening a 2d echo would help you to understand whether the fluid overload there is a diastolic dysfunction pulmonary hypertension these are important aspects you should never forget when the patient stabilizes you need to do a ct scan if you feel so why i'm saying it one thing please remember i have seen recently also patients who have got acute pulmonary embolism they come with acute onset breathlessness and they are hypoxic and respiratory rate is high but since the age is young or there is no risk factor it is not suspected that there is pulmonary embolism so please take care of these that aspect also whether the patient has embolized this is actually a acute embolism there will be many pointers to it ecg will pick up 2d echo will obviously pick up if your center d diameter that will also be used of of use to note out whether there is a pulmonary embolism and naturally if there is acute massive pulmonary embolism just giving oxygen doesn't solve the issue because there is a definitely a perfusion defect so oxygenation is not improving so with that i thank all of you and thank netflix for having me today on this occasion of independence day and i hope uh you have been benefited by whatever we discussed today thank you so much thank you so much sir for that session i would request all our audience members to uh put up their questions if they have any more in the comment box till then we'll just go over the upcoming sessions that we have so the upcoming sessions we have is tomorrow we have recent updates in art uh by dr n kumarasamy and then we have on the 22nd august that's on monday we have the approach to the case of joint pain by director mahadev desai please make sure you've reserved your seat for these sessions by going on the home page and just quickly take over the questions which sir would tajitindrasha is asking is there any role of ppi say pantoprazole not directly in terms of asthma management we would be using it in case there are since we are giving steroids and patient is having stress there is a reflux that is so to control that here okay tips for managing in rural areas uh small clinics where there aren't any hospitals available nearby so the important aspect is that you should have a nebulizer you should have preferably an oxygen concentrator because at least you can manage for a few hours till the patient is shifted or transferred definitely a rule of intravenous or infra muscular because in in situations where in the rural areas or in public hospitals where facilities are not there there is a role of dairy filing being given in fact also being given so i think you need to have these few things in your clinics and pulse oximeter i suppose everyone would have so at least the first state part you have been able to supply to this patient right uh dr jitin nair is asking is the management of acute severe asthma same for pregnant females also so the management is the same for pregnancy okay we have one raise and i just accept the request dr smith i have accepted your request please turn on your audio video when prompted to do so uh hi can you hear me yes sir actually i wanted to ask liking i've experienced some cases in which uh like the spasm was refractory to uh even a minor file in in some emergency situations or an icu even after intubation the spasm is not getting relieved tachycardia is not getting relieved after minor filing as well so sometimes we get stuck so what should we do in such situations so very rarely it does happen and again at this point the adrenaline subcutaneous has also been used in such cases and it has been useful i i don't think that it will be the best thing to do but subcutaneous adrenaline has been used substitute turbulent has been used uh and if in spite of that it doesn't improve patient patient is going into respiratory fatigue the only way out is to incubate and give him rest by sedating him till the spasm improves okay sir thank you so much okay thank you thank you so much we have one more reason dr raghunath i've accepted your request you can switch on your audience good evening i just want to know what the dose of bitter caught in children can you hear me sir yeah so buddha court is available in microgra and you're talking of children so you are going to use adequate 5200 micrograms thank you sir thank you thank you very much so much i think there is one question about uh dairy filing in opd so we basis mentioned that we can give dairy file in on opt basis but knowing the cardiac status is very important right uh so dr palak has a question could you please elaborate more on the use of monte lucas so monte lucas is a leukotylene antagonist as we know and it's a adjuvant therapy to the treatment of asthma it was never the only therapy or the first line therapy for asthma so if we go to the guidelines for asthma it is actually the first first we are going to use the bronchodilators and the steroids if not controlled we are going to increase the dose of bronchodilators and steroids if it is still not controlled that's the place where we are going to add on monte lucas or a theophylline so monte lucas has a role but has an add-on with the inhaled corticosteroid and the beta-2 agonist the more important question which i face many of the times is how long should we continue multiple now there are no specific end points to how long to use monte lucas people have i mean the studies have shown it being used for even as long as one year at the same time the black box warning is that it can lead to some neuropsychiatric ailments if used in longer duration so preferably three to six months is the safe duration according to me okay thank you sir uh dr jatin is asking is the uh do we expect any changes in the ecg in the er yes yes so ecg changes start right from that first response of the heart is going to be tachycardia so you are never going to get an acute asthma patient with a normal heart rate it is always going to be a patient with tachycardia our aim is to check whether there is a sinus tachycardia or there is a arrhythmia or there is a bpc now please remember when we are talking of metabolic derangements you need to check the potassium so as i was saying when you said the blood parameters the cbc dimers you need to have some one sample which goes in for the potassium also and if there is a tachycardia which is happening and you are nebulizing the patient check again an ecg after half an hour or one hour to see whether he's developing any further changes you may have to take help of a cardiologist because at some point the patient may need even a beta to a beta blocker to actually control the cardiac abnormalities or deltas and to control it or uh amir diron to control the tachyarray okay uh we have two questions related to is there any role of toxic filing in the given situation yes so there is the rule see there are i did not put much or attention on that is acid profiling and doxophile so doxophiline is again available and given as oral as well as parental route it is supposed to be less toxic for the cardiac aspect compared to compared to the amino filing so yes there is a definite rule the mechanism of action remains the same the side effect profile is comparatively safer as compared to a conventional amino fiber and the role of doctor firing on one more thing so both questions were same or doxophelian okay next question by dr uda is does iv a minor filing cause addiction or dependence no it none of these medications rather cause addictions or dependents next question for surya prakash is adrenaline as sublingual use i haven't used it sublingually so i really have no experience of it if in fact if he has used it whoever i mean whose doctor is asking and he can share his experience i would be more delighted to listen please dr surya if in case if you have used it would you elaborate or if you could just come on stage by clicking on raise and it would be great dr shivani has a question where to use simple oxygen mask versus rebreathing mask so see oxygen therapy itself is a lecture by itself so oxygen when we start we naturally start with nasal oxygen up to three to four liters per minute it is best to give by nasal prong if the requirement is going to five liters six liters seven liter it is best to switch from a nasal prong to a mass because that gives a better continuity and a better concentration of oxygen by a mass now at this point you are going to check whether the patient is in a rda specially having pneumonia patient needs high flow oxygen and if any of these indications are there he is not a patient of copd then you should go in for using a non-repeating mask because it will give 100 oxygen and it will improve the saturation further so you have these indications acute failure cardiac failure erds pneumonias hypoxia not improving with mass oxygen these are the patients for nrb okay so next question better raghunath is if you could explain about the combination of montelukast and levocitism so see these two combinations work differently as we all know montelukas is the leucotriene antibodies and liver circulation is antihistamine so in whom to use so the indication of this combination came up because upper airway asthma or what we call allergic rhinitis post nasal drip they are present in almost 70 percent of our asthmatics so if you have a patient of asthma who has got tendency or triggers which are related to nasal congestion rhinorrhea sneezing that will be the best indication for using a combination of monte lucas and luvo citrogen for a considerable amount of time right okay uh dr sonam is asking uh what about the vaccination in asthma the pneumococcal and its schedule as per each correct so vaccination is indicated in all chronic language not about asthma it is copd elderly with a respiratory disease bronchial our api the guidelines of vaccination are very clear if you go on the website you'll be able to see it very well influenza is now in fact indicated even in children above five years of age but in our patients of adult asthma copd we recommend an annual dose of vaccination the influenza vaccination however there is a debate should we give by by here biannual because there is a northern hemisphere vaccine or southern hemisphere vaccine but at this point of time if the simple answer for this question would be every year influenza actually is a must pneumococcal vaccine there are two types one is the conjugated vaccine and one is the polyvalent vaccine so conjugated vaccine that is the pcv 13 will be given once in a lifetime after you give that one year later you give the pneumococcal 23 polyvalent vaccine so that will be the way you will have to proceed but if it's getting too confusing if you just log on to the api guidelines on vaccination these things are very beautifully elaborated [Music] thank you so much jitendra has a question how much liter per minute oxygen can be given to keep spo to about 90 it will vary from patient to patient there is no specific answer for this it will develop its mild asthma moderate asthma severe more severe asthma the number of liters of oxygen requirement will be high it could be four liters it could be five liters and if it is mild the patient is improving you are going to go down from five to four to three to two and then gradually may be of oxygen also please remember it is yes we are deciding the oxygen therapy but it has an objective we have to have an object view that the patient's saturation has to improve and is clinical condition has to improve so it will be variable at every stage of his asthma great dr surya has written when we discussed about the sublingual adrenaline he said he has used it especially when iv line is not available okay okay next question is by dr mishra is it safer to use amino filing in pediatrics as compared to adults frankly speaking i have not got much experience about using in pediatrics i have never used parental amino filing impedance but according to what i have understood and i have known from my peers and my seniors is that it is equally sort of having equal hazards to adder in adult and seriously both of them right but pediatricians are really experts i mean they they have these doses according to the micrograms and milligrams and infusions also so in the pediatric isu's i have seen patients who have been on amino filing and monitored very very precariously okay dr raghunath is asking what should be the duration of one tail you cast i have already answered that that there is no end point as to how long there are no studies which say that only five months or six months or one year but it should not be continued without any uh you know sort of end point we need to give at least six months and monitor it because it has got a black book warning of a neuropsychiatric ailment right uh dr shivani has a question in copd how much saturation of oxygen is okay and which mask to use so dr shivan is asking it because we all know that copd patients have a tendency to retain carbon dioxide and if we give excessive oxygen their hypoxic drive goes away or gets subdued and that's why the patient starts retaining uh carbon dioxide so dr shivani the our aim for copd patients is maintain the saturation which they have been used to so usually they are enough with the saturation of 88 to 89 or even 89 to 91 percent so my aim or our aim for a copd patient is maintain saturation but not more than 92 okay great uh dr jitendra shah has a question amiodarone when to consider that and what would be the dose and which antiarrhythmic is preferred so so as i mentioned by and large when we are treating this patient none of my patients which i have seen ever required a quadrant infusion which which which really required a ventricular tachycardia and required caudal infusion so i don't fall into that you know place where i have started or used it so i don't think we really need to use it so often right thank you dr nabo and shakat is asking should steroid be our first line of treatment instead for minor filing yes so i i think we put it that way the first was the nebulized bronchodilator then we talked about steroids and then we talked about amino filing and i would say 60 to 70 percent of our asthma patients i mean it may be variable this is what i have seen is that 60 to 70 of our asthma patients respond with nebulization and steroids and oxygen yes there is a group of patients who requires aminophylline also but steroids will be given first right uh and the last question for today i think my daughter santa anandas uh what is the role of immunotherapy in asthma so immunotherapy has a role in asthma for those who practice allergy testing and immunotherapy there is uh there are school of thoughts which do allergy testing find out the exact allergens which are showing it could be fungus and the mite or the colon and then immunotherapy vials are made up by different companies and then it is given subcutaneous or intradermal and then the response is observed it's a long duration of therapy over six months to eight months but i am not experiencing immunotherapy the results have been there so i would leave it open for the you know people who practice immunotherapy i think they can be better judges to answer these questions right so just one more question by dr pallak where the beta blockers can be used in patients with cardiac disease and asthma so beta blockers which are selective like medical oil is used so this visoprolol is used so these are safe to be used in asthma okay great uh so any non-pharmacological treatment for asthma by tamjit so here we are not talking of acute asthma i think the question is towards the long-term management or asthma and it definitely has a huge role in managing asthma right from physiotherapy breathing exercises yoga pranayam proper diet lifestyle changes all these are important for understanding and maintaining the asthmatic in control right great thank you so much sir those were the questions thank you so much for the session thank you for taking out the time for us and for our doctors and for our audience members thank you so much as well and once again a very happy independence to you all see you at the next session thank you so much
Emergency Management of Asthma in Casualty
Even after numerous reviews and the publishing of worldwide and national standards , acute asthma is a prevalent medical emergency that frequently still has poor management. Viruses and environmental allergens are the most frequent causes of exacerbations. Although the start, length, and severity of airflow restriction prior to presentation are all diverse, these issues typically develop over a period of several hours. This indicates that there is a chance for early detection and prompt treatment, even in fatal or almost fatal cases. Rarely, a patient will experience an abrupt, deadly onset of severe asthma. It's uncertain if this represents a distinct asthma phenotype. Join us for this #BlockBuster Medflix select session with a renowned pulmonologist Dr. Salil Bendre.
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