Triage and Respiratory
Emergency
Marshell Tendean, MD DPCP
Department of Intenal Medicine
UKRIDA Jakarta
Objective :
To discuss about triage and clinnical approach in emergency situations
To Discuss about Severe Asthma :
Epidemiology
Approach to diagnosis
Treatment
To discuss about acute respiratory distress syndrome (ARDS) :
Epidemiology
Approach to diagnosis
Treatment
Prognosis
Triage
The sorting of patients into priority groups according to their need
and the resources available
Emergency
P priority
Q Queue (non urgent)
Emergency Case :
Emergency
Urgent
False emergency
Death
Surgery
Approach to patients in Emergency situation
Do brief history taking.
Important data to ask :
Trauma / non trauma
Surgical / non surgical
Intoxication / toxin
Do things promptly!!
Primary survey : Secondary survey :
A: Airway
Complete anamnesis
B: Breathing
Comprehensive phyrsical
C: Circulation
examination
D: Disability
Extensive ancilary
E: Environment
procedures
Definitive treatment
Severe asthma
Severe asthma
Definition of severe asthma
Asthma which requires treatment with high dose inhaled
corticosteroids (ICS) plus a second controller (and/or systemic CS)
to prevent it from becoming uncontrolled or which remains
uncontrolled despite this therapy.
Its prevalent among 5-10% of overall ashtma patients
International ERS/ATS Guidelines on Definition, Evaluation,
and
Treatment of Severe Asthma 2013
The term difficult asthma is reserved for asthma that remains uncontrolled despite the prescription of
high-intensity asthma treatment due to:
Persistently poor compliance
Psychosocial factors, dysfunctional breathing, vocal cord dysfunction;
Persistent environmental exposure to allergens or toxic substances;
Untreated or undertreated comorbidities such as chronic rhinosinusitis, reflux disease or obstructive sleep apnoea syndrome.
The term severe refractory asthma should be reserved for patients with asthma in whom alternative
diagnoses have been excluded, comorbidities have been treated, trigger factors have been removed (if
possible) and compliance with treatment has been checked, but still have poor asthma control or frequent
(>2) severe exacerbations per year despite the prescription of high-intensity treatment.
Natural history and risk factors
The severe asthma phenotypes are related to genetic factors, age of asthma
onset, disease duration, exacerbations, sinus disease and inflammatory
characteristics
Early childhood-onset asthma (over a range of severity) is characterized by allergic
sensitization, a strong family history and more recently, non-allergy/atopy related
genetic factors.
Late-onset, often severe asthma is associated with female gender, reduced pulmonary
function despite shorter disease duration, and in some subgroups, a strong association
with persistent eosinophilic inflammation, nasal polyps and sinusitis and often aspirin
sensitivity and respiratory tract infections, but less support for specific genetic factors.
Pathogenesis :
Risk factors : occupational, obesity, smoke and environmental air
polution
Epigenetics and genetics (IL-4, IL-6 pathways)
Inflamation and adaptive imunity
Respiratory infections
Activation of innate immunity pathways
Structural abnormalities
Approach to diagnosis :
Step 1. Determining that the patient has asthma
Recommendation 1
In children and adults with severe asthma without specific indications
for chest HRCT based on history, symptoms and/or results of prior
investigations we suggest that a chest HRCT only be done when the
presentation is atypical (conditional recommendation, very low quality
evidence).
Thorax 2011;66:910e917
Step 2. Assessing Co-morbidities and Contributory Factors
Rhinosinusitis/(adults) nasal polyps
Psychological factors: Personality trait, symptom perception, anxiety, depression
Vocal cord dysfunction
Obesity
Smoking/smoking related disease
Obstructive sleep apnea
Hyperventilation syndrome
Hormonal influences: Premenstrual, menarche, menopause, thyroid disorders
Gastroesophageal reflux disease (symptomatic)
Drugs: Aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), -adrenergic blockers, angiotensin converting enzyme inhibitors
(ACE-inhibitors)
Condition mimicking severe asthma.
Step 3. Approaches to Asthma Phenotyping
Step 4. Therapy
Established therapies
Recently-developed therapies and
Future approaches that will require phenotypic characterisation
ER Assesment :
Young & Salzman : pp. 1319,
24
ER Assesment
Status asthmaticus is an asthma exacerbation that is refractory to or does not significantly
improve with initial treat ment and requires escalation of treatment, usually leading to
hospital admission
CHEST 2004; 125:10811102
ER Assesment
The patient should be hospitalized if, he or she still has significant
wheezing, accessory muscle use, permanent requirement for oxygen
to maintain Spo2 92%, and a persistent reduction in lung function
(FEV1 or PEF 40% of predicted) The presence of factors indicating
high risk of asthma- related death (inadequate access to medical
care and medications, difficult home conditions, and difficult- to-
obtain transport to hospital in the event of further deterioration).
If a patient is free of symptoms, and has lung functions (FEV1 or
PEFR) 60 of predicted, the patient can be dis- charged unless other
mitigating circumstances exist.
ER Assesment :
Patients with findings of severe airflow obstruction (use of
accessory muscles of respiration, PP >12 mm Hg, diaphoresis,
inability to recline, hypercapnia, or PEFR < 40% of predicted) who
demonstrate a poor response to initial therapy (less than 10%
increase in PEFR) or who deteriorate despite therapy should be
promptly admitted to an intensive care unit.
Other indications for immediate admission to an intensive care
unit include respiratory arrest, an altered mental status, and
cardiac toxicity (tachyarrhythmias, angina, or myocardial
infarction).
Young & Salzman : pp. 1319, 24
ICU Admission :
NIPV
Intubation
Sedative during intubation
Phenothypic targeted therapy for severe
asthma
Complications of severe asthma
Pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Pneumopericardium
Myocardial infarction
Mucus plugging
Atelectasis
Theophylline toxicity
Electrolyte disturbances (hypokalemia, hypophosphatemia, hypomagnesemia)
Myopathy
Lactic acidosis
Anoxic brain injury
Acute Respiratory
Distress Syndrome
ARDS
Definition :
An Acute onset; ratio of partial pressure of arterial oxygen to frac tion of
inspired oxygen (PaO2/FiO2) of 200 or less, regardless of positive end
expiratory pressure; bilateral in ltrates seen on fron tal chest radiograph;
and pulmonary artery wedge pressure of 18 mm Hg or less when measured,
or no clinical evidence of left atrial hypertension.
Am Fam Physician. 2012;85(4):352-358
Most cases of ARDS in adults
are associated with pulmonary
sepsis (46 percent) or
nonpulmonary sepsis (33
percent)
We often deny myself for my calling
But in my missery
We will call and tell save 1 more lives
Save 1 more lives
