Reactive Airway Disease

Reactive Airway Disease

Oxygen

Other medications

Assessment

Beta Adrenergic Therapy

Treatment   Examples

Principles of Treatment

Steroids

Admission / MEDEVAC

Reactive Airway Disease

Reactive airway disease (RAD), frequently referred to as asthma, may occur from a variety of bronchial stimuli. Traditional irritants include smoke, exercise, change in weather/humidity, or respiratory infections. Other causes include foreign body aspiration, early pulmonary edema, COPD exacerbation, or bronchiolitis in infants. Pathophysiology involves the production of mucous and bronchospasm. Immediate treatment is directed at these two entities.

Assessment

Immediate assessment is clinically based; do not rely on arterial blood gases or chest radiographs. Vital signs, to include pulse oximetry, along with rapid assessment of the patient’s work of breathing should be initially ascertained. Particular attention should be paid to mental status, ability to speak in full sentences, use of accessory muscles, retractions or evidence of respiratory failure secondary to tiring. Auscultation of the chest should center on determining whether there is prolongation of the expiratory phase and/or presence of wheeze. Other objective findings include diaphoresis, inability to lie supine, a respiratory rate > 30, and a low peak expiratory flow rate (PEFR). Patients with several objective findings should be monitored more closely and considered for admission.

Principles of Treatment

Immediate treatment should be concentrated at relieving bronchospasm and decreasing mucous production.

Mental Status Changes or Cyanosis: High Flow Oxygen and Epinephrine (1:1000) 0.3cc SQ)

Oxygen
Most patients will benefit from oxygen therapy even without evidence of hypoxia. The benefits occur because oxygen is a mild bronchodilator and can assist in the V/Q mismatch transition that is expected after initiating nebulized therapy as outlined below.

  • Nasal cannula 4 l/minute or high flow non-rebreather at > 10 Liters /minute

  • Beta Adrenergic Therapy (mainstay of therapy)
    Stimulation of beta-2 receptors in the lung leads to production of cyclic AMP. This results in relaxation of bronchial smooth muscle. Inhaled beta agonists are preferred and may be repeated or given continuously, depending on severity, with close monitoring. Adding a spacer to a metered dose inhaler (MDI) is as effective as nebulized medication.

  • 2.5 mg Albuterol or Proventil Nebulized with 2.5 cc of NS or

  • 4 puffs of MDI inhaler with spacer

  • Either of the MDI or nebulized therapies should be administered x 3, every 20 minutes.

  • Steroids
    Failure to include early steroids in a treatment plan has been shown to be one of the leading causes of subsequent death from asthma. Oral dosing has been proven to be as efficacious as parental administration. Treatment of the inflammatory component of asthma with inhaled steroids is the mainstay of prophylaxis in moderate asthma.

  • Prednisone 60mg PO or Solumedrol 125 mg IV push

  • Other medications
    Theophylline, magnesium, and anticholinergics have not been proven to be more effective than giving additional beta agonists. Therefore, they should be considered as adjunctive therapy.

    Treatment Regimens Examples

    A 25 year old male presents with acute onset of SOB, wheezing, and is unable to speak in full sentences. He has central cyanosis and is confused.

    • Start high flow oxygen by non-rebreather mask with an oxygen flow rate > 10 L/minute.

    • Administer Epinephrine (1:1000) 0.3 cc SQ.

    • Obtain a full set of vital signs, attach a cardiac monitor, and begin administration of the first beta-agonist treatment.

    • Administer 60 mg Prednisone PO or Solumedrol 125 mg IV push

    • Continue beta-agonist therapy until lung sounds are clear or the patient meets admission criteria as outlined below.

    • If discharged, provide MDIs with Prednisone 60 mg QD for 5 days and an appropriate follow up plan.

    • May consider Magnesium Sulfate 2 gms IV and/or Ipratroprium Bromide (Atrovent) by nebulizer or MDI.

    A 32 year old female with known mild asthma who presents with increasing wheezing over the past 2 days associated with congestion and cough worse at night. The respiratory rate is 20 and the oxygen saturation is 92%. She is alert and able to speak 5 word sentences. Expiratory wheezing is noted on auscultation.

    • Start oxygen at 4 L/minute nasal cannula and obtain vital signs.

    • Initiate beta-agonist therapy.

    • Administer 60 mg PO of Prednisone.

    • Provide an intravenous LR or NS 500 cc to 1000 cc bolus.

    • Discharge on MDIs and Prednisone with appropriate follow-up.

    Admission / MEDEVAC Criteria

    If after three beta-agonist treatments, the following criteria should be assessed and the patient referred for specialty care.

    • RR > 30; oxygen sat < 92% with continued wheezing or complaint of shortness of breath.

    • Less than 10 percent improvement on peak expiratory flow rate (PEFR).

    • RAD associated with any lobar pneumonia.

    Patients can be admitted to a sick call holding area for continuous oxygen and Q 2 to 4 hour beta-agonist treatments if a MEDEVAC or specialty referral is not accessible.

    References

    1. Emergency Medicine & Acute Care Essays, volume 16, number 4, April 1992.

    2. Executive Summary: Guidelines for the Diagnosis and Management of Asthma, U.S. Department of Health and Human Services, June 1991.

    Prepared by LCDR Kathryn Hall-Boyer, MC, USN. Reviewed and revised by LCDR Jeffrey Disney, MC, USN, Naval Medical Center San Diego, San Diego, CA (1999).

    Preface  ·  Administrative Section  ·  Clinical Section

    The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
    Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

    This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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