Lecture 6

ACUTE EXPIRATORY DYSPNEEA + WHEEZING +COUGH

These are the expression of bronchospam which appear to the patient with asthma or acutisation
of COPD.
ASTHMA

Asthma is defined like a reversible bronchial obstruction syndrom, reversible

spontanously or after treatment, clinically expressed by the triade: expiratory dyspneea,
Wheezing, cough.
On functional respiratory side, asthma is characterized by an obstructive type of
ventilatory disturbance. Bronchial obstruction from asthma has a big variability.
Its reversibility, total or partial, spontaneously or after bronchodilator and corticosteroid
treatment
differentiates asthma from other obstructive pulmonary disseases.
Physiopathological consequences of bronhium obstruction are:
- pulmonary hyperinflation ( increased RV, TRC)
- modification of V/Q fraction, with hematosis deficite, hypoxemia and hypercapneea.
- Use of accesory respiratory muscles, increased respiratory work and needs of oxygen.
- Hypertension in pulmonary artery, overcharge of right ventricle and acute cor
pulmonale
So, asthma is defined as a chronic inflamatory disorder of the aerian tract, with intermittent
sypmtomatology, the acute episodes of bronchic are separated by remission periods,
asymptomatic clinicaly and functionaly.

CLINICAL FORMS OF ACUTE ASTHMA.

There are 3 clinical forms:
1. simple acute crises: paroxystic expiratory dyspneea with cough wheezing, preceded by
sensation of thoracic constriction;
2. acute asthma attack: succesion ino small time intervals of more simple acute crisis,
with no complete remision. Untreated or bad treated can produce status asthmaticus;
3. status asthmaticus: is a dramatical situation characterized by:
- prolonged crisis more than 24 hours,severe;
- resistant to the usually treatment;
-life threatening risk.
More rarely, status asthmaticus can start brutally ( continouing an acute asthma attack)
with aspect of respiratory distress, with vital immediately risk. This particulary situation is most
frequent in induced aspirin asthma.
Status asthmaticus usually appears during a severe asthma which presents signs of
activity.
Status asthmaticus can be induced by a bronchopulmonary infection, emotional shock,
high doses of simpaticomimetics, brutally stopping the corticosteroids, administration of
alergenic drugs - as aspirin.
In almost 40 % of cases, the trigger cause is unknow.

PRECIPITATING FACTORS ( triggers of asthma attack) are:

 1.allergens of different types;
2.cold air and phisical exercises;
3.atmospheric pollution and irritants dusts, vapor,fumes, smoke,strong perfumes;
4.non-steroidal antiinflamatory drugs: particularly aspirin;
5.viral upper respiratory infections;
6.emotional disorders, anxiety.

SIGNS OF GRAVITY IN ACUTE ASTHMA

This signs have a major importance in establishing the emergency treatment.
Clinical signs of gravity are:
- dyspneea with ortopneea, RR>30/min;
- difficulty of speaking and coughing;
- pulse rate more than 120/min.;
- intense cianosis
- paradoxal pulse (decreased the amplitute of pulse during inspiration)more than 20mm
Hg.;
- use of accesory respiratory muscles:sternocleidomastoidian muscle permanently
contracted
-silence chest to the listening of the lungs;
- alteration of mental status
- thorax blocked in inspiration
- paradoxal respiration with inverting the diafragmatic course.
Paraclinical signs of gravity:
- blood gases analisis: hypoxemia <60mmHg, hypercapneea >40mmHg
- metabolic acidosis
- PEFR <200ml/min.
- E.C.G.-signs of acute cor pulmonale.
PARACLINICAL INVESTIGATIONS IN ACUTE ASTHMA
1. Blood gases and artherial pH:
2. E.K.G
3.Chest X-ray
4. Functional respiratory exams.

DIFFERENTIAL DIAGNOSIS
1.Obstructive respiratory failure
2.Acute pulmonary oedema APE:
APE:
- cardiac history
- palor, cold sweating
- oral cianosis
- pinky aerated sputum
- dyspneea with ortopneea, Wheezing
- bilateral basal dulness
- subcrepitants bilateral in the bases, +/ - sibilants
- response to diuretics, opioids, antihypertensive
 - ECG: signs of acute myocardial infarction , left ventricular hypertrophy, ischaemic
cardiopathy
- Chest-X-ray: cardiomegaly, perihilar opacities.
Asthma:
- alergic history
- cianosis without sweating
- small sputum, perlated
- expiratory dyspneea, Wheezing
- bilateral hypersonority
- ronflants and sibilants rales
- response to corticoids, B2 mimetics
- ECG: signs of acute cor pulmonale
- Chest-x-ray-hyperinflation.
3.Pulmonary embolism is caracterized by dyspneea, tahypneea, cough, hemoptoic sputum
agitation,eventually wheezing and sibilants crackles, clinical and E.K.G. signs of acute cor
pulmonale;
Exist risky factors for pulmonary embolism. The patient doesn’t have alergic history
4.Pneumothorax appears with severe unilateral thoracic pain, hypotension, unilateral
hyperresonance, absence of the vesicular murmur; radiological: absence of pulmonary drowing
and movement of the mediastinum.
5. Nevrotic dyspneea- without pulmonary signs, hyperventilation syndrome: tachypneea,
decreased CO2 PaP, respiratory alcalosis, decreased calcium

TREATMENT include:
1. Oxygen
2. Bronchodilators : -beta stimulants:
-metilxantine;
-anticholinergic;
-magnesium sulphate;
3. Steroidal antiinflamatory drugs
4. Others therapeutical measures:
- orotraheal intubation- OTI- and asisted ventilation has the next indications:
-aggravated decreased level of councioussness
- proggressive severe hypercapneea CO2PaP>=55 mmHg
-severe methabolic acidosis with hipoxemia and hypercapneea
- associated colaps;
-respiratory arrest, respiratory rate more than 40/min. or <8/min.or paradoxal
respiration ;
-alteration of blood gases under treatment
-sedation-only in cases of mechanical ventilation. Without orotracheal intubation do not give
sedatives drugs.
-antibiotics-indicated in case of acute infections complication;
-correction of the acidosis- is not indicated in all the cases, only in severe cases: pH<7,2 under
mechanic ventilation
I. Bronchodilators
 mimetics:
A)Adrenalin (Epinephrine) , agonist: 1f=1ml=1mg
- 0,2-0,3 ml s.c. repeated after 20-30 min.;
-0,5 - 1 ml disolved in 10 ml S.F.;
ADM.-i.v. in cardiovasculary colpase with status asthamaticus.
C.I. : to the patient with HTA, chronic coronary heart disease .
Be cautions to the elderly patient.
B) 2 agonists -with selective action on the bronchic receptors;
-they have a less cardiac effects, but no minors.
There are 2 clases of 2
* Short action (4-6 hours ) administrated only in crisis. Their action start in 2-5 min.
Metaproterenol -Astmopent Spray
Salbutamol -Ventolin inhaler Spray
-Ventolin f=1ml=0,5 mg (inj.)
-Salbutamol f=5 ml=5 mg
Glaxofort nebulizer
Terbutalin Bricanyl Spray
Bricanyl f=1ml=0,5 mg(inj)
Fenoterol Berotec Spray

*Long action (12 hours). Administrated maintance -Formoterol;

-Salmeterol.
2 agonists can be administrated:
-spicer devices:-2 puffs in 1 minute, repeated after 5 min. If no effects, you must use another way
of administration. No more 8-12 puffs.
-subcutaneosly - at home or in hospital 1 phial;
-intravenous-only in hospital, with EKG view using an automatical seringe ( 0,03 mg/Kg.min.)
or 1 phial Bricanyl to each 6 hours. If tahycardia, rythm disorders, choronarian pain occur, this
require reducing the doses;
-intramuscular
-nebulized administration-we dilute 1 f Salbutamol of 5 ml with 5 mg in 3 ml saline.
Metilxanthine - like monotherapy- are less efficient than 2 mimetics.They are not used like first
therapy. The effect appears in 10-15 min. and it last 2-3 hours. The efficient doses are
closed to the toxic doses; this is why can appear: cardiovasculary problems (tahycardia,
arrythmias) and neurogical problems (convultions, coma).
Loading doses: 6 mg./ b.w. slow i.v. in 20 min.
Maintenance doses: 0,6 mg/ b.w. min.
Anticholinergic: Bromide ipratropium- Atrovent
0,5-1 ml by mask nebuliser
II. Glucocorticoids
Action:-antiinflamatory (decrease the oedema and the hypersecretion);
-bronchodilator by 2 mimetics activity.
Doses: 4-6 mg/ b.w. repeated to 6 h for HHC;
0,5-1 mg/ b.w. repeated to 6 h for Metilprednison .
For administration of glucocorticoides, there are some rules:
-immediately administration. No contraindications when exist a vital risk;
- associated with 2 agonistes;
-initialy -high doses, then fast decreasing doses function of the efficiency;
-short period of treatment 7-10 days;
-when it’s possible substitute with an oral drug.
For topic administration, you can use as inhalators glucocorticoides:
-Becotide:50-250g/puf;
-Pulmicorte:200g/puf;
-Flixotide:250g/puf;
Treatment of severe asthma :
- oxigen
- nebuliser with Ventolin 5mg + Atrovent 0,5mg + oxygen
- Brycanil s.c. 250 microg.sau i.v.( in case of intensive care hospitalisation)
- Corticoids
- Prednisolon 30-60 mg i.v.
- HHC 200mg/8ore
- Aminophylline 1 phial i.v. slowly
- Magnesium sulphate
- Sedation and orotraheal intubation and assisted ventilation.
Indications for admision to hospital are:
- previous history of status asthmaticus
- poor response to bronchodilators in first 4 hours
- alterated level of conciiousness or agitation, tiredness
- O2PaP<50mmHg
- CO2PaP>40mmHg
- Paradoxal pulse
- E.K.G. modifications other than tachycardia
- Presence of pneumonia, neumothorax, pneumomediastinum.