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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
11 A st hma
197
History
Observation
Examination
Investigations
Initial treatment
- Oxygen; saturation ≥ 95%
- Reassurance of children and parents
- Avoid sedatives and painful procedures
Moderate or severe episode.
The general advice is to administer β2-agonist until effect is achieved or untill side effects occur (tachycardia).
The child needs close observation from skilled personnel in this phase
- Inhaled β2-agonist
- Nebulised Salbutamol 1.0 mg/10 kg (max 5 mg) in 2-5 ml NaCl 9 mg/ml, may be repeated every 20 min first hour, or
- Salbutamol continuously for one hour; 1.5 mg/10 kg (max 5mg) in 5 ml NaCl 9 mg/ml given repeatedly
- Moderate episode; salbutamol MDI with spacer; 0.1 mg/dose, 1 puff/10 kg − may be repeated every 20 minutes first hour
- Inhaled adrenaline − particularly in younger children (<2 years) and in severe attacks
- Racemic adrenaline 2 − 5 mg in 2-5 ml NaCl 9 mg/ml or
- Adrenalin 1 mg/ml: 1 - 2 mg in 2-5 ml NaCl 9 mg/ml.
- repeat every 1-2 hourly
- Inhaled ipratropium bromide − may be considered in older children in addition to a β2-agonist
- Nebulised ipratropium bromide 0.25 mg in 2-5 ml NaCl 9 mg/ml
- Moderate episode; ipratropium bromide MDI with spacer, 2 puffs (40 μg) − may be repeated every 20 min first hour
- Systemic glucocorticosteroids
- Oral glucocorticosteroids (prednisolone 1-2 mg/kg or equivalent) or
- Intravenous glucocorticosteroids (methylprednisolone 1 mg/kg or hydrocortisone 4 mg/kg)
Poor improvement, severe obstruction
- continue inhalations as above (observe side effects)
- Consider
− previous medication and asthma history, particularly severe attacks
− chest movements, prolonged expiration, recessions, use of accessory muscles,
cyanosis, general condition, mental status
− wheezing or faint respiratory sounds
− oxygen saturation (blood gases when appropriate)
Oxygen requirement, physical observation and examination as above, consider blood gases
- b2-agonist intravenously (terbutaline 5-10 ug/kg/h)
- Theophylline intravenously (loading dose 6 mg/kg, maintenance 0.7-0.9 mg/kg/h)
Adjust according to plasma theophylline levels
- Magnesium sulphate intravenously; 25 – 100 mg/kg given over 20 minutes
Initial assesment
Very severe or life-threatening episode, anaphylaxis:
- Consider i.m adrenaline
(10 mg/kg; 0.1 ml/10 kg of adrenaline 1 mg/ml)
Reassessment after 1-2 hours
Oxygen requirement, physical observation and examination as above, blood gases
Deterioration –impending respiratory failure
- Decreasing breath sound– “quite chest”
- Worsening of general signs and mental status,
inability to speak or cry
- arterial pCO2 > 7.5 – 8 kPa
Consider
- BiLevel CPAP
- Mechanical ventilation
Reassessments at regular intervals
Improvement, moderate and decreasing obstruction
- continue inhalations as above, gradually increasing intervals
- step down other medications
- oral glucocorticosteroids to be continued for 1-5 days
Acute exacerbation treatment: Treatment algorithm for children with moderate or
severe asthma exacerbations. [From article: Emergency presentation and management
of acute severe asthma in children. Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine. 2009;17(1):40.
https://doi.org/10.1186/1757-7241-17-40, at
http://link.springer.com/article/10.1186%2F1757-7241-17-40/fulltext.html; by Knut
Øymar, Thomas Halvorsen, © Øymar and Halvorsen; licensee BioMed Central Ltd.
198
2009; licensed under Creative Commons Attribution License BY 2.0 http://creative-
commons.org/licenses/by/2.0] Caption from original
C. V. Pollack, Jr. et al.
Disease Course
• By denition, asthma is characterized by reversible airow obstruction, which
means the impact of asthma on quality of life varies, from year to year, sometimes from season to season, or even day to day. There is little consensus on
factors that determine disease progression versus disease stabilization.
• There is much interindividual variation is the course of asthma, and fatal
exacerbations sometimes occur but are clearly unusual.
• With good control, asthmatics lead relatively normal and functional lives and
have a normal lifespan. Poorer control is associated with impaired quality of
life, more unscheduled healthcare visits, and more common hospitalization.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
British Thoracic Society; Scottish Intercollegiate Guidelines Network. British
guideline on the management of asthma. Thorax. 2014 Nov;69 Suppl 1:1-192.
PMID: 25323740.
Lougheed MD, Leniere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, FitzGerald
M, Leigh R, Watson W, Boulet LP; Canadian Thoracic Society Asthma Clinical
Assemby.Canadian Thoracic Society 2012 guideline update: Diagnosis and
management of asthma in preschoolers, children and adults: executive summary.
Can Respir J. 2012 Nov-Dec;19(6):e81-8. No abstract available. Erratum in: Can
Respir J. 2013 May-Jun;20(3):185. PMID: 23248807. http://www.ncbi.nlm.nih.
gov/pubmed/23248807 **
Kling S, Zar HJ, Levin ME, Green RJ, Jeena PM, Risenga SM, Thula SA, Goussard
P, Gie RP; South African Childhood Asthma Working Group (SACAWG).
Guideline for the management of acute asthma in children: 2013 update. S Afr
Med J. 2013 Feb 5;103(3 Pt 3):199-207. https://doi.org/10.7196/samj.6658.
PMID: 23656745. http://www.ncbi.nlm.nih.gov/pubmed/23656745 **
http://www.ncbi.nlm.nih.gov/pubmed/25323740 **
11 A st hma
199
Lalloo UG, Ainslie GM, Abdool-Gaffar MS, Awotedu AA, Feldman C, Greenblatt
M, Irusen EM, Mash R, Naidoo SS, O'Brien J, Otto W, Richards GA, Wong ML;
South African Thoracic Society. Guideline for the management of acute asthma
in adults: 2013 update. S Afr Med J. 2012 Dec 3;103(3 Pt 2):189-98.
https://doi.
org/10.7196/samj.6526. PMID: 23656743. http://www.ncbi.nlm.nih.gov/
pubmed/236567453 **
Review
Murphy VE, Schatz M.Asthma in pregnancy: a hit for two. Eur Respir Rev. 2014
Mar 1;23(131):64-8.
24591663. http://www.ncbi.nlm.nih.gov/pubmed/24591663 **
Patadia MO, Murrill LL, Corey J.Asthma: symptoms and presentation. Otolaryngol
Clin North Am. 2014 Feb;47(1):23-32.
PMID: 24286676. http://www.ncbi.nlm.nih.gov/pubmed/24286676 **
Maslan J, Mims JW.What is asthma? Pathophysiology, demographics, and health
care costs. Otolaryngol Clin North Am. 2014 Feb;47(1):13-22. https://doi.
org/10.1016/j.otc.2013.09.010. PMID: 24286675. http://www.ncbi.nlm.nih.gov/
pubmed/24286675 **
Reddy AP, Gupta MR.Management of asthma: the current US and European guide-
lines. Adv Exp Med Biol. 2014;795:81-103. https://doi.org/10.1007/978-1-4614-
8603-9_6. PMID: 24162904. http://www.ncbi.nlm.nih.gov/pubmed/24162904 **
Shah S, Sharma G. Current clinical diagnostic tests for asthma. Adv Exp Med
Biol. 2014;795:75-80. https://doi.org/10.1007/978-1-4614-8603-9_5. PMID:
24162903. http://www.ncbi.nlm.nih.gov/pubmed/24162903 **
Croisant S.Epidemiology of asthma: prevalence and burden of disease. Adv Exp
Med Biol. 2014;795:17-29. https://doi.org/10.1007/978-1-4614-8603-9_2.
PMID: 24162900.
https://doi.org/10.1183/09059180.00008313. PMID:
https://doi.org/10.1016/j.otc.2013.10.001.
http://www.ncbi.nlm.nih.gov/pubmed/24162900 **
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Asthma”[Mesh] OR “Asthma”
Chapter 12
Atrial Fibrillation
CharlesV.Pollack,Jr.,MelissaPlatt, andVictoriaG.Riese
Name andSynonyms
Atrial Fibrillation (AF)
Incidence/Epidemiology
• The most common cardiac arrhythmia
• Affects 4 % of individuals older than 60 years and 8 % of those older than
80 years.
• It is more prevalent in men, and prevalence increases with age.
• In developed countries, hypertension and coronary artery disease are the most
common underlying disorders.
• Rheumatic heart disease is associated with a higher incidence of AF, but this
is much less common than in the past. Other causes of mitral valve disease
also may lead to AF.
C. V. Pollack,Jr. ()
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
M. Platt
Department of Emergency Medicine, University of Louisville, Louisville, KY, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_12
201© Springer Nature Switzerland AG 2019
202
• Classied as follows:
• Paroxysmal AF: terminates spontaneously or with intervention within 7
days of onset.
• Persistent AF: does not terminate within 7 days.
• Permanent AF: persists for a year or longer.
• “Lone” AF: does not occur with any other clinical or echocardiographic
cardiac problems; usually occurs in patients younger than 50.
C. V. Pollack, Jr. et al.
Differential Diagnosis
• Atrial utter
• Multifocal atrial tachycardia
• Supraventricular tachycardia
Pathophysiology andEtiology
• Instead of being coordinated, atrial contractions are irregular, disorganized,
chaotic, and very rapid.
• This electrical malfunction may result in:
• Tachypalpitations, often described by patients as a “uttering” or “butter-
ies” in the chest.
• Inadequate “topping off” of the ventricular volume prior to ventricular sys-
tole, which may result in fatigue, dizziness, or heart failure.
• Because the cardiac cycle of atrial systole followed by ventricular systole is
disrupted by the lack of regularity of impulses through the atrioventricular
node, the ventricles beat irregularly and often beat faster than normal.
• This “irregularly irregular” rhythm is classied as showing a “controlled”
ventricular response (rate <100 bpm) or “rapid” ventricular response (rate
≥100 bpm).
• The precise mechanism that causes AF is not completely understood, but AF
often is seen concomitantly with other heart and metabolic diseases,
including:
• Congestive heart failure
• Coronary artery disease
• Valvular heart disease
• Hypertension
• Hyperthyroidism
• Acute alcohol abuse, especially in binges, may cause AF (“holiday heart”).
12 Atr ial Fibrillation
203
Focal atrial premature complexes usually originating from pulmonary veins can
initiate AF.Ablation of these arrhythmogenic focal triggers can restore rhythm. This
nding opens an exciting era in electrophysiology with the possibility of curing AF
by ablation. [Grogin HR.Supraventricular tachycardia. In: Scheinman M, editor.
Arrhythmias: electrophysiologic principles. Philadelphia: Current Medicine; 1996.
Chapter 5 (Braunwald E, editor. Atlas of heart diseases; vol. 9).] Caption adapted
from original
204
C. V. Pollack, Jr. et al.
Causes of Atrial Fibrillation. [From article: Reversible atrial brillation secondary
to a mega-oesophagus. BMC Ear Nose Throat Disord. 2006 Dec 13;6(1):15. https://
doi.org/10.1186/1472-6815-6-15, at http://link.springer.com/article/10.1186
%2F1472-6815-6-15
; by Tahwinder Upile, Waseem Jerjes, Mohammed El Maaytah,
Sandeep Singh, Colin Hopper, Jaspal Mahil, © Upile etal; licensee BioMed Central
Ltd. 2006; licensed under Creative Commons Attribution License BY 2.0 http://
creativecommons.org/licenses/by/2.0] Caption from original
Atrial brillation is a multifactorial condition resulting from an interaction between
cardiovascular disease effects, aging, genetics, and environmental factors. CAD
coronary artery disease, COPD chronic obstructive pulmonary disease, EtOH alcohol use, HF heart failure, HTN hypertension, OSA obstructive sleep apnea, VHD
valvular heart disease [Eleid MF, Cha Y-M, Shen W-K.Atrial brillation and heart
failure: rate versus rhythm control. In: Bartunek J, Vanderheyden M, editors.
Translational approach to heart failure [Internet]. NewYork: Springer; 2013 [cited
2015 Aug 13]. p.129–44. Available from: http://link.springer.com/10.1007/978-1-
4614-7345-9_6] Caption from original
Presentation
Typical/“Classic”
• Not all patients with AF have symptoms, but the risk of thromboembolic complications is the same, regardless.
12 Atr ial Fibrillation
• Typical symptoms include palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, reduced exercise capacity, and dyspnea.
Atypical
• The rst presentation of AF may be a thromboembolic complication, such as
stroke or mesenteric ischemia.
• AF may present as anginal pain.
• Some patients, particularly those who are elderly, may not notice the palpitations (particularly if the ventricular rate is less than 100 bpm) and may present
with completely unrelated complaints.
Primary Differential Considerations
• Atrial utter
• Multifocal atrial tachycardia
• Supraventricular tachycardia
• Premature atrial contractions
• Premature ventricular contractions
205
History andPhysical Exam
Findings That Conrm Diagnosis
• Although an “irregularly irregular” pulse is suggestive of AF, this also may be
associated with other arrhythmias, and an ECG is required to differentiate
among them.
Factors That Suggest Diagnosis
• Irregularly irregular pulse on examination
• Palpitations plus dyspnea
• Palpitations plus syncope or near-syncope
• Palpitations and generalized weakness
• Palpitations and hypotension
• Unexplained dyspnea, syncope, generalized weakness, or hypotension
• Acute ischemic stroke
206
C. V. Pollack, Jr. et al.
Factors That Exclude Diagnosis
• ECG showing a normal sinus rhythm excludes AF “in the moment,” but does not
exclude paroxysmal AF.
Ancillary Studies
Laboratory
• Often obtained in search for underlying disorders or other associated disorders:
• B-type natriuretic peptide (BNP)
• Troponin
• Electrolytes
• Blood glucose
• Thyroid-stimulating hormone (TSH)
• Toxicology
Electrocardiography
• ECG is necessary to make the diagnosis.
• Irregular rate with an atrial rate greater than 300 bpm
• Ventricular rate may be slow, normal, or fast.
• Absent or erratic P waves are noted.
• PR interval is absent.
• QRS may be normal but may be widened if conduction delay is present.
12 Atr ial Fibrillation
207
Atrial brillation. Atrial brillation is characterized by the absence of P waves,
which are replaced by irregular f waves or no sign of atrial activity. The QRS complexes may be normal or irregular and varying in amplitude. The 12‐lead ECG
shown here demonstrates atrial brillation with moderate ventricular response rate.
[Leung J. Electrocardiographic monitoring. In: Lichtor JL, editor. Preoperative
preparation and intraoperative monitoring. Philadelphia: Current Medicine; 1997.
Chapter 7. (Miller RD, editor. Atlas of anesthesia; vol. 3).] Caption from original
Atrial brillation (AF) 12-lead surface electrocardiogram. AF is the most common
sustained arrhythmia and is particularly prevalent in the elderly. Characteristic of
AF is an irregular ventricular response and rapid irregular oscillations or brillatory
waves that vary in shape, amplitude, and timing. [Epstein L, Stevenson W, Steven
D, Seiler J, Roberts-Thomson K, See V.Arrhythmias. In: Libby P, editor. Essential
atlas of cardiovascular disease. 4th ed. Philadelphia: Current Medicine; 2009.
Chapter 7.] Caption from original
Imaging
• Transthoracic echocardiography may be performed to evaluate the size of the
right and left atria and size and function of the right and left ventricles; this
also can detect valvular heart disease.
• Transesophageal echocardiography is used to identify thrombi in the left
atrium or left atrial appendage.