CRISIS ASMÁTICA

R1 PAOLA MENDEZ NECIOSUP

HVLE
CRISIS ASMÁTICA

 Episodio de empeoramiento de los síntomas que requiere cambios en el tratamiento actual y que
ocasiona modificaciones pasajeras en la función pulmonar.

 Usualmente es la primera presentación del Asma.

Aumentos agudos
Disminución en la
Aumento de la tos o subagudos en la
tolerancia al
(> durante sueño) sibilancia o falta
ejercicio
de aliento

Global Initiative for Asthma. Asthma Management and Prevention. For adults and children older than 5 years. Updated 2019
A. Al-Shamrani et al. Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics and Adolescent Medicine.
Medicine, https://doi.org/10.1016/j.ijpam.2019.02.001
CLASIFICACIÓN DE CRISIS ASMÁTICA

 SEGÚN VELOCIDAD DE INICIO DE LA CRISIS ASMÁTICA

De instalación lenta (80%) De instalación rápida

• Días-semanas • 2-3 horas

• Infección respiratoria, virales • Por exposición a un alérgeno inhalado o
• Cambio de estación alimentario
• Mala adherencia al tratamiento de • Ingesta de AINE o BB.
mantenimiento. • Más agresivas en su inicio
• Tardan varios días en resolverse. • Respuesta al tratamiento más rápida.

Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev Alerg Mex. 2017;64 Supl 1:s11-s128
METAS DE TRATAMIENTO EN LAS CRISIS ASMÁTICAS

Corrección rápida de la obstrucción del flujo de aire.

Corrección de hipoxemia y / o hipercapnia severa.

Reducción de la probabilidad de recurrencia al garantizar una

terapia adecuada de control de referencia cuando esté indicado.

Acute asthma exacerbations in children younger than 12 years: Emergency department management – UpToDate Nov 2018
EVALUACIÓN DE GRAVEDAD
1 - 3: Low risk (<10%) of hospital admission.
4 - 7: Moderate risk (10 -50%) of hospital
admission.
8 - 12: High risk (>50%) of hospital admission.
PULMONARY SCORE

LEVE MODERADO SEVERO

0-7 7-11 12-…

Validation Of The Pulmonary Score: An Asthma Severity Score For Children. Academic Emergency Medicine. February 2002,Volume 9,
Number 2
SATURACIÓN DE OXÍGENO

 Valorar el nivel de oxigenación periférica mediante oximetría de pulso en todos los pacientes con crisis asmática.

Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev Alerg Mex. 2017;64 Supl 1:s11-s128
RADIOGRAFÍA DE TÓRAX

 Recommendations: Chest X-rays should be limited to the following conditions:

 Status asthmaticus
 Presence of complications, e.g., barotrauma pneumothorax or pneumomediastinum
 Suspected bronchopneumonia
 Suspicion of a foreign body as the cause of wheezing and respiratory distress.

A. Al-Shamrani et al. Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics and Adolescent Medicine.
Medicine, https://doi.org/10.1016/j.ijpam.2019.02.001
FLUJO ESPIRATORIO MÁXIMO

 A partir de los 5 años o cuando el paciente pueda coordinarse para hacer una espiración correcta,
 Es más fácil realizar una medición del PEF que una espirometría completa.

Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev Alerg Mex. 2017;64 Supl 1:s11-s128
Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev
Alerg Mex. 2017;64 Supl 1:s11-s128
HEMOGRAMA

 CBC Cell counts and differentials are commonly requested in the emergency department in the majority of cases
of asthma exacerbation.
 Leukocytosis is common but neutrophilia should be interpreted with caution because beta-agonists and
corticosteroids may result in the demargination of white cells and an increase in the peripheral white cell count
with a predominant left shift.
 Recommendations: CBC should not be performed routinely in cases of asthma exacerbation and leukocytosis could be a
result of dermargination.

A. Al-Shamrani et al. Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics and Adolescent Medicine.
Medicine, https://doi.org/10.1016/j.ijpam.2019.02.001
TRATAMIENTO
CRISIS LEVES - MODERADAS
 B2 AGONISTAS

A. Al-Shamrani et al. Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics and Adolescent Medicine.
Medicine, https://doi.org/10.1016/j.ijpam.2019.02.001
B2 AGONISTAS

Salbutamol aerosol : 100 ug/dosis (0,1 mg/dosis)

Salbutamol Solución: 5mg/ml

Acute asthma exacerbations in children younger than 12 years: Emergency department management – UpToDate Nov 2018
CORTICOIDES SISTÉMICOS

 Son el antiinflamatorio de primera elección.

 En crisis leves sólo se usarán
 Cuando existan síntomas de exacerbación por varios días.
 Cuando el paciente ya estaba tomando estos medicamentos de mantenimiento
 Si el paciente no ha tenido éxito con otras opciones de tratamiento.
 Si existen antecedentes de crisis graves previas que requirieron su uso.
 Si se presenta deterioro acelerado o con FEV o PEF < 60 % del valor predicho o del mejor valor personal.

Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev Alerg Mex. 2017;64 Supl 1:s11-s128
CORTICOIDES SISTÉMICOS

British Thoracic Society. Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2016
 CORTICOIDES SISTÉMICOS

A. Al-Shamrani et al. Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics and Adolescent Medicine.
Medicine, https://doi.org/10.1016/j.ijpam.2019.02.001
CORTICOIDES SISTÉMICOS

Acute asthma exacerbations in children younger than 12 years: Emergency department management – UpToDate Nov 2018
CORTICOIDES SISTÉMICOS

 The NAEPP guidelines suggest that oral administration of glucocorticoids is preferred to intravenous
administration because oral administration is less invasive and the effects are equivalent.
 Intramuscular administration of glucocorticoids may be warranted in patients who vomit orally administered
glucocorticoids yet do not require an intravenous line for other purposes.
 For severely ill patients, intravenous access should be established, and intravenous methylprednisolone may be
administered.

Acute asthma exacerbations in children younger than 12 years: Emergency department management – UpToDate Nov 2018
BROMURO IPRATROPIO

British Thoracic Society. Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2016
BROMURO IPRATROPIO

Acute asthma exacerbations in children younger than 12 years: Emergency department management – UpToDate Nov 2018
CRISIS LEVE PS:<7

 Salbutamol 100 ug/ dosis (0.1mg/dosis)

 NBZ 0.15 mg/kg

 Aerocamara: ¼ - 1/3 puff/kg c/20 – 30 min

 5-10 kg: 4 puff
 10-20 kg: 6 puff
 > 20 kg: 8 puff
Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev Alerg
Mex. 2017;64 Supl 1:s11-s128
Larenas-Linnemann D et al. Guía Mexicana del Asma. Rev Alerg
Mex. 2017;64 Supl 1:s11-s128
Acute asthma exacerbations in children younger than 12 years: Emergency
department management – UpToDate Nov 2018
 TRATAMIENTO AL ALTA

 All patients seen for an acute asthma exacerbation should have an inhaled SABA available for treatment of
symptoms.
 Every four hours during waking hours and up to every four hours as needed during sleep for the first three days after an ED
visit for an asthma exacerbation.
 After that, should be weaned as tolerated, with the goal of discontinuing by day 5 to 7.

 A three- to five-day course of prednisone or prednisolone (or a two-day course of dexamethasone).

 A course up to 10 days may be indicated in some children (eg, those who have had more than one exacerbation requiring oral
glucocorticoids in the previous two months or those who are still symptomatic after a five-day course).
 Greater than 10 days may be necessary for patients whose control regimen includes oral glucocorticoids. Glucocorticoids that
are administered for less than 10 days do not require a taper at discontinuation

Acute asthma exacerbations in children younger than 12 years: Emergency department management – UpToDate Nov 2018