Capecitabine
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By: Randolph E. Regal, BS, PharmD
- Clinical Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan
https://pharmacy.umich.edu/people/reregal
Palpation of the sacral cornua is fundamental to womens health specialist appleton wi urologic or orthopaedic surgical procedures located locating the sacral hiatus and to women's health clinic gympie successful caudal block women's health clinic pueblo co . Later pregnancy 4 weeks , progressive ossifcation of the sacrum (until 30 years anatomy old) and closing of the sacro-coccygeal angle make its identifcation more difcult. Note that anatomical anatomical landmarks (Figure 1) anomalies of the sacral canal roof are observed in 5% The sacrum is roughly the shape of an equilateral of patients and this can lead to unplanned cranial or triangle, with its base identifed by feeling the two O Raux lateral puncture. The dorsal aspect of the sacrum A Rochette The sacral canal is in continuity with the lumbar consists of a median crest, corresponding to the X Capdevila epidural space. Moving laterally, Departement d’Anesthesie cauda equina, which leave it through anterior sacral intermediate and lateral crests correspond respectively Reanimation foraminae. Terefore the needle or cannula must be cautiously advanced into the sacral canal, after crossing the sacro-coccygeal ligament. The distance between the sacral hiatus and the dural sac is approximately 10mm in neonates. It increases progressively with age (>30mm at 18 years), but there is signifcant inter-individual variability in children. Bony landmarks and airway control, the patient is positioned laterally (or ventrally), is between 5 and 15mm, depending on the child’s size. Skin disinfection should be coccygeal ligament gives a perceptible ‘pop’ when crossed, analogous performed carefully, because of the proximity to the anus. If in contact with the bony ventral wall of sacral canal, the needle must be moved back slightly. Preparation of patient lateral position with the surgical site down According to the child’s size, needle diameter and length are respectively between 21G and 25G, and 25mm and 40mm. A short bevel improves the feeling of sacrococcygeal ligament penetration 2 Figure 4. Puncture orientation of the needle and reorientation after and decreases risk of vascular puncture or sacral perforation. Use of crossing the sacro-coccygeal ligament a needle with a stylet avoids risk of cutaneous tissue coring, and the (theoretical) risk of epidural cutaneous cell graft. If a styletted needle is not available, a cutaneous ‘pre-hole’ can be made with a diferent needle prior to puncture with the caudal needle. Orientation of the needle during puncture The gluteal cleft is not a reliable mark of the midline. The needle is oriented After verifying absence of spontaneous refux of blood or cerebrospinal 60° in relation to back plane, 90° to skin surface. Where available this may be preceded with an epinephrine Update in Anaesthesia | Blood refux necessitates repeating authors have described use of a caudal catheter to prolong analgesic the puncture, however in case of cerebrospinal fuid refux caudal administration in postoperative period. In addition advancement anaesthesia should be abandoned, in order to avoid the risk of extensive of the catheter in the epidural space up to lumbar or even thoracic spinal anaesthesia. Aspiration tests should be repeated several times levels can achieve analgesia of high abdominal or thoracic areas. Subcutaneous tunnelling at a of misplacements of the needle are possible (Figure 6). The moment of distance from the anal orifce, or occlusive dressings decrease bacterial surgical incision is the true test of block success, but various techniques 11 colonization. However, most anaesthetists sphincter contraction in response to electrical nerve stimulation on the presently prefer a direct epidural approach at the desired level that is puncture needle. No clear beneft of these techniques against simple 14, 15 3, 4 appropriate to the surgical intervention. Warning symptoms are cardiac frequency E intrapelvic (risk of damaging intrapelvic structures: rectum) modifcation (an increase or decrease by 10 beats per minute), increased F 4th sacral foramen (unilateral block). T-wave amplitude change after intravascular injection of a local anaesthetic agent the 60 to 90 second period after injection (Figure 9). Analgesic neonatal rats leads us to discourage its use by caudal route in neonates spread will be two dermatomes higher on the down positioned side at 22 and infants. Spread of block as a function of caudally injected local vomiting for opioids, light sedation for clonidine, and hallucinations anaesthetic volume18 for ketamine. Teoretical risk of respiratory depression with opioids mandates adequate postoperative monitoring. This is more likely if the needle is advanced excessively in the possible, since motor block is poorly tolerated in awake children. Under general anaesthesia this and L-bupivacaine have less cardiac toxicity than bupivacaine at should be suspected if non-reactive mydriasis (pupillary dilation) equivalent analgesic efectiveness. Four to six hours analgesia is usually achieved with minimal 19, 20 a test dose, cessation of injection if resistance is felt and slow motor block. Sacral Maximal doses must not be exceeded (Table 2) but use of a more perforation can lead to pelvic organ damage. Maximal allowable doses of local anaesthestic agents • delayed respiratory depression secondary to caudally injected opioid. Anesthesiology this technique has an established role in paediatric regional anaesthesia 2004; 100: 683-9. Detection of epidural catheters with ultrasound in anaesthesia techniques are gaining popularity and may begin to replace children. Paediatric caudal regional anesthesia in children: a one-year prospective survey of the anaesthesia. Cardiovascular criteria for epidural test dosing in sevofurane and Anaesth 2000; 10: 137-41. Caudal epidural block: a review of test dosing and rate and adverse efects in 750 consecutive patients. Confrmation of caudal needle Plasma concentrations of ropivacaine following a single-shot caudal placement using nerve stimulation. Caudal injectate can be reliably efcacy of levobupivacaine, ropivacaine and bupivacaine in pediatric imaged using portable ultrasound a preliminary result. Evaluation of apoptosis and Bacterial colonisation and infectious rate of continuous epidural long-term functional outcome. Thoracic epidural catheters review of clinical and preclinical strategies for the development of placed by the caudal route in infants: the importance of radiographic safety and efcacy data. Apnoea in a former preterm infant caudal catheters reduces the rate of bacterial colonization to that of after caudal bupivacaine with clonidine for inguinal herniorrhaphy. Regional to keep the dose of local anaesthetic within safe blocks allow for a lighter plane of anaesthesia limits. Ultrasound in children: ilioinguinal/ position between the abdominal wall muscles. Anatomy (see Figure 1): Regional anaesthetic blocks are simple to do, • The iliohypogastric (T12, L1) and ilioinguinal but should be taught by an appropriately skilled (L1) nerves are terminal branches of the mentor. They lie deep to the internal performed using an aseptic technique; clean the oblique. Specialist Registrar in psoas major and pass anterior to quadratus Anaesthesia lumborum. Foundation Trust It does not abolish visceral pain due to peritoneal • The iliohypogastric nerve pierces (again) the West Derby traction or manipulation of the spermatic cord internal oblique and runs under the external Liverpool during inguinal hernia repair or orchidopexy. Anatomy of the ilioinguinal/iliohypogastric nerve block Insert the needle just through the skin into the subcutaneous dose tissues; advance the needle slowly until a fascial ‘click’ or Use a volume of up to 0. Visceral perforation (colon puncture, umbilicus (a small footprint probe is useful for infants). It is important to keep the injection point high, away from the skin crease in the groin where the surgeon will make the incision; Figure 3. Ultrasound probe position for iliinguinal/iliohypogastric nerve otherwise the operating feld will be obscured. Identify (always from the inside out) pyloromyotomy, laparoscopic surgery and excision of urachal the peritoneum (hyperechoic line, underneath it you may see remnants. The external oblique muscle may not be visible as a anatomy distinct muscle layer at this level as it may have become an • The rectus sheath encloses the rectus abdominis muscle aponeurosis. Tese aponeuroses join in the lateral border of the same orientation of the probe, to bring all three muscles into rectus muscle in the point called linea semilunaris. This may be useful if there is any • Medial to the semilunaris, the aponeuroses split with some doubt about the anatomy and the relevant planes. They lie in the plane layer of the internal oblique aponeurosis form the between the internal oblique muscle and the transversus anterior wall of the rectus sheath. Tese tendinous intersections are what separate the muscle into the well-known ‘6-pack’, but it is actually an 8-pack.
Journal of Thrombosis and Thrombolysis menstrual irregularities in perimenopause , 2016 menstrual like cramping in third trimester , Volume 41 women's health center vassar , Number 1 breast cancer vs cyst , Page 206 3Martin et al. The criteria and pros and cons below can help providers and patients make an informed decision. Prescribing information should be reviewed for complete drug-drug interaction information. Warfarin Valvular atrial fibrillation (mod/severe mitral stenosis or mechanical valve) Does patient have CrCl <30, mechanical heart Which of these options would they prefer Warfarin is affected by diet and general health status, has many medication interactions, and may require bridging around certain medical procedures. Consider other patient factors that could impact warfarin safety Possible drug interactions (drug interaction table) Ability of patient/family to comply with monitoring and dose changes and comprehend warfarin education Alcohol abuse, dementia, depression, unstable diet, co-morbidities Discuss treatment options with cardiologist if patient is also on dual antiplatelet medications 4. Select appropriate starting dose Select starting dose based on factors affecting bleeding risk and warfarin sensitivity such as age, co-morbidities, and interacting drugs. If high bleeding risk, use 3 months of anticoagulant therapy over extended therapy (no scheduled stop date) (Grade 1B). Men have about a 75% higher risk of recurrence compared to women, while patients with a positive D-dimer result have about double the risk of recurrence compared to those with a negative D-dimer. Comparison of 10-mg and 5-mg Warfarin Initiation Nomograms Together with Low-Molecular-Weight Heparin for Outpatient Treatment of Acute Venous Thromboembolism. Criteria Additional information for criteria Is the patient hemodynamically unstable More than 24h of oxygen supply to maintain oxygen saturation >90% Is pulmonary embolism diagnosed during anticoagulant treatment Medical or social reason for treatment in the hospital for more than 24h (infection, malignancy, no support system) American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines journal. There may be valid clinical reasons to adjust doses outside these recommendations. Rapid reversal with four-factor prothrombin complex concentrate is suggested over plasma. There is growing evidence that bridging can increase bleed risk without significantly reducing thromboembolic risk in some 1, 2 patient groups. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Decisions about interruption and bridging should only be made after assessment of individual patient and procedure-related factors and discussions with the patient, management team, and proceduralist. Warfarin can normally be restarted within the first 24 hours after the procedure at the patient’s usual therapeutic dose. Lung biopsy (percutaneous needle)3 *Recent evidence from Level 1 randomized, controlled trial suggests that Chest drain insertion (larger drain)3 implantation can be done without interruption Nerve block, peripheral (deep and non-compressible)3 Always discuss with proceduralist to determine bleed risk as the complexity of the procedure may vary case to case due to patient factors. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Some of the most common types of minor bleeding include epistaxis; bleeding gums; prolonged bleeding from small cuts/scrapes; bruising; and small amounts of blood in the urine, stool, or sputum. It is estimated that about 15% of patients will have at least one minor bleeding event per year. For additional moisturization For short term (less than 4-5 days) use a small amount of Vaseline Petroleum Jelly or A & D ointment or saline gel just inside the nose twice a day. If a nosebleed lasts greater than 10 minutes, spray 2 sprays of Afrin in the nostril that is bleeding and pinch both nostrils tightly for 10 minutes head upright. Avoid alcohol, hot liquids and hot or spicy foods for two days after the nosebleed. Alcohol and hot liquids in your mouth can dilate blood vessels in your nose and cause the bleeding to start again. If bleeding persists or if there is concern about the amount of bleeding, notify your anticoagulation provider for further instructions. Evidence-Based Management of Anticoagulant Therapy Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Available evidence suggests that, in most cases, resumption of anticoagulation results in better patient outcomes. Evaluate renal function (Cockcroft-Gault equation Use actual body weight in Cockcroft-Gault equation. Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy. Reduce dose to 75 mg twice daily if mg daily if CrCl 95 daily if at least two of the Reduce to 15 mg daily with CrCl 15-30 mL/min. Reduce dose following: age 80 years, body evening meal if CrCl 15-50 15 mL/min or on dialysis to 30 mg daily if CrCl weight 60 kg or serum mL/min or if on dialysis is 15-50 mL/min. Avoid if CrCl < 30 weight < 60 kg or for 12 days (knee) or 35 days L/min using any P-gp (hip) inhibitors listed above**. Even though a drug interaction is not listed specifically on package insert, it may be advisable to avoid that drug if other drugs with similar actions are listed. John’s wort Ginkgo Feverfew Sucralose Grape juice Garlic Green Tea Gingko Honokiol Ginseng Lemonin Goldenseal Notoginsenoside R1 Grapefruit Rutin Green Tea Soybean extract Milk thistle Resveratrol Rhodiola Saw palmetto Silymarin Silibinin St. John’s wort Turmeric Valerian 7, 8, * Examples of natural supplements with antiplatelet or anticoagulant properties Bromelain Fish Oil Green Tea Selenium Capsaicin Garlic L-arginine Sweet birch bark Chamomile Ginger Licorice Taurine Clove Ginkgo biloba Lycopene Vitamin E Coenzyme Q10 Ginseng Magnesium Willow bark Dong quai Glucosamine Passion Flower Wintergreen leaf Feverfew Grape seed extract Policosanol *Note that many of these interactions are theoretical, have not been adequately studied, or may require consuming higher amounts than normally taken. Drug-drug interactions in an era of multiple anticoagulants: a focus on clinically relevant drug interactions. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Pradaxa can be taken with or without food but should be taken with a full glass of water. John’s wort, dronedarone, ketoconazole, verapamil, amiodarone, clarithromycin, itraconazole, and ritonavir) What kind of lab monitoring will need to be done and how often Pradaxa must be kept in its original packaging What are some other necessary lifestyle changes European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Periprocedural management of patients receiving a vitamin k antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (Appendix 1). For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) should guide treatment decision. Patients with high risk for bleeding may include old age, history of bleeding tendency, concurrent uses of other anticoagulants/antiplatelets, liver cirrhosis or advanced liver disease, and advanced renal disease. Regional Anesthesia & Pain Medicine: May/June 2015 Volume 40 Issue 3 p 182–212. Qualitative=assess if drug is present, Quantitative=assess drug concentration *Assays or reagents may not be approved for patient care purposes; check with your local laboratories before ordering the test. Laboratory assessment of the anticoagulant effects of the next generation of oral anticoagulants. In No other infusion should be patients with hereditary administered in parallel via fructose intolerance, the same intravenous consider the combined access. Monitor zhzo)3 edoxaban patients for s/sx of or thromboembolic events betrixaban and resume would be anticoagulation therapy off-label as soon as medically appropriate. Rivaroxaban Discontinue Xarelto and start No clinical trial data are available to guide (Xarelto)3 parenteral anticoagulant at the converting patients from rivaroxaban to warfarin. Edoxaban Discontinue Savaysa and start For patients on 60 mg of edoxaban, reduce dose to (Savaysa)4 parenteral anticoagulant at the 30 mg and begin warfarin concomitantly. Using this form ensures that information is collected and analyzed in a systematic way, making it more likely that a root cause is identified and proper prevention strategies put in place. If a human error is involved, try to identify any system, process, or environmental factors that contributed to the error.
Adverse events Spices women's health clinic king st london ontario , herbs and other plant extracts have been used in traditional medicine for thousands of years breast cancer 8 years later . Most of these extracts have been effective; however their safety and toxicity have not been well-evaluated women's health issues on thrombosis . The increasing use of herbal medicine is expected to menstruation joint pain be more frequently associated with adverse reactions. Clinical evaluation of these adverse effects is not easy due lack of standardization, randomization, adequate number of patients and difficulty in using an appropriate placebo. However similar to other drugs they may induce intrinsic or extrinsic adverse effects. Some of their multiple constituents, such as anti cancer plant-derived drugs, digitalis and the pyrrolizidine alkaloids are cytotoxic. Nevertheless, their adverse effects are less frequent than those of synthetic drugs (143). Hepatotoxicity induced by curcumin and its derivatives (144) as well as by turmeric and its ethanolic extract in vulnerable mice has been reported (145). Kava (Piper methysticum), used as anxiolytic herb in Western countries has been potentially found to be hepatotoxic. Its hepatotoxicity is correlated with overdose, prolonged treatment, concurrent medication, and the quality of raw material (148). In addition to hepatic toxicity, alteration of body weight has been described in rodents treated with Foeniculum vulgare ethanolic extracts and Ruta chalepensis (150). Furthermore, in experimental model, piperine has decreased mating performance and fertility and intrauterine injection has caused loss of implants without histological abnormalities (151). Herbal-induced toxicity is influenced by herbs related factors (quality, dose and nature of constituents) and individual risk factors (genetics, age, concomitant drugs, and concomitant diseases) (152). Therefore, simultaneous administration of herbs with conventional medications should generally be discouraged (153). Herbal medicine-associated adverse reactions are expected to occur more frequently as a result of the fast mounting use of these agents in treatment. Like other medicinal plants it also interferes with cytochrome P450 activity and metabolism of other drugs (154). It may increase the clearance of some medications via cytochrome P-450 mixed-function oxidase or through P-glycoprotein efflux pump modulation. On the other hand, it may decrease digoxin, theophylline, warfarin, protease inhibitors, cyclosporine, tacrolimus, and tricyclic antidepressants concentration with subsequent reduction of their therapeutic effect. A third category of drugs such as procainamide carbamazepine and mycophenolic acid are not affected by St. A significant interference with digoxin, quinidine, procainamide, N-acetyl procainamide theophylline, tricyclic antidepressants, phenytoin, carbamazepine, valproic acid and phenobarbital serum levels is lacking (159). Due to unwanted effects, ginseng and ginkgo should not be combined with anticoagulants and valerian with barbiturates (160). Case reports of interstitial fibrosis progressing to chronic renal failure and termed as aristolochic acid nephropathy may complicate treatment with slimming herbs belonging to Aristolochia family (162). Despite all of these reports of adverse events, spices are generally safe when used in standared doses. Popular traditional Chinese medicine has relatively less adverse effects and appears safer than other drugs (163). The safety of herbal agents during pregnancy has been evaluated in 392 pregnant women 8% have reported taking chamomile, licorice, fennel, aloe, valerian, Echinacea oil 27, propolis and cranberry. Only four out 109 have reported insignificant adverse events in form of constipation after tisane, rash and itching after local application of aloe or almond oil. A higher incidence of threatening miscarriage and preterm labors was observed among regular users of chamomile and licorice (164). In disparity, many spices and plant extracts, in commonly used dose, up to 500mg/kg body weight have not exhibited adverse effect. These include cardamom (62, 68), black pepper (66), clove (67), caraway (69), saffron (70), coriander(71), peppermint (72), anise (73), davilla elliptica and nitida (74), Brazilian medical plants (75) and Alchornea triplinervia (76) and Hyptis spicigera Lam (86). Even in pregnancy, ginger, peppermint, and Cannabis have been used to treat nausea were effective and lack clinical evidence of harm (165). Clinically, spices like turmeric and curcumin have been well-tolerated even with high doses and lack any toxicity (166). The gastric ulcer protective effect of boswellic acids, a leukotriene inhibitor from Boswellia serrata, in rats. Safrole, eugenol and methyleugenol induce intrachromosomal recombination in yeast. Evaluation of the in vitro anticancer, antimicrobial and antioxidant activities of some Yemeni plants used in folk medicine. Effect of pepper and bismuth subsalicylate on gastric pain and surface hydrophobicity in the rat. Gastroprotective effect of an aqueous suspension of black cumin Nigella sativa on necrotizing agents-induced gastric injury in experimental animals. Oxidative stress disturbs energy metabolism of mitochondria in ethanol-induced gastric mucosa injury. Phloroglucinol protects gastric mucosa against ethanol-induced injury through regulating myeloperoxidase and catalase activities. Antibacterial properties of Chinese herbal medicines against nosocomial antibiotic resistant strains of Pseudomonas aeruginosa in Taiwan. Potent anti-microbial activity of traditional Chinese medicine herbs against Candida species. Inhibitory effects of anethole and eugenol on the growth and toxin production of Aspergillus parasiticus. Safety and efficacy of Ganoderma lucidum (lingzhi) and San Miao San supplementation in patients with rheumatoid arthritis: a double-blind, randomized, placebo-controlled pilot trial. Anti-inflammatory effects of red pepper (Capsicum baccatum) on carrageenan and antigen-induced inflammation. Curcumin, the active principle of turmeric (Curcuma longa), ameliorates diabetic nephropathy in rats. Antimutagenic effects of piperine on cyclophosphamide-induced chromosome aberrations in rat bone marrow cells. Anti-diabetic and hypolipidaemic properties of ginger (Zingiber officinale) in streptozotocin-induced diabetic rats. Evaluation of turmeric (Curcuma longa) for gastric and duodenal antiulcer activity in rats. Gastrin and interleukin-1beta stimulate growth factor secretion from cultured rabbit gastric parietal cells. The plant kingdom as a source of anti-ulcer remedies Phytother Res 2000;14: 581-591. Food and chemical toxicology: an international journal published for the British Industrial Biological Research Association 03/2008; 46: 409-420. Gastroprotective effect of Cissus quadrangularis extract in rats with experimentally induced ulcer. Anti-ulcer actions of phytosphingosine hydrochloride in different experimental rat ulcer models. Inhibition of gastric acid secretion by a standardized aqueous extract of Cecropia glaziovii Sneth and underlying mechanism. Gastroprotective activity of alkaloid extract and 2-phenylquinoline obtained from the bark of Galipea longiflora Krause (Rutaceae) Chem Biol Interact 2009;180: 312–317. Antiulcer and gastric antisecretory effects of Landolphia owariensis extracts in rats. Ulcer preventive and antioxidative properties of astaxanthin from Haematococcus pluvialis. Gastroprotective effect of Cissus sicyoides (Vitaceae): involvement of microcirculation, endogenous sulfhydryls and nitric oxide. Oxidative stress involvement and gene expression in indomethacin-induced gastropathy. Black pepper and its pungent principle-piperine: a review of diverse physiological effects. Gastroprotective activity of Nigella sativa L oil and its constituent, thymoquinone against acute alcohol-induced gastric mucosal injury in rats. Gastroprotective activity of isopulegol on experimentally induced gastric lesions in mice: investigation of possible mechanisms of action.
. Victoria Osteen's Message for Women - CBN.com.
Syndromes
- Chromosome studies
- Frequent bowel movements
- You have a weakened immune system due to certain diseases and medications
- Rapid or irregular heartbeat
- Dizziness (vertigo)
- Abnormally dark or light skin
- Fluid buildup in the abdomen (ascites)
- Skin gel
One found no significant differences in lung function or hospital admissions403 but a later review with additional studies found reduced hospitalizations and better lung function with continuous compared with intermittent nebulization menopause 62 years old , particularly in patients with worse lung function menstruation forecast . There is no evidence to menstrual like cramps at 33 weeks support the routine use of intravenous beta2-agonists in patients with severe asthma exacerbations406 (Evidence A) women's health center warner robins ga . Epinephrine (for anaphylaxis) Intramuscular epinephrine (adrenaline) is indicated in addition to standard therapy for acute asthma associated with anaphylaxis and angioedema. Systemic corticosteroids Systemic corticosteroids speed resolution of exacerbations and prevent relapse, and should be utilized in all but the mildest exacerbations in adults, adolescents and children 6–11 years. Where possible, systemic corticosteroids should be administered to the patient within 1 hour of presentation. The oral route is preferred because it is quicker, less invasive and less expensive. Intravenous corticosteroids can be administered when patients are too dyspneic to swallow; if the patient is vomiting; or when patients require non-invasive ventilation or intubation. In patients discharged from the emergency department, an intramuscular corticosteroid may be helpful, 412 especially if there are concerns about adherence with oral therapy. Management of worsening asthma and exacerbations for 1-2 days415 can also be used but there are concerns about metabolic side-effects if it is continued beyond 2 days. When given in addition to systemic corticosteroids, evidence is conflicting409 (Evidence B). Management of worsening asthma and exacerbations 85 Helium oxygen therapy A systematic review of studies comparing helium-oxygen with air–oxygen suggests there is no role for this intervention in routine care (Evidence B), but it may be considered for patients who do not respond to standard therapy; however, availability, cost and technical issues should be considered. Small studies have demonstrated improvement in lung function434, 435 but the clinical role of these agents requires more study. Sedatives Sedation should be strictly avoided during exacerbations of asthma because of the respiratory depressant effect of anxiolytic and hypnotic drugs. An association between the use of these drugs and avoidable asthma deaths has been reported. Reviewing response Clinical status and oxygen saturation should be re-assessed frequently, with further treatment titrated according to the patient’s response (Box 4-4, p. Criteria for hospitalization versus discharge from the emergency department From retrospective analyses, clinical status (including the ability to lie flat) and lung function 1 hour after commencement of treatment are more reliable predictors of the need for hospitalization than the patient’s status on arrival. Management of worsening asthma and exacerbations • If post-treatment lung function is >60% predicted or personal best, discharge is recommended after considering risk factors and availability of follow-up care. Other factors associated with increased likelihood of need for admission include:444-446 • Female sex, older age and non-white race • Use of more than eight beta2-agonist puffs in the previous 24 hours • Severity of the exacerbation. Overall, these risk factors should be considered by clinicians when making decisions on admission/discharge for patients with asthma managed in the acute care setting. Discharge planning Prior to discharge from the emergency department or hospital to home, arrangements should be made for a follow-up appointment within one week, and strategies to improve asthma management including medications, inhaler skills and written asthma action plan, should be addressed (Box 4-5). Incentives such as free transport and telephone reminders improve primary care follow up but have shown no effect on long-term outcomes. Patients who were hospitalized may be particularly receptive to information and advice about their illness. Health care providers should take the opportunity to review: • the patient’s understanding of the cause of their asthma exacerbation • Modifiable risk factors for exacerbations (including, where relevant, smoking) (Box 3-8, p. After emergency department presentation, comprehensive intervention programs that include optimal controller management, inhaler technique, and elements of self-management education (self-monitoring, written action plan and regular review134) are cost effective and have shown significant improvement in asthma outcomes221 (Evidence B). Referral for expert advice should be considered for patients who have been hospitalized for asthma, or who repeatedly present to an acute care setting despite having a primary care provider. No recent studies are available, but earlier studies suggest that follow-up by a specialist is associated with fewer subsequent emergency department visits or hospitalizations and better asthma control. For patients considered at risk of poor adherence, intramuscular corticosteroids may be considered412 (Evidence B). Reliever medication Transfer patients back to as-needed rather than regular reliever medication use, based on symptomatic and objective improvement. If ipratropium bromide was used in the emergency department or hospital, it may be quickly discontinued, as it is unlikely to provide ongoing benefit. An exacerbation severe enough to require hospitalization may follow irritant or allergen generally have their treatment stepped up for 2–4 weeks (Box 4-2, p. Self-management skills and written asthma action plan Field Code Changed • Review inhaler technique (Box 3-11, p. If it was inadequate, review the action plan and provide written guidance to assist if asthma worsens again. Follow up appointment A follow-up appointment within 2–7 days of discharge should be made with the patient’s usual health care provider, to ensure that treatment is continued, that asthma symptoms are well controlled, and that the patient’s lung function reaches their personal best (if known). In some children with asthma, 112 and in many adults with a history of asthma, 449, 450 persistent airflow limitation Comment [A41]: McGeachie et al 2016 added. The primary objective of the present approach, based on current evidence, is to provide practical interim advice for Deleted: this clinicians, particularly those in primary care and non-pulmonary specialties, about diagnosis, safe initial treatment, and referral where necessary. A first step in diagnosing these conditions is to identify patients at risk of, or with significant likelihood of having chronic airways disease, and to exclude other potential causes of respiratory symptoms. This is based on a detailed medical history, physical examination, and other investigations. Screening questionnaires Many screening questionnaires have been proposed to help the clinician identifying subjects at risk of chronic airways disease, based on the above risk factors and clinical features. Clinicians are able to provide an estimate of their level of certainty and factor it into their decision to treat. Doing so consciously may assist in the selection of treatment and, where there is significant doubt, it may direct therapy towards the safest option namely, treatment for the condition that should not be missed and left untreated. Symptoms vary either over time (progressive course treatment, but may result despite treatment treatment. Spirometry Spirometry is essential for the assessment of patients with suspected chronic disease of the airways. It must be performed at either the initial or a subsequent visit, if possible before and after a trial of treatment. Early confirmation or exclusion of the diagnosis of chronic airflow limitation may avoid needless trials of therapy, or delays in initiating other investigations. After the results of spirometry and other investigations are available, the provisional diagnosis from the syndrome-based assessment must be reviewed and, if necessary, revised. As shown in Box 5-3, spirometry at a single visit is not always confirmatory of a diagnosis, and results must be considered in the context of the clinical presentation, and whether treatment has been commenced. Further tests might therefore be necessary either to confirm the diagnosis or to assess the response to initial and subsequent treatment (see Step 5). An indicator of severity of An indicator of severity of predicted Risk factor for asthma airflow limitation and risk of airflow limitation and risk of exacerbations future events. Summary of syndromic approach to diseases of chronic airflow limitation for clinical practice Box 5-5 (p. The present chapter provides interim advice, largely based on consensus, for the perspective of clinicians, particularly those in primary care and non pulmonary specialties. Viral-induced wheezing Recurrent wheezing occurs in a large proportion of children aged 5 years or younger. However, wheezing in this age group is a highly heterogeneous condition, and not all wheezing in this age group indicates asthma. Therefore, deciding when wheezing with a respiratory infection is truly an initial or recurrent clinical presentation of childhood asthma is difficult. However, prospective allocation of individual children to these phenotypes has been unreliable in ‘real-life’ clinical situations, and the clinical usefulness of these systems remains a subject of active investigation. A probability-based approach, based on the pattern of symptoms during and between viral respiratory infections, 498 may be helpful for discussion with parents/carers (Box 6-1). This approach allows individual decisions to be made about whether to give a trial of controller treatment. It is important to make decisions for each child individually, to avoid either over or under-treatment. Probability of asthma diagnosis or response to asthma treatment in children 5 years and younger this schematic figure shows the probability of an asthma diagnosis499, 500 or response to asthma treatment501, 502 in children aged 5 years or younger who have viral-induced cough, wheeze or heavy breathing, based on the pattern of symptoms. Many young children wheeze with viral infections, and deciding when a child should be given controller treatment is difficult. The frequency and severity of wheezing episodes and the temporal pattern of symptoms (only with 6. Diagnosis and management of asthma in children 5 years and younger 101 viral colds or also in response to other triggers) should be taken into account.