ER Management of Acute Asthma Attack

Ahmed Al Gahtani, BSRC, RRTAssociate Director, Clinical EducationRespiratory Therapy Program Inaya Medical College

Asthma exacerbations consist of acute or sub-acute episodes of:

Coughing Wheezing

Progressively worsening SOB

Chest Tightness

Combination

Impending or Actual Respiratory Arrest

Classification of Asthma Exacerbations

SevereMild to Moderate

Mild to Moderate Exacerbation

Symptoms: SOB while at rest, prefers sitting, talk in phrases, and/or usually agitated.

Signs: PEF of ≥ 40%, Increased RR, HR 100 to 120 , use of accessory muscles, loud wheezes throughout exhalation, PaO2 ≥

60 mm Hg and/or PaCO2 < 42 mm Hg, SpO2 90 to 95 %

Severe Exacerbation

Symptoms: SOB while at rest, Sits upright, talk in wards, and usually agitated.

Signs: PEF of < 40%, Increased RR often > 30, HR > 120 , usually uses accessory muscles, loud wheezes throughout inhalation &

exhalation, PaO2 < 60 mm Hg and/or PaCO2 ≥ 42 mm Hg, SpO2 < 90 %

Impending or Actual Respiratory Arrest

Symptoms: Drowsy or confused

Signs: PEF of < 25%, Bradypnea , Bradycardia, Paradoxical thoracoabdominal movement, and Absence of wheezes

(Note: PEF testing may not be needed in very severe attacks)

Early treatment of asthma exacerbations is the best strategy for management. Important elements of early treatment at the patient’s home include a written asthma action plan; recognition of early signs and symptoms of worsening

The NAEPP Expert Panel recommendsthat all clinicians treating asthmatic patients should be prepared to treat an asthma exacerbation, recognize the signs and symptoms of severe and life-threatening exacerbations, and be familiar with the risk factors for asthma-related death. Because infants are at greater risk for respiratory failure, clinicians should also be familiar with special considerations in the assessment and treatment of infants experiencing asthma exacerbations.

Principles and Primary Goals of Care

• Relieve airflow limitation• Treat airway inflammation• Treat hypoxemia or hypercapnia if present.• Non-invasive ventilation / mechanical ventilation in

severe cases (clinical judgment).• Selected therapies: magnesium sulphate and heliox.• Limited or no role for antibiotics and

methylxanthines (aminophylline/theophylline).

Management

Pre-Hospital Management

EMS At Home

All EMS personnel should receivetraining in how to respond to the signs and

symptoms of severeairway obstruction and impending respiratory

failure

ED Management

ED Management

ED Management

Expert Panel Report 3: National Heart Lung and Blood Institute 2007https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Noninvasive Mechanical Ventilation

Invasive Mechanical Ventilation

Invasive Mechanical Ventilation

Invasive Mechanical Ventilation

Invasive Mechanical Ventilation

Invasive Mechanical Ventilation

• Heliox• Antibiotics• Systemic Aminophylline• Magnesium Sulfate • Bronchial Thermoplasty

Adjunct Therapies

Am J Respir Crit Care Med. 2012 Apr 1;185(7):709-14

Adjunct Therapies

References

• PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 6 2009Thank You