Management of Acute Asthma in Adults Emergency Department and Hospital

Management Protocol

By

Dr ASHRAF ELADAWY Consultant Chest Physcian

TB TEAM Expert ndash WHO January - 2O14

Management of Acute Asthma in Adults Emergency Department and Hospital Management

Protocol Definition

Exacerbations of asthma (asthma attacks or acute asthma)

are episodes of progressive increase in shortness of breath

cough wheezing or chest tightness or some combination

of these symptoms

Severe asthma exacerbations are potentially life

threatening and their treatment requires close supervision

Triggers of asthma exacerbation

1 Virus infection viral upper respiratory tract infections are an

important trigger of acute exacerbations of asthma

2 Allergen exposure

3 Environmental pollutants

4 Occupational sensitisersirritants

5 Smoking

6 Medications eg aspirin

Mechanisms of Status

Asthmaticus

Mucous

Hypersecretion

Bronchospasm

Mucosal edema

Increased resistance to air flow

Atelectasis Uneven ventilation

Abnormal VQ

Hyperinflation

deadspace compliance

alveolar hypoventilation WOB

pCO2

pO2

Risk factors for death from Asthma I Asthma history Those With a history of near-fatal asthma requiring

intubation and mechanical ventilation or ICU admission

Two or more hospitalizations for asthma in the past year

Three or more ED visits for asthma in the past year

Hospitalization or ED visit for asthma in the past month

Using gt2 canisters of SABA per month

Those Who are currently using or have recently stopped

using oral glucocorticosteroids

Those taking 3 or more classes of asthma medication

Difficulty perceiving asthma symptoms or severity of

exacerbations

Other risk factors lack of a written asthma action plan

sensitivity to Alternaria

II Social history Low socioeconomic status or inner-city residence

Illicit drug use

Major psychosocial problems

III Comorbidities Cardiovascular disease

Other chronic lung disease

Chronic psychiatric disease

mdash Patients at high risk of asthma-related death require closer

attention and should be encouraged to seek urgent care

early in the course of their exacerbations

mdash Most patients who present with an acute asthma

exacerbation have chronic uncontrolled asthma

mdash Many deaths have been reported in patients who have

received inadequate treatment or poor education

mdash Upon presentation a patient should be carefully assessed to

determine the severity of the acute attack and the type of

required treatment

mdash PEF and pulse oximetry measurements are complementary

to history taking and physical examination

Patient assessment

Levels of severity of acute asthma exacerbations in adults

Mild asthma exacerbation

Patients presenting with mild asthma exacerbation are

usually treated in an outpatient by stepping up in asthma

management However some cases may require short

course of oral steroid

Moderate asthma exacerbation

Patients with moderate asthma exacerbation are clinically

stable They are usually alert and oriented but may be

agitated

They are able to communicate and talk in full sentences

Their respiratory rate is between 25 and 30 per minute and

may be using their respiratory accessory muscles

Heart rate is lt120min and blood pressure is normal

A prolonged expiratory wheeze is usually heard clearly over

lung fields

Oxygen saturation is usually normal secondary to

hyperventilation

The PEF is usually in the range of 50ndash75 of predicted or

previously documented best

Measurement of arterial blood gases are not routinely

required in this category however if done it shows

widened alveolarndasharterial oxygen gradient and low PaCO2

secondary to increased ventilation perfusion mismatch and

hyperventilation respectively

Chest X-ray is not usually required for moderate asthma

exacerbation unless pneumonia is suspected

Severe asthma exacerbation

Patients are usually agitated and unable to complete full

sentences

Their respiratory rate is usually gt30min and use accessory

muscles

Significant tachycardia (pulse rate gt120min) and

Hypoxia (SaO2lt92 on room air or low-flow oxygen) are

usually evident

Chest examination reveals prolonged distant wheeze

secondary to severe airflow limitation and hyperinflation

The PEF is usually in the range of 33ndash50 of predicted

When done arterial blood gases reveal significant

hypoxemia and elevated alveolar-arterial O2 gradient

PaCO2 may be normal in patients with severe asthma

exacerbation Such finding is an alarming sign as it

indicates fatigue inadequate ventilation and pending

respiratory failure

Chest radiograph is required if complications such as

pneumothorax or pneumonia are clinically suspected

Life-threatening asthma exacerbation

Patients with life-threatening asthma are severely breathless

and unable to talk They can present in extreme agitation

confusion drowsiness or coma

Unless already in respiratory failure the patients usually

breathe at a respiratory rate gt30min and use their

accessory muscle secondary to increased work of

breathing

Heart rate is usually gt120min but at a later stage patients

can be bradycardiac

Arrhythmia is common in this category of patients

secondary to hypoxia and ECG monitoring is mandatory

Oxygen saturation is usually low (lt90) and not easily

corrected with O2

Arterial blood gases are mandatory in this category and

usually reveal significant hypoxia and normal or high

PaCO2 Respiratory acidosis might be present

PEF is usually very low (lt33 of the predicted)

Chest X-ray is mandatory in life-threatening asthma to rule

out complications such as pneumothorax or

pneumomediastinum

It is important to realize that some patients might have

features from more than one level of acute asthma severity

For the patientsprime safety heshe should be classified as the

higher level and managed accordingly

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Management of Acute Asthma in Adults Emergency Department and Hospital Management

Protocol Definition

Exacerbations of asthma (asthma attacks or acute asthma)

are episodes of progressive increase in shortness of breath

cough wheezing or chest tightness or some combination

of these symptoms

Severe asthma exacerbations are potentially life

threatening and their treatment requires close supervision

Triggers of asthma exacerbation

1 Virus infection viral upper respiratory tract infections are an

important trigger of acute exacerbations of asthma

2 Allergen exposure

3 Environmental pollutants

4 Occupational sensitisersirritants

5 Smoking

6 Medications eg aspirin

Mechanisms of Status

Asthmaticus

Mucous

Hypersecretion

Bronchospasm

Mucosal edema

Increased resistance to air flow

Atelectasis Uneven ventilation

Abnormal VQ

Hyperinflation

deadspace compliance

alveolar hypoventilation WOB

pCO2

pO2

Risk factors for death from Asthma I Asthma history Those With a history of near-fatal asthma requiring

intubation and mechanical ventilation or ICU admission

Two or more hospitalizations for asthma in the past year

Three or more ED visits for asthma in the past year

Hospitalization or ED visit for asthma in the past month

Using gt2 canisters of SABA per month

Those Who are currently using or have recently stopped

using oral glucocorticosteroids

Those taking 3 or more classes of asthma medication

Difficulty perceiving asthma symptoms or severity of

exacerbations

Other risk factors lack of a written asthma action plan

sensitivity to Alternaria

II Social history Low socioeconomic status or inner-city residence

Illicit drug use

Major psychosocial problems

III Comorbidities Cardiovascular disease

Other chronic lung disease

Chronic psychiatric disease

mdash Patients at high risk of asthma-related death require closer

attention and should be encouraged to seek urgent care

early in the course of their exacerbations

mdash Most patients who present with an acute asthma

exacerbation have chronic uncontrolled asthma

mdash Many deaths have been reported in patients who have

received inadequate treatment or poor education

mdash Upon presentation a patient should be carefully assessed to

determine the severity of the acute attack and the type of

required treatment

mdash PEF and pulse oximetry measurements are complementary

to history taking and physical examination

Patient assessment

Levels of severity of acute asthma exacerbations in adults

Mild asthma exacerbation

Patients presenting with mild asthma exacerbation are

usually treated in an outpatient by stepping up in asthma

management However some cases may require short

course of oral steroid

Moderate asthma exacerbation

Patients with moderate asthma exacerbation are clinically

stable They are usually alert and oriented but may be

agitated

They are able to communicate and talk in full sentences

Their respiratory rate is between 25 and 30 per minute and

may be using their respiratory accessory muscles

Heart rate is lt120min and blood pressure is normal

A prolonged expiratory wheeze is usually heard clearly over

lung fields

Oxygen saturation is usually normal secondary to

hyperventilation

The PEF is usually in the range of 50ndash75 of predicted or

previously documented best

Measurement of arterial blood gases are not routinely

required in this category however if done it shows

widened alveolarndasharterial oxygen gradient and low PaCO2

secondary to increased ventilation perfusion mismatch and

hyperventilation respectively

Chest X-ray is not usually required for moderate asthma

exacerbation unless pneumonia is suspected

Severe asthma exacerbation

Patients are usually agitated and unable to complete full

sentences

Their respiratory rate is usually gt30min and use accessory

muscles

Significant tachycardia (pulse rate gt120min) and

Hypoxia (SaO2lt92 on room air or low-flow oxygen) are

usually evident

Chest examination reveals prolonged distant wheeze

secondary to severe airflow limitation and hyperinflation

The PEF is usually in the range of 33ndash50 of predicted

When done arterial blood gases reveal significant

hypoxemia and elevated alveolar-arterial O2 gradient

PaCO2 may be normal in patients with severe asthma

exacerbation Such finding is an alarming sign as it

indicates fatigue inadequate ventilation and pending

respiratory failure

Chest radiograph is required if complications such as

pneumothorax or pneumonia are clinically suspected

Life-threatening asthma exacerbation

Patients with life-threatening asthma are severely breathless

and unable to talk They can present in extreme agitation

confusion drowsiness or coma

Unless already in respiratory failure the patients usually

breathe at a respiratory rate gt30min and use their

accessory muscle secondary to increased work of

breathing

Heart rate is usually gt120min but at a later stage patients

can be bradycardiac

Arrhythmia is common in this category of patients

secondary to hypoxia and ECG monitoring is mandatory

Oxygen saturation is usually low (lt90) and not easily

corrected with O2

Arterial blood gases are mandatory in this category and

usually reveal significant hypoxia and normal or high

PaCO2 Respiratory acidosis might be present

PEF is usually very low (lt33 of the predicted)

Chest X-ray is mandatory in life-threatening asthma to rule

out complications such as pneumothorax or

pneumomediastinum

It is important to realize that some patients might have

features from more than one level of acute asthma severity

For the patientsprime safety heshe should be classified as the

higher level and managed accordingly

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Risk factors for death from Asthma I Asthma history Those With a history of near-fatal asthma requiring

intubation and mechanical ventilation or ICU admission

Two or more hospitalizations for asthma in the past year

Three or more ED visits for asthma in the past year

Hospitalization or ED visit for asthma in the past month

Using gt2 canisters of SABA per month

Those Who are currently using or have recently stopped

using oral glucocorticosteroids

Those taking 3 or more classes of asthma medication

Difficulty perceiving asthma symptoms or severity of

exacerbations

Other risk factors lack of a written asthma action plan

sensitivity to Alternaria

II Social history Low socioeconomic status or inner-city residence

Illicit drug use

Major psychosocial problems

III Comorbidities Cardiovascular disease

Other chronic lung disease

Chronic psychiatric disease

mdash Patients at high risk of asthma-related death require closer

attention and should be encouraged to seek urgent care

early in the course of their exacerbations

mdash Most patients who present with an acute asthma

exacerbation have chronic uncontrolled asthma

mdash Many deaths have been reported in patients who have

received inadequate treatment or poor education

mdash Upon presentation a patient should be carefully assessed to

determine the severity of the acute attack and the type of

required treatment

mdash PEF and pulse oximetry measurements are complementary

to history taking and physical examination

Patient assessment

Levels of severity of acute asthma exacerbations in adults

Mild asthma exacerbation

Patients presenting with mild asthma exacerbation are

usually treated in an outpatient by stepping up in asthma

management However some cases may require short

course of oral steroid

Moderate asthma exacerbation

Patients with moderate asthma exacerbation are clinically

stable They are usually alert and oriented but may be

agitated

They are able to communicate and talk in full sentences

Their respiratory rate is between 25 and 30 per minute and

may be using their respiratory accessory muscles

Heart rate is lt120min and blood pressure is normal

A prolonged expiratory wheeze is usually heard clearly over

lung fields

Oxygen saturation is usually normal secondary to

hyperventilation

The PEF is usually in the range of 50ndash75 of predicted or

previously documented best

Measurement of arterial blood gases are not routinely

required in this category however if done it shows

widened alveolarndasharterial oxygen gradient and low PaCO2

secondary to increased ventilation perfusion mismatch and

hyperventilation respectively

Chest X-ray is not usually required for moderate asthma

exacerbation unless pneumonia is suspected

Severe asthma exacerbation

Patients are usually agitated and unable to complete full

sentences

Their respiratory rate is usually gt30min and use accessory

muscles

Significant tachycardia (pulse rate gt120min) and

Hypoxia (SaO2lt92 on room air or low-flow oxygen) are

usually evident

Chest examination reveals prolonged distant wheeze

secondary to severe airflow limitation and hyperinflation

The PEF is usually in the range of 33ndash50 of predicted

When done arterial blood gases reveal significant

hypoxemia and elevated alveolar-arterial O2 gradient

PaCO2 may be normal in patients with severe asthma

exacerbation Such finding is an alarming sign as it

indicates fatigue inadequate ventilation and pending

respiratory failure

Chest radiograph is required if complications such as

pneumothorax or pneumonia are clinically suspected

Life-threatening asthma exacerbation

Patients with life-threatening asthma are severely breathless

and unable to talk They can present in extreme agitation

confusion drowsiness or coma

Unless already in respiratory failure the patients usually

breathe at a respiratory rate gt30min and use their

accessory muscle secondary to increased work of

breathing

Heart rate is usually gt120min but at a later stage patients

can be bradycardiac

Arrhythmia is common in this category of patients

secondary to hypoxia and ECG monitoring is mandatory

Oxygen saturation is usually low (lt90) and not easily

corrected with O2

Arterial blood gases are mandatory in this category and

usually reveal significant hypoxia and normal or high

PaCO2 Respiratory acidosis might be present

PEF is usually very low (lt33 of the predicted)

Chest X-ray is mandatory in life-threatening asthma to rule

out complications such as pneumothorax or

pneumomediastinum

It is important to realize that some patients might have

features from more than one level of acute asthma severity

For the patientsprime safety heshe should be classified as the

higher level and managed accordingly

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

III Comorbidities Cardiovascular disease

Other chronic lung disease

Chronic psychiatric disease

mdash Patients at high risk of asthma-related death require closer

attention and should be encouraged to seek urgent care

early in the course of their exacerbations

mdash Most patients who present with an acute asthma

exacerbation have chronic uncontrolled asthma

mdash Many deaths have been reported in patients who have

received inadequate treatment or poor education

mdash Upon presentation a patient should be carefully assessed to

determine the severity of the acute attack and the type of

required treatment

mdash PEF and pulse oximetry measurements are complementary

to history taking and physical examination

Patient assessment

Levels of severity of acute asthma exacerbations in adults

Mild asthma exacerbation

Patients presenting with mild asthma exacerbation are

usually treated in an outpatient by stepping up in asthma

management However some cases may require short

course of oral steroid

Moderate asthma exacerbation

Patients with moderate asthma exacerbation are clinically

stable They are usually alert and oriented but may be

agitated

They are able to communicate and talk in full sentences

Their respiratory rate is between 25 and 30 per minute and

may be using their respiratory accessory muscles

Heart rate is lt120min and blood pressure is normal

A prolonged expiratory wheeze is usually heard clearly over

lung fields

Oxygen saturation is usually normal secondary to

hyperventilation

The PEF is usually in the range of 50ndash75 of predicted or

previously documented best

Measurement of arterial blood gases are not routinely

required in this category however if done it shows

widened alveolarndasharterial oxygen gradient and low PaCO2

secondary to increased ventilation perfusion mismatch and

hyperventilation respectively

Chest X-ray is not usually required for moderate asthma

exacerbation unless pneumonia is suspected

Severe asthma exacerbation

Patients are usually agitated and unable to complete full

sentences

Their respiratory rate is usually gt30min and use accessory

muscles

Significant tachycardia (pulse rate gt120min) and

Hypoxia (SaO2lt92 on room air or low-flow oxygen) are

usually evident

Chest examination reveals prolonged distant wheeze

secondary to severe airflow limitation and hyperinflation

The PEF is usually in the range of 33ndash50 of predicted

When done arterial blood gases reveal significant

hypoxemia and elevated alveolar-arterial O2 gradient

PaCO2 may be normal in patients with severe asthma

exacerbation Such finding is an alarming sign as it

indicates fatigue inadequate ventilation and pending

respiratory failure

Chest radiograph is required if complications such as

pneumothorax or pneumonia are clinically suspected

Life-threatening asthma exacerbation

Patients with life-threatening asthma are severely breathless

and unable to talk They can present in extreme agitation

confusion drowsiness or coma

Unless already in respiratory failure the patients usually

breathe at a respiratory rate gt30min and use their

accessory muscle secondary to increased work of

breathing

Heart rate is usually gt120min but at a later stage patients

can be bradycardiac

Arrhythmia is common in this category of patients

secondary to hypoxia and ECG monitoring is mandatory

Oxygen saturation is usually low (lt90) and not easily

corrected with O2

Arterial blood gases are mandatory in this category and

usually reveal significant hypoxia and normal or high

PaCO2 Respiratory acidosis might be present

PEF is usually very low (lt33 of the predicted)

Chest X-ray is mandatory in life-threatening asthma to rule

out complications such as pneumothorax or

pneumomediastinum

It is important to realize that some patients might have

features from more than one level of acute asthma severity

For the patientsprime safety heshe should be classified as the

higher level and managed accordingly

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Heart rate is lt120min and blood pressure is normal

A prolonged expiratory wheeze is usually heard clearly over

lung fields

Oxygen saturation is usually normal secondary to

hyperventilation

The PEF is usually in the range of 50ndash75 of predicted or

previously documented best

Measurement of arterial blood gases are not routinely

required in this category however if done it shows

widened alveolarndasharterial oxygen gradient and low PaCO2

secondary to increased ventilation perfusion mismatch and

hyperventilation respectively

Chest X-ray is not usually required for moderate asthma

exacerbation unless pneumonia is suspected

Severe asthma exacerbation

Patients are usually agitated and unable to complete full

sentences

Their respiratory rate is usually gt30min and use accessory

muscles

Significant tachycardia (pulse rate gt120min) and

Hypoxia (SaO2lt92 on room air or low-flow oxygen) are

usually evident

Chest examination reveals prolonged distant wheeze

secondary to severe airflow limitation and hyperinflation

The PEF is usually in the range of 33ndash50 of predicted

When done arterial blood gases reveal significant

hypoxemia and elevated alveolar-arterial O2 gradient

PaCO2 may be normal in patients with severe asthma

exacerbation Such finding is an alarming sign as it

indicates fatigue inadequate ventilation and pending

respiratory failure

Chest radiograph is required if complications such as

pneumothorax or pneumonia are clinically suspected

Life-threatening asthma exacerbation

Patients with life-threatening asthma are severely breathless

and unable to talk They can present in extreme agitation

confusion drowsiness or coma

Unless already in respiratory failure the patients usually

breathe at a respiratory rate gt30min and use their

accessory muscle secondary to increased work of

breathing

Heart rate is usually gt120min but at a later stage patients

can be bradycardiac

Arrhythmia is common in this category of patients

secondary to hypoxia and ECG monitoring is mandatory

Oxygen saturation is usually low (lt90) and not easily

corrected with O2

Arterial blood gases are mandatory in this category and

usually reveal significant hypoxia and normal or high

PaCO2 Respiratory acidosis might be present

PEF is usually very low (lt33 of the predicted)

Chest X-ray is mandatory in life-threatening asthma to rule

out complications such as pneumothorax or

pneumomediastinum

It is important to realize that some patients might have

features from more than one level of acute asthma severity

For the patientsprime safety heshe should be classified as the

higher level and managed accordingly

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Life-threatening asthma exacerbation

Patients with life-threatening asthma are severely breathless

and unable to talk They can present in extreme agitation

confusion drowsiness or coma

Unless already in respiratory failure the patients usually

breathe at a respiratory rate gt30min and use their

accessory muscle secondary to increased work of

breathing

Heart rate is usually gt120min but at a later stage patients

can be bradycardiac

Arrhythmia is common in this category of patients

secondary to hypoxia and ECG monitoring is mandatory

Oxygen saturation is usually low (lt90) and not easily

corrected with O2

Arterial blood gases are mandatory in this category and

usually reveal significant hypoxia and normal or high

PaCO2 Respiratory acidosis might be present

PEF is usually very low (lt33 of the predicted)

Chest X-ray is mandatory in life-threatening asthma to rule

out complications such as pneumothorax or

pneumomediastinum

It is important to realize that some patients might have

features from more than one level of acute asthma severity

For the patientsprime safety heshe should be classified as the

higher level and managed accordingly

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Assessment of Attack Severity

Clinical features Clinical features symptoms respiratory and cardiovascular signs helpful but

non-specific for severity absence does not exclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment PEF more convenient

(PEF as age previous best or predicted)

Pulse oximetry Determines adequacy of oxygen therapy and need for ABG Aim to maintain

sats gt92

Blood gasses Necessary for patients with SaO2 lt 92 or if features of life threatening asthma

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Management

Management of acute asthma in adults is the extreme

spectrum of uncontrolled asthma and represents the failure

to reach adequate asthma control

Treatment of acute asthma attacks requires a systematic

approach similar to chronic asthma management

Emergency Department and Hospital Management Goals 1 Correction of significant hypoxemia

2 Rapid reversal of airflow obstruction

3 Reduction of likelihood of recurrence

In Acute asthma management it is recommended to follow

these steps

1 Assess severity of the attack

2 Initiate treatment to rapidly control the attack

3 Evaluate continuously the response to treatment

The primary therapies for exacerbations include

1 Repetitive administration of rapid-acting inhaled

bronchodilators

2 Early introduction of systemic glucocorticosteroids

3 Oxygen supplementation

Chest

X-ray

Not routinely recommended in the absence of -

bull Suspected pneumomediastinum or pneumothorax

bull Suspected consolidation

bull Life threatening asthma

bull Failure to respond to treatment as expected

bull Requirement for mechanical ventilation

Systolic

paradox

Systolic paradox (pulsus paradox) is an inadequate indicator of the severity

of an attack and should not be used

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Initial Management of Acute Asthma

Moderate asthma exacerbation

Low-flow oxygen is recommended to maintain saturation

gt92

Oxygen nasal prongs to keep Sa O2gt92

SABA is recommended to be delivered by either

o Nebulizer 25ndash5 mg salbutamol every 20 min for

1 h then every 2 h according to response or

o MDI with spacer 6ndash12 puffs every 20 min for 1 h then

every 2ndash4 h according to the response

Steroid therapy Oral prednisolone 40 mg is recommended

to be started as soon as possible

Severe asthma exacerbation

Oxygen via face Mask or nasal prongs to keep Sa O2gt92

Nebulized SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min for 1 h then

hourly according to the response

Oxygen-driven nebulizers are preferred for nebulizing β2

agonist bronchodilators because of the risk of oxygen

desaturation while using air-driven compressors

Ipratropium bromide (05 mg) by the nebulized route is

recommended to be added to salbutamol every 4ndash6 h

Systemic steroid is recommended to be started as soon as

possible in one of the following forms

o IV hydrocortisone 200 mg STATthen 100-200 mg every

6 hours or

o Oral prednisolone 40 mg daily which could be

maintained if patient can tolerate oral intake

If there was no adequate response to previous measures

the following are recommended

Single dose of IV magnesium sulfate (1ndash2 g) intravenously

over 20 min

Chest X-Ray serial electrolytes urea creatinine

glucose 12-lead ECG ABG

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Life-threatening Asthma

Patients in this category can progress rapidly to near-fatal

asthma respiratory failure and death Hence an aggressive

management approach and continuous monitoring are

mandatory The following steps are recommended for further

management

Consult ICU service

Adequate high flow O2 to keep saturation gt92

SABA (25ndash5 mg) plus Ipratropium bromide (05

mg) nebulized with O2 in 3-5 ml normal saline is

recommended to be repeated every 15ndash20 min

for 1 h then every 1 hour according to patient

response or Deliver nebulized SABA (10 mg)

continuously over 1 h

Oxygen-driven nebulizers are preferred for

nebulizing β2 agonist bronchodilators because of

the risk of oxygen desaturation while using air-

driven compressors

Ipratropium bromide (05 mg) by nebulized route

every 4ndash6 h

Systemic steroid to be started as soon as possible

IV hydrocortisone 200 mg STAT then 100ndash200 mg

every 6 h

Single dose of IV magnesium sulfate (1-2 g)

intravenously over 20 min

Frequent clinical evaluation and serial CXR

electrolytes BUN creatinine glucose 12-lead

ECG ABGs should be implemented

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Evaluation of the Response to initial treatment

Evaluation of treatment response should be done every 30ndash

60 min and includes patients mental and physical status

respiratory rate heart rate blood pressure O2 saturation

and PEF

Response to treatment is divided into three categories

Adequate response It is defined as

1 Improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on room air

4 PEF gt60 of predicted

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

If the above criteria are met and maintained for at least 4 h the

patient can be safely discharged with the following

recommendations

Review and reverse any treatable cause of the

exacerbation

Review inhaler technique and encourage compliance

Step up asthma treatment ldquoat least step 3rdquo

Continue oral steroid for 7 days

Ensure stable on a four hourly inhaled bronchodilators

Provide a clearly written asthma self-management action

plan

Arrange follow-up appointment within 1 week

Partial response It is defined as

1 Minimal improvement of respiratory symptoms

2 Stable vital signs

3 O2 saturation gt92 on oxygen therapy

4 PEF between 33 and 60 of predicted

Patients who only achieved partial response after 4 h of the

above-described therapy are recommended the following

Continue bronchodilator therapy (SABA every 1 h andor

ipratropium bromide every 4 h) unless limited by side

effects (significant arrhythmia or severe hypokalemia)

Continue systemic steroid IV hydrocortisone 100-200 mg

every 6ndash8 h or oral prednisolone 40 mg daily

Observe closely for any signs of fatigue or exhaustion

Monitor O2 saturation serum electrolytes

electrocardiogram (ECG) and and peak expiratory flow

meter (PEFR)

If the patient fails to show adequate response after 4 h

admit to hospital

Poor response It is defined as

1 No improvement of respiratory symptoms

2 Altered level of consciousness drowsiness or severe

agitation

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

3 Signs of fatigue or exhaustion

4 O2 saturation lt92 with high-flow oxygen

5 ABGs Respiratory acidosis andor rising PaCO2

6 PEFR lt33

Patients showing poor response after 4 h of therapy should

have the following recommendations

A Consider ICU admission

B Deliver continuous nebulization of SABA unless limited

by side effects

C Continue systemic steroid IV hydrocortisone 200 mg

every 6ndash8 h

The following treatments are NOT recommended 1048590 Methylxanthines are not generally recommended

(Evidence A) In the ED Theophyllineaminophylline is not generally

recommended because it appears to provide no additional

benefit to optimal SABA therapy and increases the

frequency of adverse effects

If patients are currently taking a theophylline-containing

preparation determine serum theophylline concentration to

prevent theophylline toxicity

Some patients with near-fatal asthma or life threatening

asthma with a poor response to initial therapy may gain

additional benefit from IV aminophylline (5 mgkg loading

dose over 20 minutes unless on maintenance oral therapy

then infusion of 05-07 mgkghr) Such patients are

probably rare (BTS 2009)

1048590 Antibiotics are not generally recommended for the

treatment of acute asthma exacerbations except as needed

for comorbid conditions Viral infection is the usual cause of asthma exacerbation

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

The role of bacterial infection has been probably

overestimated and routine use of antibiotics is strongly

discouraged

the use of antibiotics is generally reserved for patients who

have fever and purulent sputum and for patients who have

evidence of pneumonia or bacterial bronchitis

When the presence of bacterial sinusitis is strongly

suspected treat with antibiotics

1048590 Aggressive hydration is not recommended for older

children and adults but may be indicated for some infants

and young children Intravenous or oral administration of large volumes of fluids

does not play a role in the management of severe asthma

exacerbations

Some infants and young children may become dehydrated

as a result of increased respiratory rate and decreased oral

intake In these patients clinicians should make an

assessment of fluid status (urine output urine specific

gravity mucus membrane moisture electrolytes) and

provide appropriate corrections

The placement of intravenous lines is not without

complication and the emotional impact of this procedure

may prove counterproductive

1048590 Chest physical therapy is not generally recommended

1048590 Mucolytics are not recommended (egacetylcysteine potassium iodide) because they may

worsen cough or airflow obstruction

1048590 Sedation is not generally recommended Anxiolytic and hypnotic drugs are contraindicated in severely ill

asthma patients because of their respiratory depressant effect

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

Admit the patient to hospital immediately if

1 Any life-threatening features are present

2 There are features of acute severe asthma present after

initial treatment

3 The patient has had a previous episode of near-fatal

asthma

Criteria for ICU referral

ICU referral is recommended for patients

o Requiring ventilatory support

o Developing acute severe or life-threatening asthma

o Failing to respond to therapy evidenced by

Deteriorating PEF

Persisting or worsening hypoxia

Hypercapnea

ABG analysis showing respiratory acidosis

Exhaustion shallow respiration

Drowsiness confusion altered conscious state

Respiratory arrest

Indications for intubation and mechanical ventilation in near-fatal asthma

Refractory hypoxemia (PaO2 lt60mmHg)

Persistent hypercapnia (PaCO2 gt55ndash77mmHg)

Increasing hypercapnia (PaCO2 gt5mmHgh)

Signs of exhaustion despite bronchodilator therapy

Worsening of mental status

Hemodynamic instability

Coma or apnea

When you cant breathe nothing else

matters

When you cant breathe nothing else

matters