HEATHER LEMON-MULÉ, MDDIRECTOR, PEDIATRIC ALLERGY &

IMMUNOLOGYST. BARNABAS HOSPITAL

JULY 28 , 2009

Acute Asthma:2009 Update

Definition of Asthma

A chronic inflammatory disease of the lungs characterized by reversible airway obstruction and airway hyper-reactivity

Acute asthma exacerbations are paroxysmal episodes of wheeze, cough, tachypnea, dyspnea, hypoxia, respiratory failure

Etiology of Acute Exacerbations

Viral agents identified in >80% of pediatric asthma exacerbations and >50% of adult asthma exacerbations

Rhinovirus is identified in>65% of wheezing episodes caused by URIs

Peaks in hospital admissions for asthma correlate with RV seasons (spring and fall)

Acute Asthma Etiology

Etiology of Acute Asthma Exacerbations

Allergen exposure (aeroallergen)ExerciseAtypical bacteriaGERDSinusitisASA/NSAID ingestion (AERD)

Pathophysiology

Pathophysiology: Virus-Induced Wheezing

Pathophysiology of Acute Asthma

Pathophysiology: Virus-Induced Wheezing

RV in Asthma: Innate Immune Defect?

Interferons are anti-viral proteins produced in the innate immune response to viral infections

IFN-β induces apoptosis in infected cells; decreased production of IFN-β in asthmatics allows increased viral replication

Asthmatics also have decreased production of IFN-α and IFN-λ

Allergy and Viral Infections: Synergy?

Murray et al (Thorax 2006) showed allergen-exposed, atopic asthmatic children at greater risk for hospital admission with LRT viral infections

Similar findings in adult asthmatic patients (BMJ 2002)

Allergen Sensitization and Exposure

Exposure to seasonal allergens implicated in sudden asthma-related deaths

Alternaria sp exposure is associated with exacerbations and a 200-fold increased risk for respiratory arrest

HDM, cat and CR sensitization are RF for emergency treatment

Grass pollen sensitization (“thunderstorm asthma”) is associated with asthma exacerbation epidemics

Role of Atypical Bacteria?

Cunningham et al (Eur Respir J 1998) showed strong correlation between C. pneumoniae-specific IgA in NLF and asthma exacerbation frequency in children

Wark et al (Eur Respir J 2002) found 38% of adults treated in ED for asthma exacerbations had serologic evidence of C. pneumoniae reactivation and greater lower airway inflammation

Both studies had high viral detection rates (85% and 76%)

Role of Atypical Bacteria?

Johnston et al (NEJM 2006) performed RDBPCT with telithromycin in adult asthmatics experiencing acute exacerbations

>50% of patients had serologic evidence of infection but only 3 by PCR assay (C. pneumoniae)

Telithromycin treated patients had improved symptom scores, but not lung function compared with placebo

Differential Diagnosis of Acute Asthma

Bronchiolitis (and other viral PNAs)CroupBacterial Pneumonia (typical or atypical)Foreign BodyVocal Cord DysfunctionAllergic ReactionPanic AttackCongestive Heart FailurePertussisCF exacerbation

Determining Exacerbation Severity

Clinical signs and symptoms

Objective measurements (functional assessment)

Implications for management

Signs and Symptoms of Acute Asthma

Symptoms Mild Moderate Severe Impending Respiratory Arrest

Breathlessness While walking At rest (Infants – softer, shorter cry, difficulty feeding)

At rest (Infants – stops feeding)

Can lie down Prefers sitting Sits uprightTalks in Sentences Phrases Words Unable to speakAlertness May be agitated Often agitated Usually agitated Drowsy or

confusedSignsRespiratory Rate Often increased Usually increased Increased May be decreasedUse of Accessory Muscles

Usually not Commonly Usually Paradoxical thoracoabdominal movement

Wheeze Often only end expiratory

Throughout expiration

Throughout inhalation/expiration

Absence of wheeze

Heart Rate Usually normal Usually increased Increased Often BradycardicPulsus paradoxus Absent (<10 mm

Hg)May be present (10-25 mm Hg)

Often Present (20-40 mm Hg) (>25 mm Hg adult)

Absence suggests respiratory muscle fatigue

Modified from NAEPP Guidelines 2007

Determining Severity: PEF

Symptoms & Signs Initial PEF (or FEV1) Clinical Course

Mild Dyspnea only with activity (infants: tachypnea only and does not interfere with feeding)

PEF ≥70% predicted or personal best

Prompt relief with SABA;Usually cared for at home;Oral steroids usually not required

Moderate Dyspnea interferes with or limits activity (may interfere with infant feeding)

PEF 40-69% predicted or personal best

Requires office/ED visit; Relief from frequent inhaled SABA; Oral steroids often required; sx last 1-2 days after Rx initiated

Severe Dyspnea at rest; interferes with conversation (and infant feeding)

PEF <40% predicted or personal best

Usually requires ED visit and hospitalization; partial relief from SABA; oral steroids required; sx last >3 days after Rx initiated; adjunctive therapies helpful

Life Threatening Too dyspneic to speak; perspiring

PEF < 25% predicted or personal best

Requires ED/hospitalization and probable ICU; poor response to SABA; IV steroids required; adjunctive therapies helpful

Determining Severity: Functional Assessment

Functional Assessment

Mild Moderate Severe Subset: Life-Threatening

PEF (% predicted or personal best)

≥70 40-69 or response lasts < 2 ours

<40 <25 (may not be needed or pt may not be capable)

PaO2 (on RA)

and/or

PaCO2

Normal (test usually not required)

<42 mm Hg (test usually not required)

≥ 60 mm Hg (test usually not required)

<42 mm Hg (test usually not required)

<60 mm Hg: possible cyanosis

≥ 42 mm Hg: possible respiratory failure

SaO2 (on RA) at sea level

>95% 90-95% <90%

RF for Asthma-Related Death: Asthma History

Previous severe exacerbations (especially history of ETI or ICU admission)

≥2 admissions for asthma within previous 12 months

≥3 ED visits for asthma within previous 12 months

Hospitalization or ED visit within past monthUse of >2 canisters of SABA/monthDifficulty perceiving asthma symptoms or

severity of exacerbations

Other RF for Asthma-Related Death

Social: low SES or inner city residence, illicit drug use or other major psychosocial problems

Comorbidities: cardiovascular disease, other chronic lung disease, chronic psychiatric disease

Special Consideration: Infants

Infants high-risk group for respiratory failure Greater peripheral airway resistanceFewer collateral channels of ventilationFurther extension of airway smooth muscle

into the peripheral airwaysLess elastic recoilMechanical disadvantage of the diaphragmVentilation/perfusion characteristics promote

hypoxemia more readily than older children/adults

Special Consideration: Infants

Use of accessory muscles, inspiratory/expiratory wheezing, paradoxical breathing, cyanosis and RR>60 suggest serious distress

SaO2<90% also sign of serious distress; SaO2<92% after 1 hour of treatment good indicator of need for hospitalization

Initial Assessment: Brief History

Time of onset and any potential causes of current exacerbation

Severity of symptoms, especially compared with previous exacerbations, and response to any already given treatments

All current medications and time of last dose, especially of asthma medications

Any prior episodes of respiratory insufficiency due to asthma

Other potentially complicating illness

Initial Assessment: Physical Examination

Assess the severity of the exacerbation: overall patient status, including level of alertness, fluid status, and presence of cyanosis, respiratory distress, and wheezing

Identify possible complications Rule out upper airway obstructionClues to the presence of alternative reasons for

dyspnea include dysphonia, inspiratory stridor, monophonic wheezing loudest over the central airway, normal values for PaO2, and unexpectedly complete resolution of airflow obstruction with intubation.

Laboratory Studies: Indications

CXR: obtain if complicating process suspectedCBC: consider for patients with suspected serious

bacterial infectionsABG: indicated in patients suspected of

hypoventilation, severe distress or FEV1 or PEF ≤25% predicted or personal best after initial treatment

VBG: PCO2>45 mmHg may serve as a screening test but cannot substitute for an ABG

Serum electrolytes generally not indicated unless patient at risk for electrolyte disturbances

Treatment Goals

Correction of hypoxemia

Rapid reversal of airflow obstruction

Reduction of likelihood of relapse or recurrence of exacerbation

Assess SeverityPatients at high risk for a fatal attack require immediate medical attention after initial treatment.Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness should result in initial treatment while immediately consulting with a clinician.

Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps as listed below.

If available, measure PEF—values of 50–79% predicted or personal best indicate the need forquick-relief mediation. Depending on the response to treatment, contact with a clinician may also be indicated. Values below 50% indicate the need for immediate medical care.

Initial TreatmentInhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs by MDI+ VHC or nebulizer treatments.

Good Response: No wheezing or dyspnea (assess tachypnea in young children). PEF ≥80% predicted or personal best.Contact clinician forfollow-up instructions/management

May continue inhaled SABA every 3–4 hours for 24–48 hours.

Consider short course of oral systemic corticosteroids for high-risk patients

Incomplete Response: Persistent wheezing and dyspnea (tachypnea). PEF 50–79% predicted or personal best.Add oral systemic corticosteroid.

Continue inhaled SABA.

Contact clinician urgently (this day) for further instruction.

Poor Response: Marked wheezing and dyspnea. PEF <50% predicted or personal best. Add oral systemic corticosteroid. Repeat inhaled SABA immediately. If distress is severe and nonresponsive to initial treatment:—Call your doctor AND—PROCEED TO ED;—Consider calling 9–1–1 (ambulance transport).

To EDModified from NAEPP Guidelines 2007

Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.

Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient

Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS

Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS

Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed

Moderate ExacerbationPhysical exam: moderate symptoms; FEV1 or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours

Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS

Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress

Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms

Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion

Individualized decision re: hospitalization

Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up

Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2

Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation

ImproveImprove

Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.

Admit to Hospital Intensive Care

Modified from NAEPP Guidelines 2007

Inhaled SABA

Onset of action within 5 minutesPeak effect in 30-60 minutesDuration of action 4-6 hours

Promote bronchodilation by smooth muscle relaxation

May be given intermittently or continuously (nebulized)

Inhaled SABAs

Medication Children ≤ 12 years old Children > 12 years old CommentsAlbuterol nebulizer solution (0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/3 ml, 5 mg/ml)

0.15 mg/kg (min of 2.5 mg) q20mins for 3 doses then 0.15-0.3 mg/kg (max 10 mg) q1-4h prn OR 0.5 mg/kg/hr continuous nebulization

2.5-5 mg q20mins for 3 doses then 2.5-10 mg q1-4h prn OR 10-15 mg/hr continuously

Dilute aerosols to minimum of 3 ml; gas flow at 6-8 L/min.

Albuterol MDI (90 mcg/puff)

4-8 puffs q20min for 3 doses then q1-4h prn; use VHC; add mask in children <4 years old

4-8 puffs q20min up to 4 doses then q1-4h prn

MDI plus VHC equally efficacious as nebulized therapy in mild-moderate exacerbations

Levalbuterol nebulizer solution (0.63 mg/3 ml, 1.25 mg/0.5 mL, 1.25 mg/3 mL)

0.075 mg/kg (min dose 1.25 mg) q20min for 3 doses then 0.075-0.15 mg/kg up to 5 mg q1-4h prn

1.25-2.5 mg q20min for 3 doses then 1.25-5 mg q1-4h prn

Comparable efficacy to albuterol; not evaluated by continuous nebulization

Levalbuterol MDI (45 mcg/puff)

Same as albuterol MDI dosing

Same as albuterol MDI dosing

Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.

Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient

Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS

Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS

Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed

Moderate ExacerbationPhysical exam: moderate symptoms; FEV1 or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours

Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS

Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress

Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms

Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion

Individualized decision re: hospitalization

Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up

Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2

Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation

ImproveImprove

Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.

Admit to Hospital Intensive Care

Modified from NAEPP Guidelines 2007

Inhaled Anticholinergics

Medication Children ≤12 yo Children >12 yo CommentsIpratropium bromideNebulized solution (0.25 mg/ml)

0.25-0.5 mg q20min for 3 doses, then prn

0.5 mg q20min for 3 doses then prn

Added to SABA during severe exacerbations; no proven benefit for mild/moderate exacerbations; no proven benefit once patient hospitalized

Ipratropium bromideMDI (18 mcg/puff)

4-8 puffs q20min prn up to 3 hours

8 puffs q20min prn up to 3 hours

Children should use VHC; studies have examined MDI up to 3 hours only

Ipratropium bromide with albuterolNebulized solution (each vial contains 0.5 mg ipratropium and 2.5 mg albuterol)

1.5-3 ml q20min for 3 doses then prn

3 ml q20min for up to 3 doses then prn

Reserved for first 3 hours of treatment of severe exacerbations; no proven benefit once patient hospitalized

Ipratropium bromide with albuterol MDI (18 mcg ipratropium and 90 mcg albuterol per puff)

4-8 puffs q20min prn up to 3 hours

8 puffs q20min prn up to 3 hours

Children should use VHC; indications as above

Systemic Corticosteroids

Prednisone/Methylprednisolone/Prednisolone

Children ≤ 12 yo: 1-2 mg/kg/day (max 60 mg/day) for 3-10 days until PEF is 70% predicted or personal best

Children >12 yo: 40-80 mg/day for 3-10 days until PEF is 70% predicted or personal best

Preschool Wheezers: The Great CS Debate

Panickar et al (NEJM 2009) performed RDBPCT comparing oral prednisolone to placebo in 687 children between ages of 10 and 60 months

Majority of children experienced mild-moderate wheezing

Primary outcome was length of hospitalization; secondary outcomes were PRAM score, albuterol use and 7-day symptom scores

Preschool Wheezers: The Great CS Debate

Prednisolone no better than placebo for any outcome

Study strengths: RDBPCT, large number of patients, use of standardized scoring (PRAM), majority of patients with viral wheezer phenotype

Limitations: possibly under-dosing of prednisolone for a significant number of patients, lack of data on subjects refusing participation, no provision of age of patients at high-risk for persistent asthma, no viral studies

Preschool Wheezers: The Great CS Debate

Several other studies have found contradictory results, particularly in patients at high-risk for the development of atopic asthma (positive API)

Recent study found reduced rate of relapse in subjects infected with RV when treated with prednisolone as compared to placebo

Study by Ducharme et al (NEJM 2009) showed decreased exacerbation severity in subjects treated with high-dose inhaled fluticasone at the onset of a URI-induced exacerbation

Systemic Corticosteroids: Summary

Always indicated for patients with severe exacerbations

Generally not indicated for patients with mild exacerbations unless high-risk for asthma-related death

Indicated for patients with moderate exacerbations if no immediate response to SABA treatment or high-risk for asthma-related death

Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.

Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient

Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS

Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS

Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed

Moderate ExacerbationPhysical exam: moderate symptoms; FEV1 or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours

Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS

Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress

Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms

Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion

Individualized decision re: hospitalization

Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up

Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2

Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation

ImproveImprove

Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.

Admit to Hospital Intensive Care

Modified from NAEPP Guidelines 2007

Magnesium Sulfate (IV)

Meta-analyses (adult and peds studies) show that hospitalization rates decreased when MgSO4 added to conventional Rx for severe exacerbations

Dose 25-75 mg/kg up to 2 g

NAEPP recommendation: “consider in patients with life-threatening exacerbations and patients who remain in the severe category after 1 hour of intensive conventional therapy”

Heliox

Theoretical benefit for improving gas exchange because of helium’s low density

Studies contradictory

Three studies (1 peds, 2 adult) showed improvement in subjects experiencing moderate-severe exacerbations treated with Heliox-driven SABA treatments when compared to subjects receiving O2-driven SABA treatments

Leukotriene Receptor Antagonists

RT showed significant improvement in pulmonary function within 10 minutes of administration of IV montelukast to patients with moderate-severe exacerbations

Oral montelukast does not take effect before 90 minutes from time of administration

Systemic β2 Agonists

Medication Children<12 yo Children ≥12 yo Comments

Epinephrine 1:1000 (1 mg/ml)

0.01 mg/kg up to 0.3-0.5 mg sq q20min for 3 doses

0.3-0.5 mg sq q20min for up to 3 doses

No proven benefit over aerosol

Terbutaline (1 mg/ml) 0.01 mg/kg sq q20min for up to 3 doses then q2-6h prn

0.25 mg sq q20min for up to 3 doses

No proven benefit over aerosol

When to Intubate

Signs of impending respiratory failure: Inability to speakAltered mental statusWorsening fatigueSignificant and prolonged retractionsPCO2 ≥ 42 mm Hg

Theoretical benefit of ketamine as a premedication for ETI has not born out in studies (limited data)

Assessing Response to Treatment

Serial physical examinations

Serial FEV1 or PEF

Serial pulse oximetry measurements

Signs and symptom scores

Predicting Need for Hospitalization

Kelly et al (Respir Med 2004) showed that severity assessment at 1hour after initial treatment with SABA was better predictor of need for hospitalization than initial assessment

After 1hour if meets criteria for severe exacerbation >86% chance of hospitalization; if moderate after 1 hour >84% chance of hospitalization; if mild then only 18% chance of hospitalization

SaO2 <92-94% at 1 hour better predictor of need to hospitalize than initial SaO2

Initial Assessment Brief history, physical examination , PEF or FEV1, oxygen saturation, and other tests as indicated.

Mild-to-Moderate (FEV1 or PEF ≥40%)Oxygen to achieve SaO2 ≥90%SABA up to 3 doses in first hourOral CS if no immediate response or recently took oral CS or high-risk patient

Severe (FEV1 or PEF <40%)Oxygen to achieve SaO2 ≥90%SABA + ipratropium q20min or continuously for 1h; Oral CS

Impending or Actual Respiratory ArrestIntubation and mechanical ventilation (FiO2 1.0)Nebulized SABA + ipratropium; consider adjunct therapies; Intravenous CS

Repeat AssessmentSymptoms, physical examination, PEF, O2 saturation, other tests as needed

Moderate ExacerbationPhysical exam: moderate symptoms; FEV1 or PEF 40–69%Inhaled SABA q1h; Oral CSContinue treatment 1–3 hours if improvement; make admit decision in <4 hours

Severe ExacerbationPhysical exam: severe symptoms at rest, accessory muscle use, chest retractions; FEV1 or PEF <40%. History: high-risk patient.No improvement after initial treatment: Oxygen, Nebulized SABA + ipratropium, hourly or continuous; consider adjunct therapies, Oral CS

Good Response (FEV1 or PEF ≥70%)Response sustained 1 hr after last SABA Physical exam: normal; no distress

Incomplete Response (FEV1 or PEF 40–69%)Mild-to-moderate symptoms

Poor Response (FEV1 or PEF <40%)•PCO2 ≥42 mm Hg•Physical exam: symptoms severe, drowsiness, confusion

Individualized decision re: hospitalization

Discharge Home•Continue inhaled SABA.•Continue course of oral CS.• Consider initiation of an ICS.•Patient education:− Review medications, including inhaler technique.− Review/initiate action plan.− Recommend close medical follow-up

Admit to Hospital Ward•Oxygen•Inhaled SABA•Systemic (oral or intravenous) CS•Consider adjunct therapies•Monitor vital signs, FEV1 or PEF, SaO2

Admit to Hospital Intensive Care•Oxygen•Inhaled SABA hourly or continuously•Intravenous CS•Consider adjunct therapies•Possible intubation and mechanical ventilation

ImproveImprove

Discharge Home•Continue treatment with inhaled SABAs.•Continue course of oral CS•Continue on or consider initiating ICS.•Patient education (e.g., review meds, including inhaler technique, environmental control measures; review/initiate action plan; recommend close medical follow-up.•Schedule follow-up appointment with PMD and/or asthma specialist in 1–4 weeks.

Admit to Hospital Intensive Care

Modified from NAEPP Guidelines 2007

Plan for Discharge

Provide patients written instructions regarding dose, frequency and correct use of medications

Consider initiating or continue with ICS

Schedule follow-up appointment with PMD or asthma specialist within 4 weeks