acute asthma management

MANAGEMENT OF ACUTE ASTHMA IN THE ACCIDENT

AND EMERGENCY DEPARTMENT

By: Marika Mohammed,Group B 2015

Asthma is characterized by paroxysmal or persistent symptoms such as dyspnoea, chest tightness, wheezing, sputum production and cough.

There is variable airflow limitation and a variable degree of hyper-responsiveness of

airways to endogenous or exogenous stimuli

Caribbean Health Research CouncilManaging Asthma in the Caribbean

In-text: (Caribbean Health Research Council, 2009)Bibliography: Caribbean Health Research Council, (2009). Managing Asthma in the Caribbean. St. Augustine:

University of the West Indies, p.3.

Caribbean Health Research CouncilManaging Asthma in the Caribbean

In-text: (Caribbean Health Research Council, 2009)Bibliography: Caribbean Health Research Council, (2009). Managing Asthma in the Caribbean. St. Augustine:

University of the West Indies, p.3.

At the Port-of Spain General Hospital in Trinidad and Tobago, asthma has been reported as accounting for between 8-10% of admissions to the emergency room

ACUTE EXACERBATIONS OF

ASTHMA

INITIAL ASSESSMENT

Clinical Features- non-specific, absence does not rule out a severe attack.

PEF or FEV1- Airway calibre measurements to determine severity and intensity of treatment.

Pulse Oximetry- To determine adequacy of O2 therapy (aim: SpO2 94-97%) and need for ABG measurement.

Scottish Intercollegiate Guidelines NetworkBritish Guideline on the Management of Asthma

In-text: (Scottish Intercollegiate Guidelines Network, 2014)Bibliography: Scottish Intercollegiate Guidelines Network, (2014). British Guideline on the Management of Asthma.

London: British Thoracic Society, pp.57-60.

Arterial Blood Gases- If SpO2 is <92% (risk of hypercapnoea) or clinical features of life-threatening asthma present.




Markers of severity

‘Normal’ or raised PaCO2 (>35 mmHg)

Severe hypoxia (PaO2 <60 mmHg)

Low pH (or high H+)

Chest X-Ray- not routinely recommended

Pulsus Paradoxus- inadequate indicator of attack severity, should not be used.




LEVELS OF SEVERITY OF ACUTE

EXACERBATIONS Clinical Features

MANAGEMENT

Measure Peak Expiratory Flow and Oxygen Saturation

Moderate Acute Severe Life Threatening


In-text: (Scottish Intercollegiate Guidelines Network, 2014)Bibliography: Scottish Intercollegiate Guidelines Network, (2014). British Guideline on the Management of

Asthma. London: British Thoracic Society, pp.116

Salbutamol- 4 puffs then 2/

2min up to 10 via spacer

Salbutamol 5mg via nebulizer

Contact ICU if life-threatening features present

Time: 0-5 minutes



In-text: (Scottish Intercollegiate Guidelines Network, 2014)Bibliography: Scottish Intercollegiate Guidelines Network, (2014). British Guideline on the Management of

Asthma. London: British Thoracic Society, pp. 116.

Clinically Stable, PEF>75%

Clinically stable, PEF,75%

No life-threatening features, PEF 50-75%

Life- threatening features or PEF< 50%

O2 to maintain SPO2 94-98%

Salbutamol 5mg + ipratropium 0.5mg via nebulizer

Prednisolone 40-50 mg orally or 100 mg IV hydrocortisone

Measure Arterial Blood Gasses

Repeat Salbutamol 5mg nebulizer.

Prednisolone 10-50mg orally.

Possible discharge

Time 15-20 mins



In-text: (Scottish Intercollegiate Guidelines Network, 2014)Bibliography: Scottish Intercollegiate Guidelines Network, (2014). British Guideline on the Management of Asthma. London: British Thoracic Society,

pp.116.

Patient recovering PEF >

75%

No signs of severe asthma PEF 50-

75%

Signs of severe asthma

PEF <50%

Salbutamol 5 mg + ipratropium 0.5 mg via nebuliser After 15 minutes consider �continuous salbutamol nebuliser 5-10 mg/hr

Consider IV �magnesium sulphate 1.2-2 g over 20 minutes

Correct �fluid/electrolytes, especially K+ disturbances

Chest X-ray �

Repeat ABG�

Observe and Monitor:-SpO2-Heart Rate-Resp Rate

Potential Discharge

Time 60 mins




London: British Thoracic Society, pp.116

Patient stable PEF > 50%

Signs of severe asthma or PEF <50%

Admit Patient accompanied by nurse or doctor at all times

Potential discharge

Time 120 mins

Potential Discharge

In all patients who received nebulised β2 agonists

Prior to presentation, consider an extended observation period prior to discharge If PEF<50% on presentation, give �

prednisolone 40-50 mg/day for 5 days � Scottish Intercollegiate Guidelines Network

British Guideline on the Management of AsthmaIn-text: (Scottish Intercollegiate Guidelines Network, 2014)

Bibliography: Scottish Intercollegiate Guidelines Network, (2014). British Guideline on the Management of Asthma. London: British Thoracic Society, pp.116

In all patients ensure treatment supply of inhaled

steroid and β2 agonist and check inhaler technique

Arrange follow up 2 days post-discharge �

� Refer to chest clinic�



London: British Thoracic Society, pp.116

What are the markers for severe exacerbation of asthma on measuring arterial blood gases?

a.PaCO2 <35 mmHg,PaO2 >60 mmHg,Low pH

b.PaCO2>25mmHg, PaO2>60mmHg, Low pHc. PaCO2 >35 mmHg,PaO2 <60 mmHg,Low

pHd.PaCO2<25mmHg, PaO2< 60mmHg, Low

pHe. PaCo2>35mmHg, PaO2<60mmHg, High

pH

What is the initial treatment of an acute severe exacerbation of asthma in the emergency room?

a. Prednisolone 10mg orallyb. Salbutamol 5mg via nebulizerc. Ipratropium 0.5mg via nebulizerd. Salbutamol 2 puffs every 2 minutes via

spacere. Salbutamol 20mg via nebulizer

THANK YOU!

acute asthma management

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