management of acute asthma in adults
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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
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