ACUTE SEVERE ASTHMA

WHY DO PATIENTS DIE:

DISEASE FACTORS

MEDICAL MANAGEMENT FACTORS

PATIENTS BEHAVIOUR AND

PSYCHOSOCIAL FACTORS
 DISEASE FACTORS

CHRONIC SEVERE B.A.

MINORITY MILD / MODERATE

BRONCHIAL ASTHMA
( The severity of acute asthma attack is usually
underestimated by patients, their relatives and their doctors,
mainly due to failure to assess the condition objectively )
MEDICAL MANAGEMENT FACTORS

INADEQUATE TREATMENT

INADEQUATE OBJECTIVE MONITORING

AND FOLLOW UP

NOT REFERRING TO SPECIALIST

INCREASING USE OF BETA2 AGONIST AND

UNDERUSE OF STEROIDS
MEDICAL MANAGEMENT
FACTORS CONTD.

INAPPROPRIATE PRESCRIPTION OF
BETABLOCKER THERAPY

HEAVY SEDATION

PATIENT SENSITIVE TO NSAID

NOT GIVEN WRITTEN MANAGEMENT PLAN

PSYCHOSOCIAL
& BEHAVIOURAL FACTORS

NON-COMPLIANCE WITH TREATMENT

FAILURE TO ATTEND APPOINTMENTS

SELF DISCHARGE FROM HOSPITAL

AIMS OF MANAGEMENT
TO PREVENT DEATH
TO RELIEVE SYMPTOMS
TO RESTORE PATIENTS LUNG FUNCTION
TO THE BEST POSSIBLE LEVEL AS SOON
AS POSSIBLE.

TO PREVENT EARLY RELAPSE

 ASSESSMENT

NEED TO ASSESS SEVERITY RAPIDLY

GIVE APPROPRIATE TREATMENT

HISTORY
PHYSICAL EXAMINATION
PEFR MEASUREMENT
 MILD ASTHMA
PERSISTENT COUGH

INCREASED CHEST TIGHTNESS

BREATHLESS WHEN WALKING

NORMAL SPEECH

PULSE RATE < 100/MIN.

RESP. RATE < 25/ MIN

MODERATE WHEEZE

PEF > 75% OF PT’S BEST OR PREDICTED

SpO2 > 95% ON ROOM AIR

 MODERATE ASTHMA
BREATHLESS WHEN TALKING

TALKS IN PHRASES

PULSE RATE 100 – 120 / MIN

RESPIRATORY RATE 25 – 30 BREATHS / MIN

LOUD WHEEZE

PEF BETWEEN 50 T0 75 % OF PREDICTED

OR BEST VALUE

SPO2 91 – 95 % ( ON ROOM AIR )

 SEVERE ASTHMA
BREATHLESS AT REST

TALKS IN WORDS

PULSE RATE > 120 / MIN

RESPIRATORY RATE > 30 BREATHS / MIN

LOUD WHEEZE

PEF < 50 % OF PREDICTED OR BEST VALUE

SPO2 < 90% ( ON ROOM AIR )

Life threatening asthma
CENTRAL CYANOSIS
FEEBLE RESPIRATORY EFFORT
SILENT CHEST
BRADYCARDIA
EXHAUSTION
CONFUSION
PEF < 30% OF BEST OR PREDICTED
ABG:
NORMAL OR HIGH PaCO2
SEVERE HYPOXAEMIA (60mmHG)
LOW pH
• Prednisolone tablets at 30 – 60 mg should be
commenced immediately. If patient is unable to
tolerate orally, intravenous hydrocortisone 200 mg
stat should be given.

The response to treatment is monitored by :

• The patient’s symptoms

• Physical findings
• Measurement of PEF 15 – 30 minutes after
initiating treatment.
BEFORE DISCHARGE FROM A&E
REVIEW ADEQUACY OF USUAL TREATMENT & STEP UP IF
NECCESARY

GIVE PREDNISOLONE 30 – 60 MG DAILY FOR 7 – 14 DAYS, PLUS

REGULAR INHALED STEROIDS AND INHALED BETA2 AGONIST.

ENSURE PT. HAS ENOUGH SUPPLY OF MEDICATION

CHECK INHALER TECHNIQUE AND CORRECT IF FAULTY

FOLLOW UP WITHIN 2 WKS. OR EARLIER

ADVISE PT. TO RETURN IMMEDIATELY IF ASTHMA WORSENS

 MANAGEMENT IN THE WARD
CONTINUE O2 >40%

I.V HYDROCORTISONE 6 HRLY/ PREDNISOLONE 30-60 MG/ D.

NEBULISED BETA2 AGONIST EVERY 15MIN ( 2-4HRLY )

DEPENDING ON SEVERITY + ANTICHOLINERGIC.

IF STILL NO IMPROVEMENT:

I.V. AMINOPHYLLINE > 0.5-0.9 MG/KG/HR. IF CONTINUED

FOR MORE THAN 24 HRS MONITOR BLOOD LEVELS.

ALTERNATIVE:

BETA2 AGONIST INFUSION 3-20 MCG / MIN AFTER INITIAL I.V

BOLUS OF 250mcg.OVER 10 MIN.
 MANAGEMENT IN WARD
(CONTD.)

STILL INADEQUATE RESPONSE:

I.V. MAGNESIUM SULPHATE 2G IN 50

ML N/SALINE INFUSED OVER 10-20
MIN.
MONITORING RESPONSE

PEF. MEASUREMENT 15-30 MIN LATER

MAINTAIN ARTERIAL O2 SATURATION

ABOVE 92%

RPT. ABG IF INITIALLY WAS NECESSARY

OR IF PT. DETERIORATES.

MONITOR PEF AT LEAST 4 TIMES DAILY.

OTHER INVESTIGATIONS

SERUM ELECTROLYTES:

HYPOKALAEMIA IS A RECOGNISED
COMPLICATION
OF TREATMENT WITH BETA2 AGONIST
AND CORTICOSTEROIDS

E.C.G. IF INDICATED
REFERRAL TO INTENSIVE CARE

DETERIORATING PEF
PERSISTENT OR WORSENING
HYPOXIAEMIA
HYPERCAPNIA
EXHAUSTION OR FEEBLE
RESPIRATION
DROWSINESS OR CONFUSION
COMA OR RESPIRATORY ARREST
DISCHARGE PLAN FOR
HOSPITALISED PT.

BEFORE DISCHARGE PT. SHOULD BE:

STARTED ON INHALED STEROIDS FOR AT LEAST

48 HRS + CONTINUE ORAL STEROIDS FOR FEW
DAYS MORE + BRONCHODILATORS

PEF > 75%, DIURNAL VARIABILITY OF < 20%

ABLE TO USE INHALER CORRECTLY, IF

NECESSARY ALTERNATIVE INHALER DEVICES
COULD BE PRESCRIBED.
DISCHARGE PLAN (CONTD.)
PT. IS EDUCATED ON :

DISCHARGE MEDICATION

HOME PEF MONITORING

SELF MANAGEMENT PLAN

IMPORTANCE OF REGULAR FOLLOW UP.

GIVEN AN EARLY FOLLOW-UP APPOINTMENT WITHIN

2 – 4 WEEKS FOR REASSESSMENT OF THE CONDITION
AND FOR ADJUSTMENT OF THE MEDICINES.