TREATMENT OF THE ASTHMATIC EMERGENCY

OUTLINE
Definition Initial assessment of acute severe asthma Investigations Management

Definition

Acute severe asthma, previously termed status asthmaticus is defined as severe asthma that has not been controlled by the patients use of medication

Kumar & Clark Clinical Medicine, 6th edition pg 921

Initial Assessment
Clinical features PEF measurement Arterial blood gas analysis Pulse oximetry

Davidsons Principles and Practices of Medicine, 20th edition, pg 677

Classification of acute severe asthma

Acute severe asthma

PEF 33-50% predicted Respiratory rate 25/min Heart rate 110/min Inability to complete sentences in 1 breath

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Life-threatening asthma

PEF <33% predicted SpO2 <92% PaO2 <60 mmHg PaCO2 normal Silent shest Cyanosis Feeble respiratory effort

Bradycardia or arrhythmias Hypotension Exhaustion Confusion Coma

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Near-fatal Asthma

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Moderate asthma exacerbation

Increasing symptoms PEF > 50-75% best or predicted No features of acute severe asthma

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Brittle asthma
Type 1- wide PEF variability (>40% of diurnal variation for >50% of the time over a period of >150 days despite intense therapy) Type 2- sudden severe attacks on a background of apparently well controlled asthma

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

INVESTIGATIONS

Chest X ray

1) 2)

3)
4) 5) 6) 7)

Not immediately necessary unless a complicating cardiopulmonary process is suspected, such as: Pneumothorax Pneumomediastinum Pneumonia Lobar atelectasis Congestive cardiac failure Life threatening asthma Requirement for ventilation

ABG
Patients with SpO2 < 92% or other features of life threatening asthma require ABG measurement SpO2 <92% is associated with a risk of hypercapnoea

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

MANAGEMENT

OXYGEN

High flow oxygen to all patients with acute severe asthma to maintain an SpO2 of 9498%

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

2 Agonist Bronchodilators

Inhaled beta2 agonists are as efficacious and preferable to intravenous beta2 agonists Use high dose inhaled beta2 agonists as first line agents in acute asthma and administer as early as possible. Reserve IV therapy for those patients in whom inhaled therapy cannot be used reliably

In acute asthma with life threatening features, the oxygen driven route is recommended

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Steroid Therapy

Reduce mortality, relapses, subsequent hospital admissions and requirement for beta2 agonist therapy Oral therapy is as effective as injected steroids, provided they can be swallowed and retained Prednisolone 40-50mg daily or parenteral hydrocortisone 400mg daily are as effective as higher doses

Continue prednisolone 40-50mg daily for at least 5 days or until recovery

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Ipratropium bromide

Add nebulised ipratroprium bromide (0.5mg 4-6 hourly) to beta2 agonist treatment for patients with acute severe or life threatening asthma or those with a poor initial response to beta2 agonist therapy

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

Magnesium Sulphate

A single dose of IV magnesium sulphate is safe and may improve lung function in patients with acute severe asthma

Rowe Bh, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department(Cochrane Review) Issue 3, 2001

Intravenous Aminophylline

IV aminophylline is not likely to result in any additional bronchodilation in acute asthma compared to standard care with inhaled bronchodilators and steroids Use only after consultation with seniors

Parameswaran K, Belda J, Rowe BH. Addition of intravenous aminophylline to beta2 agonists in adults with acute asthma (Cochrane Review) Issue 3, 2001

Leukotriene receptor antagonists

There is insufficient evidence to make a recommendation about these in the management of acute asthma

British Thoracic Society; Scottish intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised June 2009

QUESTION 1
All of the following are indications for a chest X ray in a patient with acute severe asthma except: Suspected pneumomediastinum Life-threatening asthma Failure to respond to treatment satisfactorily Moderate exacerbation of asthma Requirement of ventilation

A)

B)
C) D)

E)

QUESTION 2
All of the following are true except: A) Routine prescription of antibiotics is not indicated for acute asthma B) Hypokalaemia can be caused by beta2 agonist treatment C) Intramuscular methylprednisolone is more effective than oral prednisolone D) Oxygen-driven nebulisers are preferred for nebulising beta2 agonist bronchodilators because of the risk of oxygen desaturation while using air-driven compressors E) Combining nebulised ipratropium bromide with a nebulised beta2 agonist produces significantly greater bronchodilation than a beta2 agonist alone