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Lab.3.
THE MANAGEMENT OF
AN ACUTE EPISODE OF ASTHMA
The initial medical assessment of the severity of the current episode is critical to the acute management of
patients. Indicators of severity include:
ASTHMA HISTORY AND EXAMINATION
Increasing wheeze or dyspnoea, or respiratory distress with tachypnoea (>25 breaths/min) are clinical
features of worsening asthma. The patient's own assessment may be important.Information regarding the
duration of episode, medication used pre-hospital, whether the patient regularly uses corticosteroids and
previous asthma episodes is important.
Assessment of severity by patient or doctor on clinical observation alone however, can be misleading and
should be backed up by objective measurement. Evidence for this comes from studies of perception of
asthma symptoms and from reviews of asthma deaths. Assessment of all vital signs is important in
establishing the level of severity of this episode of illness. Although the pulse rate may be elevated as a
result of some of the medication which has been administered, its elevation may also be due to the
severity of the underlying asthma episode.
Peak Expiratory Flow Rate (PEF) Measurements
These should be compared with either percentage of predicted normal values (%pred) or, if known, the
patient's own best measurement
Gas Exchange
Many adults requiring treatment for an acute asthma episode are hypoxic/ Pulse oximetry is a simplified
assessment of oxygenation but gives incomplete information. High or rising arterial CO2 (PaCO2)
pressures reflecting hypoventilation correlate with life-threatening asthma
There is some evidence to suggest that it may be reasonable to rely on oxygen saturation (SpO2)
measurement (pulse oximetry) alone at levels of 92 per cent or above but the evidence is not yet
conclusive
Therefore any patient in severe distress or who fails to respond to bronchodilator treatment should have
arterial blood gas (ABGs) measurement.
Chest X-ray
There is no indication for routine chest Xrays. Chest Xray is required if a respiratory complication is
suspected from the clinical examination (e.g. pneumothorax, pneumonia).
Blood Tests
There is no indication that routine blood tests should be undertaken. Patients who have been classified as
severe and/or are requiring admission to ICU should have creatinine & electrolytes and a full blood count.
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Summary Guide to Establishing the Level of Severity of this episode
E
Finding
examination Level Level of severity
Finding
Severe
Moderate
Triage Category*
1 or 2
3
Conscious State
May be altered
Normal
Speaking Ability
Words/None
Phrases
Respiratory rate (b/min) >25
20 25
SaO2**
<92%
92 95%
Air Entry
Poor: may have
Moderate
silent chest
PEF (%pred or best
known value)
Level
<30%
30 - 50%
Mild
4 or 5
Normal
Sentences
<20
> 95%
Good
>50%
* Initial values indicated in table are assuming patients measurement is made on room air. As all
patients will be on supplemental oxygen, the inspired oxygen concentration should be noted when
measurements of SaO2 are made.
Recommendations for initial assessment (Grade C)
1. Clinical assessment: respiratory rate; pulse rate; ability to speak in sentences; past history of asthma,
especially ICU admissions and episodes of mechanical ventilation and medication taken prior to hospital,
especially corticosteroids.
2. PEF: before (if possible) and after bronchodilator.
3. Gas exchange: Measurement of SpO2 (pulse oximetry) as a routine. Arterial blood gas measurement
should be undertaken only in patients who are assessed as severe or who fail to respond to initial
bronchodilator treatment.
INITIAL MANAGEMENT
Beta2 Agonists
High dose beta2 -agonists are the bronchodilators of choice in acute asthma. Inhalational therapy has been
shown to be an efficacious method for delivery of beta2 -agonists(28). Initially doses of salbutamol 5mg
by nebuliser every 15 minutes are recommended and thereafter as required. All nebulised therapy is
driven by an oxygen source set at 6 8 L/min. Continuous delivery from a nebuliser is only required for
some patients. If asthma is assessed as severe, continuous nebulisation is the usual requirement, but
patients assessed as moderate or mild, should only require treatment on an intermittent basis. Difficulties
with inhaler technique have made nebulisation the delivery mechanism of choice in the initial phase but
some studies suggest that large volume spacer devices may be equally effective
Oxygen Therapy
High flow oxygen which will maintain the SpO2 at >92% should be started immediately in all patients.
Initial hypoxia can become worse temporarily after bronchodilators. Nasal cannulae, although more
comfortable, deliver a variable level of enrichment. Gas flow provided through Hudson-type masks is
inadequate when patients are tachypnoeic and a Venturi oxygen system should be used. This leads to both
an increase in the work of breathing and reduced inspired oxygen concentration levels for the patient.
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Corticosteroids
The use of corticosteroids in adults has been shown to improve outcome from acute asthma Under-use of
corticosteroids has been found in surveys of asthma deaths. Intravenous hydrocortisone has been shown
to be effective within 2 hours. For severe asthma episodes, the initial regimen recommended is
hydrocortisone sodium succinate 300 400 mg IV in the first 24 hours(34). The initial dose is IV
hydrocortisone 100 mg. For moderate and mild episodes of acute asthma, only oral prednisolone should
be prescribed. Commence dose atprednisolone 50mg per day. For the subgroup of patients with chronic
asthma, whose symptoms are controlled on maintenance doses of an oral corticosteroid, it is suggested
that the initial dose of hydrocortisone is 250mg IV. If a different dose is prescribed, the reason should be
documented in the patients record.
Adrenaline
Intravenous adrenaline has been shown to be effective in the treatment of the patients assessed as having
severe asthma and not showing a response to nebulised bronchodilators. The recommended dose is 0.5 to
2 mcg/min and a written protocol for its administration is displayed in the Resuscitation Room of the
Emergency Department.
Ipratropium
The current literature suggests that the additional clinical benefit of ipratropium in acute asthma is small
in terms of bronchodilatation, reduced admission rates or length of stay
Ipratropium is expensive. The Airways Group of the Cochrane Collaboration are currently examining this
issue. The provisional recommendation is that ipratropium is not indicated for routine use in adults with
asthma. In patients with a severe episode, nebulised ipratropium 250 or 500mcg may be given in
conjunction with salbutamol on a 4 6 hourly basis for the first 24 hours.
If ipratropium is prescribed, the reason should be documented in the patients record.
Systemic aminophylline
The current literature suggests that, while intravenous aminophylline is a bronchodilator, it does not
improve outcomes when added to inhaled beta-agonists and systemic corticosteroids. It may increase side
effects. The recommendation is that aminophylline should not be routinely used in asthma. If
aminophylline is prescribed, the reason should be documented in the patients record.
Ketamine
The postulated mechanisms of action of ketamine in asthma are a sympathomimetic effect, direct relaxant
effects on bronchial muscle, antagonism of histamine and acetylcholine and a membrane stabilising effect
Anecdotal evidence has suggested that, in intubated patients, the use of a ketamine infusion aids
improvement. However a randomised trial, at doses low enough to avoid dysphoria, failed to show any
benefit From a consensus of expert opinion, it is recommended that if patients with severe asthma require
endotracheal intubation, ketamine is the induction agent of choice. The usual dose is 1 mg/kg.
Magnesium
The role of magnesium sulphate (MgSO4) in the treatment of asthma is as a bronchodilator by impeding
the uptake of calcium ions into smooth muscle cells and as an anti-inflammatory agent by attenuation of
the neutrophil respiratory burst associated with acute asthma.
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Studies have shown that for adult patients with severe asthma, an infusion of 2g of MgSO4 in addition to
standard steroid and nebulised beta-agonist therapy, reduced admission rates and led to statistically
significant improvements in FEV1 at both 120 and 240 minutes.A similar finding for a weight-based dose
of MgSO4 was made for children with asthma, not responding to standard therapy. These studies involved
small numbers of patients and showed small but statistically significant improvements in pulmonary
function.
Patients with severe asthma may receive MgSO4 2g IV as an infusion over 30 mins. If magnesium is
prescribed, the reason should be documented in the patients record.
Antibiotics
The routine use of antibiotics in the management of an acute episode of asthma is not recommended(48).
Indications for the addition of antibiotics to the therapeutic regimen include radiographic evidence of
pneumonia in which case oral antibiotics such as roxithromycin, erythromycin, amoxycillin or
doxycycline are generally recommended.
Recent research implicating bacterial organisms such as Chlamydia pneumoniae and Mycoplasma
pneumoniae in the aetiology of asthma has not reached definitive conclusions about their role and routine
use of antibiotics to address their potential presence is not advocated
More research in this area is required before recommendations about antibiotic prescription can be made.
Recommendations regarding initial treatment
1. Oxygen therapy via a Venturi system with an inspired oxygen concentration which will maintain
arterial oxygen saturation at >92 per cent. (Grade A)
2. Administration of high-dose inhaled bronchodilator (salbutamol 5mg via nebuliser, initially every 15
minutes for 3 doses and thereafter as clinically required). The nebuliser should be administered using an
oxygen flow rate of 6 - 8 L/min. (Grade A)
3. Corticosteroids should be given within one hour of presentation. Hydrocortisone 100mg IV q.i.d.
should be administered for patients assessed as severe but for patients on maintenance
glucocorticosteroids hydrocortisone 250mg IV q.i.d. is recommended. For patients assessed as mild or
moderate, prednisolone 50 mg orally should be administered. (Grade A)
4. In severe asthma, not responding to nebulised salbutamol, administration of IV adrenaline by infusion
0.5 to 2mcg/min should be considered. A protocol for administration is available in the ED Resuscitation
Room. (Grade C)
5. Ketamine is recommended as the induction agent of choice, if patients with severe asthma require
endotracheal intubation. (Grade C)
6. It is recommended that patients with severe asthma should receive 2g IV MgSO4 as an infusion over
30 mins (Grade B)
7. Antibiotics should not be administered as a routine. Evidence of a bacterial infection is required before
a course of antibiotics is prescribed. (Grade C)
Monitoring Response to Initial Treatment
Clinical examination
Improvement within 4 - 6 hours in clinical signs, e.g. reduced wheeze in association with increasing PEF
and reducing accessory muscle use, respiratory and heart rates, are all associated with discharge from ED.
Peak Expiratory Flow
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This is the most convenient method of objective assessment. When using PEF to evaluate response,
remember the following:
Initial values may overlap and be unreliable. However, initial values, >50 %pred or patients best known
value, are unlikely to result in admission.
After initial treatment values, >60 %pred or patients best known value, will usually result in discharge
home from ED.
Recommendations for monitoring response to initial treatment
1. Signs of an inadequate response - respiratory rate, heart rate and oxygen saturation. In those patients
who are not responding to treatment, arterial blood gas measurements should be initiated if not already
taken. (Grade C)
2. Peak flow monitoring before and after bronchodilator. (Grade C)
Disposition from Emergency Department
From ED, patients may be admitted into acute wards of the hospital or discharged home. The decision to
admit will be based on the severity of the presenting episode, the patients response to treatment and the
patients support system in the community.
Hospital admission
Hospital admission is more likely to be necessary if:
- PaCO2 is elevated at presentation;
- Prolonged attack of asthma of > 24 hours duration;
- Presenting for medical attention, twice or more in a 24 hour period;
- Use of regular oral corticosteroids at home;
- Age > 40 years;
- Poor long term control.
Intermediate Respiratory Care Unit (IRCU) Assessment
Patients who present with a moderately severe episode of asthma and have a post treatment PEF of
between 30 50 %pred or best known value and are responding to initial treatment should be assessed for
admission to IRCU. The Respiratory Medicine Unit is to be contacted for admission to this unit.
See Appendix 2 for the guidelines for admission and discharge from the IRCU.
Intensive Care Assessment
The following groups of patients should be assessed for admission to Intensive Care:
Patients whose condition is deteriorating and / or not responding to initial treatment.
Patients with a PEF is < 30 %pred (post treatment) of their usual best value or %pred
Patients with evidence of hypoxia (SaO2<90% or PaO2 < 60 on an FIO2 of 0.5) or persistent
hypercapnoea (PaCO2 >45mmHg);
Patients requiring ventilatory support
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Discharge of patients from the Emergency Department to Home
Patients who respond well to initial treatment will usually be discharged from ED to home. Most patients
suitable for discharge to home will have a PEF greater than 60 %pred. or usual best.
Patients who do not respond quickly to treatment or who have presented with a severe episode will
usually be admitted into the hospital.
For patients who are responding well to initial treatment discharge planning should commence
immediately.
The patient's previous asthma management should be reviewed and any specific cause of the acute
exacerbation identified before discharge. Appropriate patient education and attention paid to longer-term
management at this stage are likely to reduce the frequency of further acute exacerbations(51-53). It is
important to ensure that the patient's ability to perform activities of daily living is reviewed. Where the
patient has identified a GP whom they attend, a fax of the discharge letter and asthma management plan
should be sent to the patients regular GP at discharge.
Recommendations for patient disposition from ED (Grade C)
1. The disposition of patients from ED will depend upon the response to treatment and the severity of the
presenting condition.
1.1 Patients who are in severe distress, not responding to treatment, showing signs of continuing
deterioration or in need of ventilatory support should be assessed for admission to Intensive Care.
1.2 Patients who are assessed as having a moderate to severe condition and whose post treatment PEF is
still between 30 to 50 %pred. should be assessed by the Respiratory Unit for admission to IRCU.
1.3 Patients whose post treatment PEF is > 50 but < 60%pred. will usually require admission to an acute
bed in the respiratory ward under the care of physicians experienced in the management of asthma.
