Acute asthma exacerbation management

Asthma is a common chronic disease worldwide and affects approximately 25 million persons in the United States. It is the most common chronic disease in childhood, affecting an estimated 6 million US children. The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness.

Signs and symptoms of asthma include the following:

*Wheezing

*Coughing

*Shortness of breath

*Chest tightness/pain

Other nonspecific symptoms in infants or young children may be a history of recurrent bronchitis, bronchiolitis, or pneumonia; a persistent cough with colds; and/or recurrent croup or chest rattling.

Oxygen should be provide to all patients with severe asthma including those with normal saturations. Maintain SPO2 at >92%.

Support ABCs

Initiate treatment of underlying cause.

Check PEF (Peak Expiratory Flow) and record predicted or best PEF.

Do not measure PEF in patients with impending /actual respiratory, arrest, drowsiness, confusion or silent chest. START treatment immediately.

1.Drowsiness, confusion or silent chest

-Consider RSI with ketamine(if there are no C/I)

-Ventilation with 100% oxygen.

-Anticipate cardiovascular collapse post intubation.

-Nebulize with salbutamol and ipratropium bromide every 20 minutes or 3 doses for 1 hour.

-IV hydrocortisone 2mg/kg immediately.

-IV high dose MgS04,2gm in 5% dextrose over 20 minutes

-CXR

-Admit Critical Care Unit.

2.Mild/moderate

PEF >50% predicted or best

-Talks in phrases, prefers sitting to lying, not agitated, Oxygen saturation 90-95%,PR-100-120

-Nebulize with salbutamol and ipratropium bromide every 20minutes or 3 doses for 1 hour.

-Give oral corticosteroids if patient is able to swallow, otherwise give iv immediately.

-Reassess hourly or after every 3 doses

PEF > 60-80% ,no distress, physical exam normal, response sustained 60 minutes after last treatment, Discharge home.

3.Severe

PEF <50% predicted or best

-Talks in words, sits hunched forward, agitated, O2 saturation on room air <90%, PR >120bpm.

-Nebulize with salbutamol and ipratropium bromide every 20minutes or 3 doses for 1 hour.

-Give iv hydrocort 2mg/kg immediately.

-Give high dose iv magnesium,2gm in 5% dextrose over 20 minutes in patients who fail to reach PEF >60% of predicted or personal best after 1 hour of treatment.

-Reassess hourly or after every 3 doses.

-PEF > 60-80% of predicted or personal best, no distress, physical exam normal, response sustained 60minutes after last treatment.

4.Discharge home

-Continue treatment with inhaled SABA(salbutamol)-2 puffs QID for 3-5 days.

-Give oral systemic corticosteroids: Dexamethasone 0.6mg/kg or 12mg for adults as single dose or prednisone.

-Review medication including inhaler technique.

-Consider therapy for underlying cause of exacerbation.

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