|Acute Severe Asthma
|Cardiogenic Pulmonary Oedema
|Respiratory (Chest) infections Pneumonia
Prevention is key and all patients at risk of severe exacerbations should have an individualised plan to manage any exacerbation early with Short-acting beta-agonists and oral steroids and seeking medical help.
|Initial Status Asthmaticus Management Summary|
- ABC, Ensure Oxygen 15 L/min non rebreathe and IV access
- Salbutamol [Albuterol] 5 mg Nebs or Terbutaline 10 mg Nebs every 15-30 mins with High flow Oxygen.
- Add Ipratropium bromide 0.5 mg 4-6 hrly Nebs
- Hydrocortisone 200 mg IV stat or Prednisolone 40 mg PO
- Consider Magnesium Sulphate 1.2-2.0 g over 20 mins IV
- Consider IV Salbutamol [Albuterol] 5-20 mcg/min or 250 microgram bolus over 1 minute
- Get input early if not responding. Criteria for ITU: see below
- Portable CXR and ABG. Senior help if fails to respond
- Asthma, is a chronic disease characterised by intermittent reversible airways obstruction
- The incidence appears to be increasing but this has been balanced by better management and access to inhaled steroids
- Patients should not be left unobserved by healthcare staff for any period of time e.g. in radiology.
- Patients with Acute severe asthma can suddenly deteriorate.
- Typical asthma symptoms are wheeze, shortness of breath, chest tightness, cough
- Ensure patient sitting up and supported and as comfortable as possible, reassurance, hydration, encourage slower and deeper respirations
- A positive confident competent attitude from staff can help greatly. The patient is working hard and in extremis and often terrified.
- Monitor closely in a well-staffed area and continuous ECG and O2 sats monitoring.
- Patient must be observed at all times (e.g. if they need a CXR they must be accompanied by staff and treatment continued) as rapid and sudden deterioration and cardiac arrest is possible.
- Acute Severe
- SpO2 > 92%
- PEF 33-50% predicted or PEF < 200 L/min
- Resp rate > 25/min
- Heart rate > 110/min
- Unable to complete sentence one breath
- Life threatening
- PEF < 33% predicted or SpO2< 92%
- ABG: PaO2 < 8 kPa (60 mmHg) or Normal or raised PaCO2
- Silent chest, Cyanosis, Feeble respiratory effort, Exhaustion
- Hypotension, Bradycardia/arrhythmias
- Confusion, Coma
- Near fatal Asthma
- Raised PaCO2
- Need for intubation and mechanical ventilation
- Symptoms, particularly nocturnal symptoms, have improved
- PEFR is 75% of best. Diurnal variation (i.e. ‘morning dips’) <25%.
- Improving and compliance is expected to be good
- Home on Inhaled steroids + Oral + Inhaler technique checked
- Management plan for deterioration
Chest X-ray is not routinely recommended unless
- Suspected pneumomediastinum
- Suspected pneumothorax
- Suspected consolidation
- Life-threatening asthma
- Failure to respond to treatment
- Requirement for ventilation
Management IF PEFR < 50% of best or predicted and signs of Acute Severe Asthma
- Admit, ABC High flow Oxygen, Take senior advice and consider ITU review if failing to respond in 15-20 mins
- High flow O2 at 15 l/min target sat of 94-98%. Always use high flow O2 to drive nebulisers.
- IV fluids to avoid dehydration. Add some 20 mmol K per litre as Salbutamol [Albuterol] can lower serum potassium.
- IV Antibiotics if clear evidence of Bacterial infection.
- Nebulised Salbutamol [Albuterol] 5mg repeated every 15-20 minutes initially and then 1-2 hourly. Alternative is Terbutaline 5-10 mg given as nebulisers with high flow oxygen
- Nebulised Ipratropium bromide 500 mcg (0.5 mg) 4-6 hourly given with Salbutamol [Albuterol]
- Prednisolone 40-60 mg stat orally or Hydrocortisone 200 mg IV stat and then 100 mg IV 6 hourly or as oral Prednisolone until recovery (min 5 days)
- Do not routinely perform chest X-ray or blood gases, or routinely prescribe antibiotics, for asthma exacerbations.
Management : PEFR > 50% and no signs of Acute Severe Asthma
- No features of Acute Severe Asthma
- Give up to 10 puffs of Salbutamol [Albuterol] via volumatic spacer device
- Give Prednisolone 40 mg PO
- Good response: PEFR > 75% in 1 hour. Continue Prednisolone 40-50 mg for 5 days. Check inhaler technique, check compliance. Ensure inhaled corticosteroids prescribed at least 400 micrograms. Advice to return if relapse. Can get home
- Response: PEFR < 75% in 1 hour. Give Salbutamol [Albuterol] 2.5 mg - 5 mg nebulisers. Consider IV magnesium. Continue Prednisolone 40 mg OD for 5 days. Admit if not responding. Take advice if unsure.
Failing to respond please take senior advice. Ensure patient is on telemetry and in an area getting high level nursing care
- Magnesium Sulphate 1.2 - 2.0 g (8 mmol) over 20 mins IV may help FEV1.
- Consider loading dose of 5 mg/kg IV bolus over 20 mins unless already on oral aminophylline or theophylline. ECG monitor. For those already on the drug a maintenance dose of 0.5 mg/hr may be considered with expert advice.
- Aim for plasma concentration of 10-20mcg/mL (55-110umol/L). Can cause low BP arrhythmias, cardiac arrest at concentrations > 25mcg/mL. Watch K.
- Adrenaline 0.5 mg IM If bronchospasm as part of anaphylaxis reaction e.g. peanut or bee sting.
- Salbutamol [Albuterol] IV may be considered at 5-20 micrograms per minute. Watch serum lactic acidosis will develop in 2-4 hrs in 70%.
- Intubation and Mechanical ventilation criteria. Involve ITU/Outreach early well BEFORE this stage so they are fully aware of patient and can admit quickly as needed
- Progressive exhaustion, comatose, drowsy, delirium
- Respiratory arrest
- PaO2 <8 kPa despite FiO2 of 0.6
- PaCO2 >6 kPa
- Exhausted, delirium, drowsiness
- Check inhaler technique and ensure has a preventer medication
- Continue Oral Prednisolone for 5-10 days
- Review asthma maintenance treatment
- Smoking cessation advice
- Allergen avoidance
- Stop nebulisers 24 hrs before discharge
- Written agreed action plan
- PEF meter and diary
- GP/Asthma nurse and Respiratory clinic follow up in 4 weeks