Approche to acute asthma management

ACUTE ASTHMA
MANAGEMENT

ANAS SAHLE , MD
DAMASCUSE HOSPITAL

Risk factors for death from asthma
1. Prior severe exacerbation(eg: ICU admit, intubation).
2. 2 or more asthma hospitalization in past year.
3. 3 or more ED visit for asthma in past year.
4. Hospitalization or ED visit for asthma in prior month.
5. Use of >2 SABA canisters per month.
6. Difficulty perceiving asthma symptoms or severity of
exacerbation.
7. Lack of written asthma action plan, sensitve to
ALTERNARIA(fungus).
8. Other social and comorbidity risks.

EPR-3 national heart lung and blood 2007

Risk factors for death from asthma
1. Sudden severe attacks
2. Recent systemic steroids.
3. >2 SABA canisters in prior month.
4. HospitalER in last month.
5. ≥ 2 ERhospitalization in last year.
6. Prior intubationICU stay.
7. Illicit drug use.
8. Heartpsychiartic disorder.
9. Low socioeconomic class.

curr Opin pulm med 2008

PEFR≥75% predicted Mild
exacerbation

Β2 Agonist(neb),(MDI)
Check 15-30 min
PEFR≥75% and PEFR<75% and
clinically stable clinically stable

Observe 2H and Treat as moderate
discharge if stable exacerbation

PEFR=50-75% predicted Moderate
exacerbation

5 mg SALBUTAMOL(NEB)
30-60 mg PREDNISOLONE
Check at 30 min
PEFR<50%
PEFR=50-75% clinically stable Or clinically
deteriorating

Repeat 5 mg SALBUTAMOL(NEB) Treat as severe

Check at 30 min
PEFR<50% or
clinically PEFR>50% ,clinically stable
deteriorating

Deteriorating : Observe for 2H
Treat as severe discharge if stable
treat as severe +PEF increasing

PEFR=33-50%predicted ,
Severe
cannot complete sentences , exacerbation
RR>25min , HR>110min

High flow O2,
5mg salbutamol(neb),
30-60mg prednisolone200mg hydrocortisone(IV)
CHECK at 15 min
If not improving
If improving: admit
repeat 5mg salbutamol(neb) every 15-30 min till improving
continue 4-6 hourly (neb)
500mcg ipratropium(neb)
continue prednisolone
consider magnesium(1,2-2)g over 20 min(IV)
40-50mg daily
check ABG
CHECK at 15 min
IF ABG: If improving: admit
If not improving
continue 2-4 hourly nebs
normalraised PCO2 start aminophylline(IV) daily
severe hypoxia<58 treat as life-threatening
low PH prednisolone or 6 hourly
discuss with ICU
hydrocortisone

PEFR<33%
O2 SAT<92%
Silent chest
Cyanosis Life-threatening
exacerbation
Bradycardia
Hypotension
Exhaustionconfusion

REFER
TO
High flow O2
ICU measure ABG
5mg salbutamol (neb)
500mcg ipratropium (neb)
hydrocortisone100mg (IV)
magnesium 2g(IV)
±250mg aminophylline (IV)

REFERRAL TO INTENSIVE CARE
• deteriorating PEF
• persisting or worsening hypoxia
• Hypercapnea
• arterial blood gas analysis showing fall in pH
• exhaustion, feeble respiration
• drowsiness, confusion, altered conscious state
• respiratory arrest

NON-INVASIVE VENTILATION
• It is unlikely that NIV would replace intubation
in these very unstable patients.
• but it has been suggested that this treatment
can be used safely and effectively.

Discharge
On dischargeplanning
, all patients should have:
1. Patients should be on home medication for 24
hours prior to discharge.
2. PEF>75% predicted , <25% variability.
3. Prednisolone 40mg for at least 5 days.
4. Oral antibiotics if confirmed evidence of
infection.
5. Supply of all inhalers and technique checked.
6. PEF meter.

Definition

 The peak expiratory
flow rate is an effort-
dependent
assessment of a
patients ability to
forcibly expel air
from their lungs
 Airways Obstruction

Peak Expiratory Flow Rate / PEFR

 Usually used in children over 5 years
 Assessment of Reversibility of Airways
limitation or Hyperresponsiveness
 Diurnal variation : Self -Monitoring in
asthma

Peak expiratory flow rate measurement


Ask the patient to
stand up & hold the
peak flow in a
horizontal position


Take care not to place
your fingers
over the scale


Ask the patient now to
take a deep breath in
& make a tight seal
with their lips around
the mouth piece


Now ask the patient
to blow out as hard
& as fast as they
can


Remember fast
blast is better than
slow blow


Note the number
where the sliding
pointer has
stopped on the
scale


Reset the pointer to
'zero'

 Personal Best PEFR Value
 Baseline Predicated PEFR Value

Personal Best PEFR Value

 A baseline measure
 The baseline values should be obtained
when the patient is feeling well after a
period of maximal asthma therapy


 The patient should then record PEFR
measurements 2 to 4 times daily for
two weeks


 The personal best is generally the
highest PEFR measurement achieved
during this post-treatment monitoring
period


 The patient's normal PEFR range is
defined as 80 and 100 percent of the
patient's personal best.

Baseline Predicated PEFR Value

Tall – 80 X 5 = Prv PEFR
Example: 150 – 80 x 5 = 350 L/min

Predicated PEFR value vs Personal Best value
of PEFR

 The patient's normal value of PEFR:
 Self -Monitoring in asthma

Percentage PEFR Variability

Highest – Lowest
/ Highest x 100

Reversibility of PEF

Inhalation of 200-400 µg of
Salbutamol

Reversibility

A 20% improvement
in PEF from
baseline

L/min PEFR
PEFR
Reversibility
PEFR Ventoline
Reversibility

250 – 150 / 250 = 40 %
Yes

Self -Monitoring in asthma

100 %
All clear
80 %

Caution
50 %

Medical Alert

Approche to acute asthma management

Approche to acute asthma management

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