Acute asthma Flashcards
what is acute asthma
progressive worsening of asthma symptoms, including breathlessness, wheeze, cough, chest tightness
an acute exacerbation is marked by reduction in baseline objective measured of pulmonary function e.g.
PEF and FEV1
most asthma attacks that are severe enough to require hospitalisation usually develops relatively slowly over a period of 6 hours or more - true or false
TRUE
these 2 birth related factors may be risk factors for recurrent wheeze
low birth weight and/or prematurity
define moderate acute asthma according to symptoms, PEF
- increasing symptoms of asthma
- no features of acute severe asthma
- peak flow >50-75% best or predicted
define severe acute asthma speach, peak flow, HR, RR
any one of the following
PF 33-50% best or predicted
respiratory rate ≥25/min
HR ≥110/min
inability to complete sentences in one breath
a peak flow of 33-50% best of predicted is a sign of
severe acute asthma
a peak flow >50-75% best or predicted is a sign of
moderate acute asthma
in life threatening acute asthma, pt can have any one of the following
peak flow <33% best or predicted
SpO2 <92%
PaO2 <8kPa
normal PaCO2
silent chest
cyanosis
poor respiratory effort
arrhythmia
exhaustion
altered conscious level
hypotension
a peak flow of <33% best or predicted, or SpO2 <92% is a sign of
life threatening acute asthma
silent chest is a sign of
life threatening acute asthma
near fatal acute asthma is defined by
raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures
patients with this acute asthma should be treated at home or in primary care and their repsosne to treatment should be assessed
moderate acute asthma
however hospital referral may be warranted depending on circumstance e.g. response to treatment, social circumstance, concomitant disease
pt with features of severe or life threatening acute asthma need to be treated
ASAP and be referred to hospital immediately
who do you need to give supplemental oxygen to and what SpO2 level do you need to maintain
give to all hypoxaemic (lower than normal oxygen levels in blood) pt with severe asthma
maintain SpO2 level between 94-98%
do not delay supplementary oxygen if pulse oximetry unavailable
management of acute asthma in adults - 1st line (for mild to moderate, and severe to life threatening)
high dose inhaled SABA (e.g. salbutamol) ASAP
if mild to moderate, can use pMDI and spacer
acute severe or life threatening symptoms: recommended to administer via oxygen driven nebuliser if available
if response to initial dose of nebulised SABA is poor, consider continuous nebulisation with appropriate nebuliser
reserve IV beta agonists for pt in whom inhaled therapy cannot be used reliably
in all cases of acute asthma in adults, need to be prescribed the following
+ alt
adequate dose of oral prednisolone
continue usual ICS during oral CC treatment
alt in pt unable to take oral prendisolon: parenteral HC or IM methylpredinosolone
should patients continue with their usual ICS during oral CC treatment for acute asthma?
yes
All adults who have had acute asthma need to be prescribed oral prenisolone therapy. what about pt who cannot take oral prednisolone?
IV HC
IM methylprednisolone
the following combination may be used in patients with severe or life threatening acute asthma, or in pt with poor initial response to beta agonsist therapy to provide greater bronchodilation
Nebulised iptratropium bromide may be combined with nebulised b2 agonist
some evidence suggests that magnesium sulphate has bronchodilator effects. a single IV dose of it can be considered in the following pt …
in pt with severe acute asthma (peak flow <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy (unlicensed)
in acute asthma, is IV aminophylline likely to produce any additional bronchodilation compared to standard therapy with inhaled bronchodilators and CCs?
No it is not
However in some pt with near fatal or life threatening acute asthma with a poor response to inittial therapy, IV aminophylline may provide some benefit
Only use aminophylline or magnesium sulphate IV infusion after consultation with
senior medical staff
any acute exacerbation needs to be correctly differentiated from poor asthma control and its severity categories in order to be appropriately treated - true or false
true
moderate acute asthma signs in children
Able to talk in sentences
SpO2 ≥ 92%
Peal flow ≥ 50% best or predicted
HR ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years;
Respirstory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5
severe acute asthma signs in children
Cant complete sentences in one breath or too breathless to talk or feed
SpO2 <92%
Peak flow 33-50% best or predicted
HR >140/min in children 1-5, HR > 125/min in children over 5
Respiratory rate >40/min in children ages 1-5 years, respitatory rate >30/min in children over 5
life threatening acute asthma signs in children
SpO2 <92%
Peak flow <33% best or predicted
Silent chest
Cyanosis
Poor respiratory effort
Hypotension
Exhaustion
Confusion
management of acute asthma in children 2yrs and over - who needs to be sent to hospital
start treatment asap and refer to hospital immediately following initial assessment
any child to fails to respond to treatment adequately at any time should also be referred to hospital immediately
management in children 2 and over
who do you give supplementary oxygen to and what do you need to maintain levels at
Supplementary high flow oxygen (via a tight fitting face mask or nasal cannula) should be given to all children with life threatening acute asthma or SpO2 <94% to achieve normal saturations of 94 to 98%
1st line for acute asthma, 2 and over
inhaled SABA given ASAP
mild to moderate - pMDI and spacer preferred
Dose given should be individualised according to severity and adjusted based on response
Pt/carers of children with acute asthma at home should seek urgent medical condition if initial symptoms are not controlled with up to 10 puffs of salbutamol via spacer
If symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention
what to do if a child’s symptoms of acute asthma return within 3-4 hours
urgent medical attention
can also give a further or larger dose (max 10 puffs salbutamol via spacer) whilst awaiting medical attention
For children with acute severe or life threatening symptoms, administration of salbutamol via …….. is recommended if available
oxygen driven nebuliser
In all cases of acute asthma, children should be prescribed an adequate dose of oral prednisolone. Treatment for the following duration is usually sufficiency but the course should be tailed to the number of days necessary to bring about recovery
+ what to do if vomit, unable to have oral, and what to do about normal ICS
3 days
Repeat the dose in children who vomit and consider the IV route in those who are unable to retain oral meds
It is considered good practice that inhaled CCs are continued at their usual maintenance dose whilst receiving additional treatment for the attack, but they should not be used as replacement for oral CC
for children with poor intial response to b2 agonist therapy consider the following combo to provide greater bronchodilation
Nebulised ipratoprium bromide can be combined with nebulised b2 agonsit
children over 2 - when would you consider adding magnesium sulphate
Consider adding magnesium sulphate to each nebulised salbutamol and ipratoroim bromide in the first hour in children with a short duration of severe acute asthma symptoms presenting with an oxygen saturation less than 92%
what to do with children ever 2 with continuing severe acute asthma despire frequent nebulised b2 agonists + ipratropium plus oral CCs, and those with life threatening features
Urgent review by specialist with a view to transfer to a high dependency unit or paediatric ICU to receive 2nd-line IV therapies
In children who respond poorly to first line treatments, this as 1st line IV treatment
magnesium sulphate IV
In severe asthma attack where child has not responded to initial inhaled therapy, early edition of a single bolus dose of ….. may be an option
IV salbutamol
consider the following in children with unreliable inhalation or severe refractory asthma
continuous IV salbutamol infusion, administered under specialist supervision with continuous ECG and electrolyte monitoring
consider the following in children with severe or life threatening acute asthma unresponsive to maximal doses of bronchodilators and corticosteroids
IV aminophylline
acute asthma treatment for all children under 2 should be given in …
hospital
treatment of children under 1 should be under …
direct guidance of respiratory paediatrician
management in children <2 with moderate and severe acute asthma attack
immediate treatment with oxygen via a tight fitting face mask or nasal prongs should be given to achieve normal SpO2 saturation’s of 94-98%
Trial an inhaled SABA and if response is poor, combined nebulised ipratropium bromide to each nebulised beta 2 agonist dose
Consider oral prednisolone daily for up to 3 days, early in the management of severe asthma attacks
In children not responsive to 1st line treatments or have life threatening features, discuss maangeemnt with senior paediatrician of the PICU team
follow up in all cases
- eps of acute asthma may be a failure of preventatives
- review needed to prevent further episodes
- take careful history to establish reason for acute asthma
- check inhaler technique and review regular treatment
- give pt written asthma action plan
after a pt is discharged from emergency department or hospital following an asthma attack, how soon does GP need to be informed and how soon do they need to be reviewed by GP
GP needs to be informed within 24h of discharge
patient to be reviewed within 2 working days by GP
true or false - A respiratory specialist should follow up all patients admitted with severe asthma attack for at least one year after the admission
true
true or false - Patients who have had a near fatal asthma attack should be kept under specialist supervision indefinitely
true
For life threatening or severe asthma what is the dose of nebulised salbutamol you would give to adults and children
For life-threatening or severe asthma, give nebulized salbutamol (5 mg to all people aged over 5 years, and 2.5 mg to children aged 2–5 years).
For life-threatening or severe asthma, give nebulized salbutamol (5 mg to all people aged over 5 years, and 2.5 mg to children aged 2–5 years). If they have poor response to this initial treatment, consider the addition of nebulized ipratropium bromide at the following doses
500 micrograms for adults and 250 micrograms for children aged 2–12 years, do not repeat within 4 hours
For acute asthma, give a first dose of prednisolone (40–50 mg for adults, 30–40 mg for children over 5 years, 20 mg for children aged 2–5 years, and 10 mg for children aged under 2 years). If medication cannot be swallowed, consider the following alternatives
intramuscular methylprednisolone 160 mg as an alternative in adults, or IV hydrocortisone 100 mg in people aged over 5 years, and 50 mg in children aged 2–5 years.
If a nebulizer is not available (for severe or life threatening), or if the attack is of moderate severity, use a pressurized metered-dose inhaler with a large-volume spacer. How often would you do this and how many puffs? (children and adults)
For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
Repeat every 10-20 minutes if clinically necessary. For a child, give a puff every 30–60 seconds, up to 10 puffs. If the response is poor, give further doses while awaiting hospital admission, and switch to a nebulizer if available.
