Acute Asthma in Adults, 12+ years Flashcards
Personalized management for adults and adolescents to control symptoms and minimize future risk
Selecting initial controller treatment in adults and adolescents with a diagnosis of asthma
Red Flags
Silent chest
Bradycardia
Anaphylaxis
Pregnancy
Examination
Conscious state
Ability to speak whole sentences
Peak expiratory flow rate
Oxygen saturation
Respiratory rate and effort
Heart rate and blood pressure
Temperature
Chest auscultation
Acute asthma severity
Mild to moderate:
PEF: > 50% of best or predicted
O2 Sats: > 96%
Heart rate: Normal
No features of severe asthma
Severe:
PEF: 30 to 50% of best or predicted
Sats: 92 to 96%
HR: ≥ 110
Increasing symptoms, unable to complete sentences in one breath,
RR > 25
Life-threatening:
PEF: < 30% of best or predicted
Sats: < 92%
Bradycardia or extreme tachycardia
Unable to talk, silent chest, exhaustion, cyanosis, hypotension, feeble respiratory effort
Note: * indicates additional symptoms that may be present in life-threatening asthma.
Assessment
If you suspect anaphylaxis, treat according to the Anaphylaxis pathway.
Assess improvement after bronchodilator treatment.
Bronchodilator response is the key indicator of ongoing severity and the need for hospital admission.
Take a history once the patient starts to stabilize:
Rapidity of onset of symptoms.
Current medications: inhaler usage (number of puffs of beta-agonist inhaler used in the last 24 hours) and correct spacer usage.
Co-morbidities.
Recent asthma control.
Pregnancy.
Exposure to allergens and smoking status.
Consider other causes of acute dyspnea:
Respiratory: pulmonary embolism, pneumothorax, and upper airway obstruction.
Cardiac: acute coronary syndrome, acute heart failure, arrhythmia.
Anxiety or hyperventilation.
Risk factors for acute deterioration
- Pregnancy
- Exacerbating factors;
. Slow response to bronchodilator treatment
. Acute deterioration despite being on oral corticosteroids
. Limited availability of facilities to monitor and manage
. Significant co-morbidities e.g., diabetes - Persisting dyspnoea with PEF or FEV1 < 70% of best normal
- Risk factors for severe or fatal asthma;
Risk factors for severe or fatal asthma
Frequent or severe exacerbations:
. One or more exacerbations requiring oral corticosteroids within the past 12 months
. Any previous ventilation or ICU admission for asthma attack
. Hospital admission or emergency department presentation for asthma in the last year
. Frequent attenders for emergency treatment (general practice, after hour surgeries, emergency departments)
. Precipitous asthma (onset to severe in < 4 hours)
. High short-acting beta2-agonists (SABA) use (> 3 inhalers per year)
. Māori and Pacific peoples aged 15 to 49 years are approximately three times more likely to be admitted with asthma, with 14% experiencing a readmission rate within 90 days.
Social factors:
. Underuse of inhaled corticosteroid (ICS) treatment
. Disconnection from regular medical care
. Socio-economic disadvantage
. Poor housing e.g., cold, damp, mouldy, or heated by unflued gas heaters
. Occupational asthma
Co-morbidities:
. Smoking
. Psychosis, depression, and other psychiatric illness
. Alcohol and drug abuse
. Aspirin or other nonsteroidal anti-inflammatory drug (NSAID) sensitivity
. Anaphylaxis, food allergy
Practice point
There is insufficient evidence for the use of a combination budesonide/formoterol for the treatment of acute severe asthma. A short acting beta agonist (SABA) remains the preferred medication in this setting.
Management, Life-threatening
1) Start treatment immediately:
Give continuous nebulised salbutamol immediately via oxygen (6 to 8 litres/minute to maintain O2 > 92%).
Give one immediate dose of ipratropium 500 micrograms via oxygen-driven nebuliser.
Remain calm.
Call an ambulance.
Notify the admitting officer.
Monitor the patient closely and do not leave them unattended.
2) Give a systemic corticosteroid – prednisone 40 mg orally or hydrocortisone 100 mg intravenously (IV).
3) Prepare to assist ventilation with a bag valve mask and prepare to intubate if able.
4) If the patient has a respiratory arrest, intubate immediately with an ET tube. It is preferable to intubate rather than use a laryngeal mask airway (LMA):
Ventilate at 10 to 12 breaths per minute initially (use a watch).
Go carefully. There is a risk of pneumothorax with high pressures, and risk of arrest with breath stacking. Allow sufficient expiratory time.
5) Continue treatment and prepare the patient for ambulance transfer:
Keep giving salbutamol via nebuliser continuously
Give 500 micrograms ipratropium via nebuliser up to hourly
Give oxygen to maintain saturations 92 to 96%
Establish IV access where possible
Consider IV infusion magnesium sulphate 1.2 to 2 g over 20 minutes if available.
POAC funding is available to cover the cost of the magnesium sulphate and any extra equipment required for giving it.
Consider obtaining ABG, urea, and electrolytes
Management, Severe
1) Give immediate bronchodilators via spacer or nebuliser with oxygen as required to maintain saturations above 92%:
MDI plus spacer – 6 puffs salbutamol 100 micrograms and 6 puffs ipratropium 20 micrograms, or
Oxygen-driven nebuliser – Salbutamol 2.5 mg and ipratropium 500 micrograms
2) Closely monitor the patient, and reassess severity:
O2 saturation.
Heart rate.
Peak flow.
3) Titrate O2 flow to maintain saturation of 92 to 96%.
4) Continue salbutamol:
. Repeat as required every 20 minutes for first hour. If more frequent doses are needed, treat as life-threatening.
. If the patient is improving, continue every 20 minutes until they are stable.
. Consider Primary Options for Acute Care (POAC) funding if treatment time is > 30 minutes and extended observation is required.
5) Give oral prednisone 40 mg.
6) Reassess the severity to determine the patient’s response to initial treatment, and adjust accordingly.
7) Arrange transfer to the emergency department if the patient is not stabilising, especially if PEF remains < 50% or they are deteriorating.
8) Request emergency department assessment if the patient is stabilising but at ongoing risk of acute deterioration.
9) If the patient improves and remains stable after 1 to 2 hours of observation with no signs of severe asthma, PEF > 70%, and no risk factors for acute deterioration, then consider discharging them home:
. Check their inhaler technique.
. Provide a specific asthma plan for the next 24 hours and the following week.
. Prescribe a course of oral prednisone 40 mg daily, for at least five days (can be given on PSO to ensure there are no barriers to getting the medication).
. Ensure they have a supply of ICS inhaler. Consider taking the opportunity to switch patients to AIR therapy with budesonide + formoterol as maintenance and reliever to reduce the risk of future severe exacerbations.
Management, Mild or moderate
- Give 6 puffs salbutamol via MDI plus spacer.
- Closely monitor the patient:
. O2 saturation – should be normal i.e., > 92% saturation
. Heart rate
. Peak flow - Repeat salbutamol 6 puffs every 20 minutes while PEF < 70% or as needed for relief.
- Consider giving oral prednisone 40 mg.
- Reassess the severity to determine the patient’s response to treatment.
- Continue treatment according to the patient’s condition:
. Unstable or PEF < 50%: Manage as severe asthma and arrange transfer to the emergency department.
. PEF < 70% but worsening symptoms: Manage as severe asthma.
Improving: Monitor in general practice until stable, no signs of severe asthma, and PEF > 70%.
. Consider Primary Options for Acute Care (POAC) funding if treatment time is > 30 minutes and extended observation is required.
. See NZ Asthma Guidelines – Quick Reference Guide: Algorithm for Management of Acute Severe Asthma in Adolescents and Adults. - Prepare the patient for discharge home:
. Check their inhaler technique.
. Provide a specific asthma plan for the next 24 hours and the following week.
. Consider prescribing a course of oral prednisone 40 mg daily, for at least five days (can be given on PSO to ensure there are no barriers to getting the medication).
. Ensure they have a supply of ICS inhaler. Consider taking the opportunity to switch patients to AIR therapy with budesonide + formoterol as maintenance and reliever to reduce the risk of future severe exacerbations. - Consider implementing a nurse standing order for salbutamol administration into your practice.
. This will allow nurses to commence salbutamol before doctor assessment if needed.
. Follow nurse standing order – Salbutamol 100 microgram for mild to moderate acute asthma exacerbations.
Follow up general practitioner appointment
Book an early follow-up appointment:
Look at preventing further exacerbations by:
. checking corticosteroid inhaler technique.
. ensuring continuation of inhaled corticosteroid.
. improving asthma management, including a personalised asthma action plan.
Ask about and assist with any difficulties accessing medical care and medication.
Schedule their next regular review and vaccinations.
Support them to achieve and maintain a smoke-free environment.
Consider arranging further support to address barriers to good asthma control
Further support;
. Social support, funding, and advocacy
. Fitness and lifestyle support
. Respiratory physiotherapy for breathing techniques – if chronic breathing dysfunction suspected due to an over-reliance on relievers when PEFR is reasonable
Breathing techniques ;
. Asthma that has been poorly controlled can produce chronically overactive chest wall and neck muscles.
. Breathing training programs and yoga and Buteyko exercises can be effective in improving patient-reported outcomes such as symptoms, quality of life and psychological impact, and may reduce the use of rescue bronchodilator medication.
