acute severe asthma

Question 1

presentation of a patient with an acute asthma attack

Answer 1

Acute breathlessness and wheeze

Question 2

Acute breathlessness and wheeze DD

Answer 2

asthma, Acute infective exacerbation of COPD, pulmonary oedema,
upper respiratory tract obstruction, pulmonary embolus, anaphylaxis.

Question 3

Acute breathlessness and wheeze investigations

Answer 3

PEF—but may be too ill; arterial blood gases if saturations <92%; CXR
(if suspicion of pneumothorax, infection or life-threatening attack); FBC; U&E.

Question 4

Assessing the severity of an acute asthmatic attack - severe vs life threatening

Answer 4

Severe attack:
• Unable to complete sentences
• Respiratory rate >25/min
• Pulse rate >110 beats/min
• Peak expiratory fl ow 33–50% of predicted or best

Life-threatening attack:
• Peak expiratory fl ow 4.6kPa (32mmHg)
•PaO2 <7.35

Question 5

managment of acute severe asthma

Answer 5

1 - Assess severity of attack
PEF, ability to speak, RR, pulse rate, O2 sats
Warn ICU if severe or life-threatening attack

2 - Immediate treatment1
Salbutamol 5mg (or terbutaline 10mg) nebulized with O2
Hydrocortisone 100mg IV or prednisolone 40–50mg PO or both if very ill
Start O2 if saturations <92% (also check ABG), aim sats 94–98%

3 - If life-threatening features present:
• Inform ICU and seniors
• Give salbutamol nebulizers every 15min, or 10mg continuously
per hour. Monitor ECG; watch for arrhythmias
• Add in ipratropium 0.5mg to nebulizers
• Give single dose of magnesium sulfate (MgSO4) 1 . 2–2g IV over
20min

3a - If not improving:
Refer to ICU for consideration of
ventilatory support and intensifi -
cation of medical therapy, eg aminophylline,
IV salbutamol if any of
the following signs are present:
• Deteriorating PEF
• Persistent/worsening hypoxia
• Hypercapnia
• ABG showing low pH or high H+
• Exhaustion, feeble respiration
• Drowsiness, confusion, altered
conscious level
• Respiratory arrest

3b - If improving within 15–30
minutes:
• Nebulized salbutamol every
4 hours
• Prednisolone 40–50mg PO OD for
5–7 days
• Monitor peak fl ow and O2 sats,
aim 94–98% with supplemental
if needed

Question 6

discharge after acute severe asthma

Answer 6

Discharge Patients, before discharge, must have:

• Been stable on discharge medication for 24h.
• Had inhaler technique checked.
• Peak fl ow rate >75% predicted or best with diurnal variability <25%.
• Steroid (inhaled and oral) and bronchodilator therapy.
• their own PEF meter and have management plan.
• GP appointment within 1wk.
• Respiratory clinic appointment within 4wks.

Question 7

salbutamol - what is it and side effects

Answer 7

(beta2-agonist) SE: tachycardia, arrhythmias, tremor, K+ decrease.

Question 8

Aminophylline - what is it and side effects

Answer 8

is used much less frequently and is not routinely recommended in
current BTS guidelines, but may be initiated by respiratory team or ICU. It inhibits
phosphodiesterase; increase [CAMP]. SE: pulse increase, arrhythmias, nausea, seizures. The amount
of IVI aminophylline may need altering according to the individual patient: always
check the BNF. Monitor ECG.

Question 9

Hydrocortisone what is it

Answer 9

steroid - reduces inflam like prednisolone