Asthma is a chronic inflammatory airway disease characterized by reversible airway obstruction. During an exacerbation, patients experience worsening symptoms such as shortness of breath, cough, and wheezing. The document outlines guidelines for assessing and managing acute asthma exacerbations in the emergency department. Treatment involves administering inhaled bronchodilators, systemic corticosteroids, supplemental oxygen, and magnesium sulfate for severe exacerbations. The document also provides guidance on determining whether patients can be discharged or require hospital admission based on post-treatment lung function.

1. Asthma in the Emergency
Department
BY
DR.MAHMOUD ALFEKY
Pulmonary Diseases specialist
MSc. Chest Diseases and tuberculosis, Faculty
of Medicine, Cairo University

3. What is Asthma?
• Chronic inflammatory disorder of
airways
• Inflammation causes airway hyper -
responsiveness often associated with
symptoms (wheezes, cough, SOB).
• Obstruction is reversible

4. Pathophysiology of Asthma (3Ss)
• 1. Spasm of smooth muscle hypertrophy which
contracts during an attack
• 2. Swelling or oedema of bronchial mucosa
• 3. Secretions from hypertrophy of mucus glands
leading to thick & tenacious mucus
• All the above cause bronchial narrowing

5. Asthma: Pathological changes

6. Asthma Exacerbation
• Episodes of progressive increase in shortness of
breath, cough, wheezing, or chest tightness, or
some combination of these symptoms.
• Respiratory viral infection, the main trigger of
severe exacerbations of asthma.

7. Which aspects of asthmatics
history are important to current
exacerbation?

9. Others
• Prior hospitalizations
• ICU admissions
• Recent ED visits
• Current meds
• Co-morbid conditions

10. How to assess Asthma severity?
Due to be updated 2007

11. Indicators of Severe Asthma
Clinically
• Anxious & diaphoretic appearance
• Breathlessness at rest; inability to speak in full
sentences
• PaCO2 normal or increased
• PEFR < 150 L/min or <50% predicted
• Pulse oximetry < 91% on room air
• Tachycardia (HR>120) and tachypnea (RR>30)

12. Risk Factors for death From Asthma

13. Risk Factors for Death From Asthma ((ccoonnttiinnuueedd))

14. Management of severe asthma
Aim:
1 -Correction of significant hypoxemia.
Oxygen
2- To relieve airflow obstruction
Repetitive administration of rapidly acting
bronchodilators.
Early systemic corticosteroids

15. Oxygen Assessment
• Pulse oximetry - in all severe asthmatic patients.
• Arterial desaturation and hypercarbia only
develop in life-threatening asthma.
• As result, pulse oximetry is a suitable means for
routine assessment of ventilatory status.
• Measure PEFR: patients with severe distress
if PEFR <50% predicted

16. In interpretation of arterial blood
gases
• in patients with suspected hypoventilation,
severe distress, or with or PEFR <30%
predicted after initial treatment
• primarily on PaCO2 with normal value in
breathless asthmatic being a warning sign of
impending hypoventilation.

17. • values above (45 mm Hg) indicating a life
threatening attack and probable need for transfer
to a high dependency unit or intensive care unit
(ICU).
OXYGEN
To achieve arterial oxygen saturation
of greater than or equal to 90
percent, oxygen should be
administered by nasal cannulae or
by mask

18. CXR, Bloods and other investigations
• Chest radiograph is not routinely needed, for:
1. those who do not respond to initial
treatment
2. other diagnosis as pneumothorax or
pneumonia.
• Microbiological investigations are seldom
required, although purulent sputum should be
cultured if present.

19. Inhaled bronchodilators
• Inhaled b2-agonists are the mainstay of
bronchodilator therapy
• Metered dose inhalers with a spacer produce
outcomes that are at least equivalent to
nebulizer therapy in severe asthma
• The addition of ipratropium bromide to inhaled
b2-agonist therapy provides an increase in the
bronchodilator response in severe asthma.

20. • If PEFR <50%: Inhaled high-dose beta2-agonist
and anticholinergic (ipratropium bromide) by
nebulization every 20 minutes or continuously for
1 hour.
• Repeat assessment (symptoms, physical exam,
PEF, O2 saturation, other tests as needed)

21. Systemic corticosteroids
• There is no benefit in using very high intravenous
doses in severe asthmatics needing hospital
admission.
• intravenous hydrocortisone 50 mg four times a day
for two days, followed by prednisone 20 mg daily, is
as effective in resolving acute severe asthma as
either hydrocortisone 200 mg or 500 mg four times
daily followed by prednisone 40 or 60 mg daily,
respectively.
• Prednisone is commonly given P.O in doses of 40-
60mg
• Side effects of short term steroid use include rise in
glucose, fluid retention, decrease in potassium,
peptic ulcers.

22. Route of administration
• Oral cortisones are usually as effective as intravenous
and are preferred because this route of delivery is less
invasive and less expensive.
• If vomiting has occurred shortly after administration of
oral cortisones, then an equivalent dose should be re-administered
intravenously.
• In patients discharged from the emergency department,
intramuscular administration may be helpful.
• Oral cortisones require at least 4 hours to produce
clinical improvement.

23. Is there a role for IV aminophylline
• Has been used for hundred’s of years
• Narrow therapeutic window, should only be
considered as an alternate therapy
• Increase in adverse effects (palpitations,
vomiting)
• Used in severe life threatening asthma
• Serum theophylline concentration must be
done first.

24. Magnesium Sulphate
• Intravenous magnesium now recommended in
patients with life-threatening attacks. Not
recommended for routine use in asthma
exacerbations
• Its use leads to an improvement in lung function
and a reduction in hospital admissions.
• Currently, a single dose (2 g MgSO4 diluted in 50
ml 0.9% normal saline administered over 30 min) .
• If an intravenous bronchodilator is to be
administered, current evidence favours the use of
intravenous magnesium rather than intravenous
b2-agonist or aminophylline.

25. Should IV b2-agonist therapy be used?
• No significant differences were found in IV
b2-agonists in addition to, or instead of,
inhaled b2-agonists
• If the patient can tolerate inhaled b-2
agonists, there is no evidence to support
the use of IV b2-agonists

26. Does Pregnancy change the management
of acute asthma?
NO!
• Treat Aggressively
• Prevent Maternal Hypoxia
• Fetal Morbidity/Mortality
• “Risks from respiratory failure and severe acute
asthma are greater than from therapy with
standard medications”

27. How can I tell if my patient is
improving?
• Ask them how they feel
• Re-examine
• Obtain objective measurements
(PEFR)

28. Who should be intubated?
• Endotracheal intubation is not curative,
only a very small percentage of patients
presenting to the ED with acute severe
asthma will require endotracheal
intubation and assisted ventilation.
• Exhaustion, hypoxaemia, deterioration
in clinical features despite optimal
therapy, PaCO2 is increasing, and
depression of mental status strongly
indications for intubation

29. How should I decide if my patient
can be discharged?
Hospitalize
Patients with a pre-treatment
FEV1 or
PEF < 25% percent
predicted or personal
best, or those with a
post-treatment FEV1
or PEF < 40% percent
predicted or personal
best, usually require
hospitalization.
Discharge
• Patients with post-treatment
lung
function of 40-60%
predicted may be
discharged, provided
that adequate follow-up
is available.
• Patients with post-treatment
lung
function ≥ 60 %
predicted can be
discharged.

30. Antibiotics in severe asthma
• Purulent sputum may not indicate infection, and
is usually a result of eosinophils in respiratory
secretions
• Antibiotics should not be routinely prescribed as
bacterial infections seldom provoke
exacerbations (in contrast to viral respiratory
tract infections), and their routine prescription
does not influence outcome in exacerbations of
asthma.

31. SEDATION
should be strictly avoided during exacerbations of
asthma because of the respiratory depressant effect
of hypnotic drugs.

32. ANTIHISTAMINICS and CHEST
PHYSICAL THERAPY
No established role in the treatment of acute
asthma exacerbations.