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A 56-year-old man presents to ED with the history of shortness of breath for 45 minutes. He reports that he was feeling well and in his usual state of health until about an hour ago, when he smelled something burning. Twenty minutes later, he began to fell short of breath and was wheezing. He tried using his albuterol inhaler without success, so he proceeded to the ED. At the ED, he was tachycardia, tachypnea, wheezing and hypertensive. His O2 sats on RA were 87% to 88%. His last admission for an asthma attack was 2 months ago.
Severe acute asthma is a medical emergency requiring hospitalisation.
Treatment includes (Bronchodilators reverse the bronchospasm of the immediate phase; anti-inflammatory agents inhibit or prevent the inflammatory components of both phases )
oxygen (in high concentration, usually ≥ 60%),
inhalation of nebulised salbutamol , and
intravenous hydrocortisone followed by a course of oral prednisolone .
Additional measures occasionally used include nebulised ipratropium ,
intravenous salbutamol or aminophylline ,
and antibiotics (if bacterial infection is present).
Monitoring is by PEFR or FEV 1 , and by measurement of arterial blood gases and oxygen saturation.
Salbutamol: β 2 -Adrenoceptor agonists act as physiological antagonists of the spasmogenic mediators but have little or no effect on the bronchial hyper-reactivity
Glucocorticoids: These reduce the inflammatory component in chronic asthma and are life-saving in status asthmaticus (acute severe asthma).
Theophylline (often formulated as aminophyllin) relaxant effect on smooth muscle has been attributed to inhibition of phosphodiesterase (PDE) isoenzymes, with resultant increase in cAMP and/or cGMP
ipratropium: Muscarinic receptor antagonists
Cysteinyl leukotriene receptor antagonists
Histamine H1-receptor antagonists
Cromoglicate and nedocromil: Given prophylactically, they reduce both the immediate- and late-phase asthmatic responses and reduce bronchial hyper-reactivity.
Omalizumab is a humanised monoclonal anti-IgE antibody. It is effective in patients with allergic asthma as well as in allergic rhinitis. It is of considerable theoretical interest (see review by Holgate et al., 2005), but it is expensive and its place in therapeutics is unclear