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Emergency Protocol for Bronchial Asthma

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Emergency Protocol for Bronchial Asthma

  1. 1. Management of asthma exacerbations in adults Ala’Eldin Hassan Ahmed, MD, FRCP, FCCP Faculty of Medicine, University of Khartoum
  2. 2. Acute Asthma Exacerbations in Adults Definition: Asthma is an inflammatory disorder of the airways associated with reversible airflow obstruction. Airflow obstruction is assessed by measuring peak expiratory flow (PEF). Clinically asthma presents as cough, and/or shortness of breath, and/or wheeziness. and/or chest tightness. The symptoms of asthma tend to be variable, intermittent, worse at night, and provoked by triggers including exercise. Differential diagnosis:  Congestive heart failure.  Pulmonary embolism.  Chronic obstructive pulmonary disease.  Mechanical airway obstruction.  Vocal cord dysfunction (rare). Directed Approach to Acute Asthma Exacerbations: History: Determine how good or bad is the patient’s asthma control in the chronic stable state  Symptoms especially the presence of nocturnal symptoms  Range of home peak expiratory flow rates (PEFs), if available  Frequency of emergency department visits and ICU admissions.  Long term medications including oral steroid dependence Evaluate the following concerning the current exacerbation:  duration  severity (see next)  potential precipitants  medications taken in response Physical examination:  Asses asthma severity: Features of severe asthma are: PEF < 50% best or predicted; respirations >/= 25/min; pulse rate >/= 110 beats/min; can’t complete sentences in one breath.  Features of life threatening asthma are: SpO2 < 92%; silent chest; cyanosis; poor respiratory effort; bradycardia; arrhythmia; hypotension; exhaustion; confusion; coma.  These findings are not sensitive indicators of severe attacks; up to 50 percent of patients with severe airflow obstruction will not manifest many of these abnormalities.  Look for signs of pneumothorax or pneumomediastinum. Diagnostic studies: 1. PEF measurement:  This is the best test for assessing the severity of an asthma attack.  It is easy to perform and when repeated over time can be used to monitor a patient's response to treatment.
  3. 3.  Predicted values for an individual differ with size, age, gender, and ethnicity, but a peak flow rate below 200 L/min indicates severe obstruction for all but unusually small adults. 2. Arterial blood gas (ABG) analysis:  This is generally indicated only among patients with persistent dyspnea (despite initial bronchodilator therapy) whose PEF remains below 33 percent of predicted or those with signs of life threatening asthma. 3. Chest x-ray:  Generally not recommended for all patients.  It can be limited to those patients with suspected complications such as pneumothorax, pneumomediastinum, or consolidation. Those with Life threatening asthma and those who fail to respond to treatment satisfactorily. For a stepwise approach for treating acute asthma exacerbations please refer to the attached flowchart. Notes:  Give high flow oxygen to all patients with acute severe asthma.  Ipratropium bromide provides greater bronchodilation for patients not rapidly responding to initial beta agonist therapy.  Avoid I.V. aminophylline if salbutamol is available. The combination of salbutamol and itravenous aminophylline results in no further bronchodilation than that achieved with nebulized beta agonists alone and may lead to increased risk of toxicity.  Rarely, however, some patients with near fatal asthma or life threatening asthma with poor response to inhaled therapy may gain additional benefit from IV aminophylline 5 mg/kg loading dose over 20 minutes unless on maintenance oral therapy then give infusion of 0.5 – 0.7 mg/kg/h.  If PEF is < 50% on presentation prescribe prednisolone 40 – 50 mg/day. Continue prednisolone 40 – 50 mg daily for at least five days or until recovery. This should be followed by treatment with regular inhaled corticosteroids.  In the absence of vomiting, oral administration of corticosteroids can be substituted for intravenous administration. Oral formulations are rapidly absorbed and exhibit comparable efficacy.  If a nebulizer is unavailable, salbutamol may be delivered via a metered dose inhaler (MDI) with a spacer. The equivalent dose has not been precisely defined, but four to six carefully administered inhalations from an MDI with spacer have generally been found to equal one nebulizer treatment.  Routine prescription of antibiotics is not indicated for acute asthma.
  4. 4. Drugs used in this section: Drug Main indication Recommended dose Prednisolone Acute asthma  Oral: prednisolone 40 – 50 mg per day as single dose. Continue for at least five days or until recovery Hydrocortisone Acute asthma  I.V. 100 mg 6 hourly is as effective as higher doses Salbutamol (via a nebulizer OR a metered dose inhaler with a spacer) Acute asthma  Inhalation: 90 mcg/puff: 4 - 6 puffs every 20 minutes for up to 4 hours, then every 1 - 4 hours as needed.  Nebulization: 5 mg continuous flow nebulization every 20 minutes for three doses. May also give via continuous nebulization, administering approximately 10 mg over one hour. Ipratropium bromide Acute asthma  Nebulization: 500 mcg 4 times/day.  Metered dose inhaler: 2 inhalations 4 times/day, Aminophylline Acute asthma  I.V. loading dose (in patients not currently receiving oral aminophylline or theophylline): 5 mg/kg over 20 minutes (given in normal saline or 5% dextrose); administration rate should not exceed 25 mg/minute  I.V. maintenance dosage continuous infusions in normal saline: 0.5 – 0.7 mg/kg/hour. Dosage should be adjusted according to serum level measurement (if available) Magnesium sulphate Acute asthma  IV. 1.2 – 2 grams infusion in normal saline or 5% dextrose over 20 minutes (single dose)
  5. 5. Management of acute severe asthma in adults in emergency department Measure Peak Expiratory Flow and Arterial Saturations PEF>75% best or predicted Mild PEF 33-75% best or predicted Moderate - severe PEF < 33& best or predicted Or any life threatening features Give usual bronchodilator Give salbutamol 5 mg by oxygen driven nebuliser Obtain senior ICU help High concentration oxygen > 60% Salbutamol 5 mg plus ipratropium0.5 mg via oxygen driven nebulizer Prednisolone 40 – 50 mg orally or IV hydrocortisone 100 mg Measure arterial blood gases Markers of severity PaOCO2 > 4.6 kPa PaO2 < 8 kPa Low pH Give/repeat Salbutamol 5 mg plus ipratropium0.5 mg via oxygen driven nebulizer after 15 minutes Consider continous salbutamol nebuliser 5-10 mg/hr Consider IV magnesium 1.2 – 2 grams over 20 minutes Correct fluid/electrolytes disturbances Chest X ray Life threatening features Or PEF < 50% No life threatening features And PEF 50 –75% Clinically Stable and PEF<75% Clinically Stable and PEF>75% Repeat salbutamol 5 mg nebuliser. Give prednisolone 40 – 50 mg orally Admit ICU accompanied by doctor Signs of severe asthma or PEF < 50% No signs of severe asthma and PEF 50 -75% Patient recovering and PEF > 75% Monitor SpO2, heart and respiratory rates Signs of severe asthma or PEF < 50% Patient stable and PEF > 50% Potential discharge
  6. 6. Management of acute severe asthma in adults in emergency department Measure Peak Expiratory Flow and Arterial Saturations PEF>75% best or predicted Mild PEF 33-75% best or predicted Moderate - severe PEF < 33& best or predicted Or any life threatening features Give usual bronchodilator Give salbutamol 5 mg by oxygen driven nebuliser Obtain senior ICU help High concentration oxygen > 60% Salbutamol 5 mg plus ipratropium0.5 mg via oxygen driven nebulizer Prednisolone 40 – 50 mg orally or IV hydrocortisone 100 mg Measure arterial blood gases Markers of severity PaOCO2 > 4.6 kPa PaO2 < 8 kPa Low pH Give/repeat Salbutamol 5 mg plus ipratropium0.5 mg via oxygen driven nebulizer after 15 minutes Consider continous salbutamol nebuliser 5-10 mg/hr Consider IV magnesium 1.2 – 2 grams over 20 minutes Correct fluid/electrolytes disturbances Chest X ray Life threatening features Or PEF < 50% No life threatening features And PEF 50 –75% Clinically Stable and PEF<75% Clinically Stable and PEF>75% Repeat salbutamol 5 mg nebuliser. Give prednisolone 40 – 50 mg orally Admit ICU accompanied by doctor Signs of severe asthma or PEF < 50% No signs of severe asthma and PEF 50 -75% Patient recovering and PEF > 75% Monitor SpO2, heart and respiratory rates Signs of severe asthma or PEF < 50% Patient stable and PEF > 50% Potential discharge

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