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MANAGEMENT OF ACUTE SEVERE ASTHMA
This document provides guidelines for the management of acute severe asthma. Initial assessment involves measuring peak expiratory flow, vital signs, and arterial blood gases. Treatment includes high doses of inhaled bronchodilators, systemic corticosteroids, oxygen, intravenous fluids and magnesium. Mechanical ventilation may be required if the patient deteriorates or is unable to be adequately ventilated. Close monitoring of peak expiratory flow, oxygen saturation, and serum aminophylline levels is important.
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MANAGEMENT OF ACUTE SEVERE ASTHMA
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- 2. Introduction • A life-threateningexacerbation of asthma symptoms • Findings: PEF (peak expiratory flow) 33-50% predicted (< 200 l/min) Respiratory rate ≥ 25/min Heart rate ≥ 110/min Arterial blood gas analysis PaO2 (N: 75-105 mm Hg)and PaCO2 (N: 35-45 mm Hg) Inability to complete sentences in 1 breath
- 3. Management • Initial assessment •Treatment • Mechanical ventilation • Monitoring
- 4. Initial assessment Immediate assessmentof ability to speak Vital signs Measurement of PEF is mandatory unless the patient is too ill to cooperate Arterial blood gas analysis
- 5. Treatment • Oxygen • Highdoses of inhaled bronchodilators • Systemic corticosteroids • Intravenous fluids • Subsequent management
- 6. Treatment contd… • Oxygen –High concentrations of oxygen (humidified if possible) – Goal: SaO2 > 92% – Failure to achieve appropriate oxygenation assisted ventilation.
- 7. Treatment contd… • Highdoses of inhaled bronchodilators – Short-acting β2-agonists (Salbutamol 5mg/hr) • via nebuliser driven by oxygen or via a metered dose inhaler through a spacer device – An inhaled anticholinergics (Ipratropium bromide µg) may be added
- 8. Treatment contd… • Systemiccorticosteroids – intravenous hydrocortisone 200 mg : in patients who are unable to swallow or vomiting. – Oral prednisolone 0 mg
- 9. Treatment contd… • Intravenousfluids – To correct dehydration and acidosis – Normal saline + sodium bicarbonate/lactate infusion – Potassium supplements to treat hypokalemia induced by Salbutamol
- 10. Treatment contd… • Subsequentmanagement – If patients fail to improve • Intravenous magnesium sulphate(1.2–2 g over 20 min) • Intravenous β2 agonists(e.g. Salbutamol) • Intravenous aminophylline (5mg/kg loading dose over 20 minutes followed by continuous infusion at mg/kg/hr ) • Intravenous leukotriene receptor antagonists • Anaesthetics (e.g. halothane)
- 11. Mechanical Ventilation • Initialgoals – To correct hypoxaemia – To achieve adequate alveolar ventillation – To minimize circulatory collapse – To buy time for medical management to work • Indications – Coma – Respiratory arrest – Deterioration of arterial blood gas tensions despite optimal therapy – Exhaustion, confusion, drowsiness
- 12. Monitoring of treatment •PEF should be recorded every 15-30 minutes • Pulse oximetry should ensure that SaO2 remains > 92% • If aminophylline is given, then monitor the serum concentration (therapeutic range 10–20 µg ml • Repeat arterial blood gases if – initial PaCO2 measurement was raised – PaO2 was < 8 kPa (60 mmHg) or – the patient deteriorates.
Editor's Notes
- #3 Hot potato speech or fragmented speech
- #5 ABG : to determine the PaCO2elevated level being particularly dangerousVital signspulse raterespiratory rateBlood pressure andSaO2 (oxygen saturation)
- #7 The presence of a high PaCO2 should not be taken as an indication to reduce oxygen concentration but is a warning sign of a severe or life-threatening attack.
- #8 Ipratropium + salbutamol : greater bronchodilation than salbutamol aloneif there is not a satisfactory response to β2-agonists alone
- #9 reduce the inflammatory response and hasten the resolution of exacerbations. should be administered to all patients with an acute severe attack.
- #10 Normally, respiratory acidosis is compensated by metabolic alkalosis. If compensation is not complete, then sodium bicarbonate should be given. Potassium supplements indicated only if potassium level < 5.5 mEq/ l
- #11 MgSO4: (bronchodilation in patients with PEF< 30% predicted); Rapid administration may be associated with hypotensionhypermagnesaemia is associated with muscle weakness and may exacerbate respiratory failure in spontaneously breathing patients. also used in eclampsia, arrythmia, laxative etc.Aminophylline : 5 mg kg−1 loading dose over 20 min unless on maintenance oral therapy, then infusion of 0.5–0.75 mg kg−1 min−1); side effects (arrhythmias, restlessness, vomiting, and convulsions)If non-respondent to conventional bronchodilators, may benefit from an anaesthetics (e.g. halothane)
- #12 PaO2 < 8 kPa (60 mmHg) and falling PaCO2 > 6 kPa (45 mmHg) rising pH low and falling (H+ high and rising)