Acute Asthma in ED presentation by Dr Adel Abdel Aziz delivered in World Asthma Day organized by As Salam International Hospital, Cairo, Egypt

1. Acute Asthma in Emergency
Department
Dr. Adel Abdel Aziz
University Hospital Southampton NHS Foundation Trust/ UK

2. Disclosures
I have nothing to disclose with respect to this presentation.

3. Objectives
 Facts
 Review of current BTS guidelines
 Diagnosing Acute Asthma in ED
 Managing Acute Asthma
 When to admit/safe discharge

4. UK key Facts
 One of the common conditions seen at Emergency
Department (ED) is asthma.
 5.4 million people in the UK are currently receiving
treatment for asthma: 1.1 million children (1 in 11) and 4.3
million adults (1 in 12)
 Asthma prevalence is thought to have plateaued since the
late 1990s, although the UK still has some of the highest
rates in Europe and on average 3 people a day die from
asthma.
 In 2014 (the most recent data available) 1216 people died
from asthma.
 The NHS spends around 1 billion a year treating and
caring for people with asthma—NOT COPD

5. Evidence shows people with an asthma action plan are
four times less likely to be admitted to hospital
because of their asthma.

6. Aim in ED
 Focus on ED management with emphasis that:
Emergency Medicine is a : “Prevention, Resuscitation,
Stabilization and appropriate disposition”1 to the
appropriate specialty.
Step1. Diagnosis
Step 2. Assess the severity
Step 3. Treatment
Step 4. Assess the response

7. Which aspects of asthmatics history are
important to current exacerbation?
 Prior hospitilizations
 ICU admissions
 Recent ED visits
 Current meds
 Co-morbid conditions

8. How to assess Asthma severity?

9. BTS Asthma guidelines
 BTS guidelines for asthma
categorizes presentation into severity
and helps guide treatment with
regards to the category

10. BTS - Moderate exacerbation asthma
• increasing symptoms
• PEFR >50-75% best or predicted
• No features of acute severe asthma

11. BTS - Acute severe asthma
 Any one of following;
• PEFR 33-50% best or predicted
• respiratory rate ≥25/min
• heart rate ≥110/min
• inability to complete sentences in one breath

12. Life threatening exacerbation of
asthma
Patient with acute severe asthma with any one of
• PEFR <33% best or predicted
• SpO2 <92%
• PaO2 <8 kPa
• normal PaCO2 (4.6-6.0 kPa)
• silent chest/cyanosis/poor respiratory effort
• Arrhythmia/exhaustion/altered conscious level

13. Key objectives of management
 Aim:
- To relieve airflow obstruction and
hypoxaemia
- To prevent relapses
 Repetitive administration of rapidly acting
bronchodilators.
 Early systemic corticosteroids.
 Oxygen
 Complications - (pneumothorax)

14. Management of Acute Asthma
 Assessment
 Clinical features
 PEFR
 Pulse oximetry
 Blood gases (ABG)
 Chest X-ray
 Not routine
 Suspected pneumothorax, consolidation, life threatening, failure
to respond, requiring ventilation

15. Initial Assessment and Management
Assess severity
Good
response
Incomplete
response
Poor
response
Inhaled
SABA
History
Physical Exam
Peak flow determination

16. Treatment of Acute Asthma
Bronchodilator therapy
 Salbutamol provides rapid, dose-dependent
bronchodilation.
 Continuous administration may be more
effective in severe exacerbations.
 Ipratropium bromide is an anticholinergic
bronchodilator with a slow onset of action and
peak effectiveness at 60 to 90 minutes.

17. Treatment of Acute Asthma
Corticosteroid therapy
 Oral administration of prednisolone is often
equivalent to iv methylprednisolone unless there is
nausea.
 Current evidence is insufficient to permit
conclusions about using inhaled corticosteroids in
acute asthma.
 For severe exacerbations unresponsive to
Salbutamol and corticosteroid therapy, adjunctive
treatments may be used: iv magnesium sulphate or
heliox.

18. Magnesium Sulphate
 Intravenous magnesium now recommended in patients
with life-threatening attacks. Not recommended for
routine use in asthma exacerbations
 Currently, the evidence relates to a single dose (2 g over
20 min)
 If an intravenous bronchodilator is to be administered,
current evidence favours the use of intravenous
magnesium rather than intravenous b-agonist or
aminophylline.
 Nebulized salbutamol administered in isotonic
magnesium sulfate provides greater benefit than if it is
delivered in normal saline (Evidence A) contentious !!!

19. Treatment of Acute Asthma
Heliox
 Heliox is a mixture of helium and oxygen
(usually a 70:30 helium to oxygen ratio) that
is less viscous than ambient air.
 Heliox improves delivery and deposition of
nebulized salbutamol.

20. Moderate
PEF >50-75%
SpO2 >92%
No features of severe
Acute Severe
PEF 33-50%
RR >25
SpO2 >92%
HR >110
Cannot complete
sentences
Life threatening
33-92-CHEST
PEF <33%
SpO2 <92%
Cyanosis/Confusion,
Hypotension,
Exhaustion, Silent chest,
Tachycardia
Senior help (ITU,
anaesthetics)
O SHIT!
•O2 to maintain sats 94-98%
•Salbutamol 5mg via O2 driven nebs
•Hydrocortisone IV/oral prednisolone
•Ipratropium via O2 driven nebs
•Consider Magnesium Sulphate IV
ABG, CXR
Salbutamol 4 puffs, then 2
puffs every 2 mins
Salbutamol 5mg via O2
driven nebuliser
If life threatening
features present
Repeat salbutamol nebs,
give oral prednisolone 40-
50mg

21. Asthma in ED short stay unit
(CDU)
 Emergency short stay units have been used in the
ED worldwide for several decades.
 Studies have shown that they:
 Reduce length of stay ( Daly S et al; 2003, Rydman RJ et
al 1999 & 1997, Khan SA et al; 1997)
 Improve ED efficiency (Bazarin J et al; 1996)
 Are cost-effective ( Graff L G et al; 1988), and
 Reduce the number of inpatient admissions (Martinez E
et al; 2001).

22. When is it safe to discharge?
 Significant improvement in symptoms
 Significant improvement in peak flow –
should be at least 75% of predicted /
personal best

23. ASSIH ED
Asthma pathway
OPD
ADMIT

24. Conclusions
 Asthma is frequently under treated
 Use current guidelines to aid diagnosis and help in
acute management
 If patients are not responding as you would expect
 Is the diagnosis right?
 Are they having the appropriate management?
 Are psychological or social factors hindering management?

25. References
 1] Daly S, Campbell DA, and C. PA, "Short-stay units and observation medicine: a systematic
review," Med. J. Aust, vol. 178, pp. 559-63, 2003.
 [2] Bazarin J, Schneider S, Newman V, and Chodosh J, "Do admitted patients held in the
emergency department impact the through-put of treat and release patients.," Acad. Emerg. Med,
vol. 3, pp. 1113-18, 1996.
 [3] Martinez E, Reily BM, Evan AT, and Roberts RR, "The observation unit: a new interface
between inpatient and outpatient care.," Am. J. Med, vol. 110, pp. 274-7, 2001.

26. THANK YOU
?