medicine

1. Scheme of presentation
• Introduction
• Acute exacerbation of bronchial asthma
• Assessment of severity of the exacerbation
• Management of Acute severe asthma.
• Follow up care

2. Asthma
• Asthma is a chronic inflammatory disorder of the
airways which presents as
– recurrent episodes of wheezing
– breathlessness
– chest tightness
– cough
• It is characterized by bronchial hyperreactivity
with variable airflow obstruction which is often
reversible either spontaneously or with therapy.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

3. Acute severe asthma
• An exacerbation of asthma is characterized by
worsening of one or more of the asthma
symptoms (cough, wheezing, chest tightness,
dyspnea), leading either to increased need for
rescue medications or hospitalization
• These exacerbations may range from mild to
life threatening.
Lung India. 2015 Apr;32(Suppl 1):S3-S42.

4. • Exacerbations represent a change from the
patients usual status that is suffficient to
require a change in treatment.
• They can occur in patients with an existing
diagnosis or it could be the first presentation
of asthma.
• They occur in response to an external agent or
due to poor adherence with controller
medication.
Curr Opin Allergy Clin Immunol. 2017 Apr;17(2):99-103.

5. Risk factors
• Patients developing frequent exacerbations
may have one or more of the following risk
factors:
• Previous history of mechanical ventilation.
• Hospitalization in the previous 1 year.
• Not currently on inhaled steroids.
Curr Opin Allergy Clin Immunol. 2017 Apr;17(2):99-103.

6. • Use of >1 canister/month on inhaled SABA.
• Need of 3 or more classes of asthma
medication
• Poor compliance
• History of psychiatric illness or drug abuse
• Lack of social support
• Presence of co-morbidities

7. NEED FOR ASSESSING SEVERITY
• As an exacerbation of asthma may range from
a mild episode to a life threatening episode,
the management may vary.
• Hence a need arises to classify the
exacerbation according to severity, so that
those requiring aggressive measures are
identified earlier and managed.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

8. HOME MANAGEMENT OF AEBA
• Patients of asthma, who are currently
experiencing increase in symptoms, suggestive
of an exacerbation , can assess their peak
expiratory air flow and act accordingly.
• A wright’s peakflowmeter, a hand held device
can be used to to assess peak flow objectively.

9. WRIGHTS PEAKFLOWMETER

12. SEVERE ASTHMA
ANY TWO OF THE FOLLOWING:
Symptoms:
Inability to complete sentences
Agitation
Signs:
Use of accessory muscles
• Respiratory rate >30/min Heart
rate >110/min
• Pulsus paradox >25 mmHg
• Silent chest
• PEF <60% of predicted or
personal best
• PaO2 <60 mmHg or SpO2 ≤92%*
• These patients are best managed
in the emergency department.
LIFE THREATENING ASTHMA
PRESENCE OF ANY ONE
QUALIFIES AS LIFE THREATENING
EXACERBATION:
• Alteration in mental status
• Orthopnea
• Cyanosis
• Paradoxical breathing
• PaCO2 >40 mmHg with
worsening pH
• Heart rate <60/min (excluding
drug related bradycardia)
• These patients are best
managed in an ICU setting, as
they may need monitoring
and mechanical ventilation
Lung India. 2015 Apr;32(Suppl 1):S3-S42

13. NON SEVERE ASTHMA
• An exacerbation that does not satisfy the
criteria of either severe or life threatening
asthma is classified as non severe
exacerbation
• These patients are to be managed in the out
patient setting.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

14. Lung India. 2015 Apr;32(Suppl 1):S3-S42.

15. Curr Opin Allergy Clin Immunol. 2017 Apr;17(2):99-103

16. Curr Opin Allergy Clin Immunol. 2017 Apr;17(2):99-103

17. Differential diagnosis
• Acute exacerbation of COPD
• Acute decompensated heart failure
• Pulmonary thromboembolism
• Pneumothorax
• Panic attacks
• Foreign body inhalation.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

18. Initial evaluation
• History of medications currently being used
• Compliance with asthma medication
• Presence of comorbidities
• Clinical signs signifying a severe exacerbation

19. • The current PEF is measured and a PEF value
less than 60% of predicted (or personal best)
is an indication for referral to emergency
department.
• SpO2<92% signifies a severe exacerbation
• No additional laboratory investigations are
required for non-severe exacerbation
Lung India. 2015 Apr;32(Suppl 1):S3-S42

20. • ABG analysis should be done when SpO2< 92%
• Patients should be investigated to rule out an
alternate diagnosis, if clinically indicated
(complete blood count, electrolytes,
creatinine, urea, electrocardiogram, chest
radiograph, echocardiogram and others).
Lung India. 2015 Apr;32(Suppl 1):S3-S42

21. ROLE OF RADIOGRAPHY
• To look for complications , like
• Pneumonia
• Pneumonathorax
• When diagnosis itself is doubtful.
• When patient is an iv drug abuser,
immunosuppressed, chronic lung disease.

22. GOALS OF MANAGEMENT
• The goals of managing acute exacerbation of
asthma include
• Adequate oxygenation
• Relief of symptoms
• Reversal of bronchial obstruction
• Prevention of the next episode of
exacerbation.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

23. OXYGEN
• Routine oxygen use is not recommended for
all patients with acute exacerbation of
asthma.
• Oxygen can be supplemented in those with
hypoxia ( SpO2 < 92%).
Thorax. 2011 Nov;66(11):937-41.

24. BRONCHODILATORS
• Relief of symptoms can be achieved by the
use of inhaled bronchodilators.
• SABA are the first-line agents used due to
their rapidity of action.
• Salbutamol is the most commonly used.
• Continuous (2.5 mg salbutamol every 15
min, or >4 nebulization per hour)
nebulization is better than intermittent (2.5
mg salbutamol every 20 min, or ≤3
nebulization per hour) nebulization .
Lung India. 2015 Apr;32(Suppl 1):S3-S42

25. BRONCHODILATORS
• Subsequently dose of nebulized salbutamol
should be 2.5 mg every 2-4 h depending on
the clinical response.
• Combination of ipratropium bromide with
salbutamol produces better bronchodilation
than either drug alone. Ipratropium (500 μg
once then 250 μg q4-6 h) should be used in all
patients with severe exacerbations of asthma.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

26. BRONCHODILATORS
• MDI with a spacer device is as effective as
nebulizer in the management of acute asthma
.
• In patients unable to use MDI with spacer,
drugs can be delivered via a nebulizer.
• Once stabilized patient should be switched
over to spacer from nebulizer.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

27. BRONCHODILATORS
• Formoterol has no added advantage over
salbutamol, hence it is not recommended for
routine use in acute asthma.
Ann Allergy Asthma Immunol. 2010 Mar;104(3):247-52.

28. CORTICOSTEROIDS
• Systemic glucocorticoids should be used in all
patients with severe acute asthma.
• Oral route is as effective as parenteral route
except in very sick patients.
• Daily doses of glucocorticoids equivalent to
30-40 mg of prednisolone or equivalent are to
be used.
Cochrane Database Syst Rev. 2001;(1):CD002178

29. CORTICO…
• Systemic steroids can be stopped without
tapering if given for less than 3 weeks.
Lancet. 1993 Mar 20;341(8847):772.

30. CORTICOSTEROIDS
• In non-severe exacerbations, patients should
be initially managed with increase in dose of
inhaled SABA If there is no response in 1 h,
oral prednisone 30-40 mg once a day for 5-7
days should be started.
• ICSs do not provide any additional benefit
when used along with systemic
corticosteroids.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

31. CORTICOSTEROIDS
• The dose of inhaled steroids (in patients
already on inhaled steroids) should be hiked
up for 2-4 weeks at discharge from ED in
addition to oral steroids.
.
Cochrane Database Syst Rev. 2012 Dec 12;12:CD002316.

32. MAGNESIUM
• There is no role of intravenous or inhaled
magnesium sulfate in routine management of
acute exacerbation of asthma.
• Intravenous magnesium sulfate as a single
dose of 2 gm over 20 min may be used in
exceptional situations in those with severe
asthma not responding to conventional
measures.
Curr Opin Pulm Med. 2008 Jan;14(1):70-6.

33. LEUKOTRIENE RECEPTOR
ANTAGONISTS
• Limited evidence exists to support a role for
either oral or intravenous Leukotriene
Receptor Antagonists in acute exacerbation of
bronchial asthma.
Thorax. 2011 Jan;66(1):7-11.

34. ANTIBIOTICS
• Antibiotics should not be routinely used in
acute asthma except in demonstrable
bacterial infection with features such as
• Fever
• Purulent sputum
• Radiographic evidence of pneumonia.
http://www.lungindia.com/text.asp?2012/29/6/27/99248

35. HELIOX
• Heliox- a mixture of helium and oxygen
• Theoretically reduces the work of breathing by
reducing airway resistance by creating laminar
air flow.
• However a systematic review of studies
comparing heliox with air-oxygen suggests
there is no role for this intervention in routine
care.

36. HELIOX
• It may be considered in patients who do not
respond to standard therapy.
Manthous CA, Morgan S, Pohlman A. Heliox in the
treatment of airflow obstruction: A critical review of the literature.
Respir Care 1997

37. PARENTERAL BETA AGONISTS
• Routinely not used.
• Because their efficacy is less and side effects
are more pronounced.

38. EPINEPHRINE
• It can be used when patient is having
anaphylactic reaction or when not able to take
nebulized bronchodilators
• 0.3 to 0.5 mg s/c or i.m ( 1:1000) can be
given.

39. TERBUTALINE
• 0.25 mg s/c every 20 minutes for 3 times can
be tried in those not responding to standard
therapies ( terbutaline and epinephrine should
not be given together).

41. MEDICATION DOSE
SALBUTAMOL ( NEBULIZER SOLUTION)
( 0.63 mg/1.25 mg/2.5 mg/5 mg)
2.5 mg to 5 mg every 20 minutes for 3
doses,then 2.5 mg to 10 mg every 1 to 4
hours. OR 10 to 15 mg continuously.
SALBUTAMOL ( MDI) – 90 mcg/puff 4 TO 8 puffs every 20 minutes up to 4 hours.
LEVOSALBUTAMOL ( NEBULIZER )
(0.63/1.25)
1.25 TO 2.5 mg every 20 minutes for 3 doses
Then 1.25 to 2.5 mg once every 1 to hours.
LEVOSALBUTAMOL (45 MCG/PUFF) 4 TO 8 puffs every 20 minutes up to 4 hours
TERBUTALINE ( S/C OR I/M) 0.25 mg every 20minute for 3 doses s/c or i/m
EPINEPHRINE 1:1000 ( 1mg/ml) 0.3 mg every 20 minutes for 3 doses
subcutaneously or intramuscularly.

42. ROLE OF NIV
• Evidence regarding the role of NIV in asthma is
weak.
• A systematic review identified five studies
involving 206 participants with acute severe
asthma treated with NIV or placebo.
• Two studies found no difference in need for
intubation but one study identified fewer
admissions in the NIV group

43. ROLE OF NIV
• Given the small size of the studies , no
recommendation is offered.
Respir Care. 2010 May;55(5):536-43.
Cochrane Database Syst Rev. 2012 Dec 12;12:CD004360.

44. INDICATIONS OF MECHANICAL
VENTILATION
• The absolute indications of MV in severe acute
asthma are
• Coma
• Respiratory or cardiac arrest
• Refractory hypoxemia
Lung India. 2015 Apr;32(Suppl 1):S3-S42

45. INDICATIONS OF…
• Relative indications include
• Inadequate response to initial management
• Hypercapnia
• Fatigue,
• Somnolence and
• Cardiovascular compromise.
Lung India. 2015 Apr;32(Suppl 1):S3-S42

46. VENTILATOR SETTINGS IN AEBA
Lung India. 2015 Apr;32(Suppl 1):S3-S42

47. CRITERIA FOR DISCHARGE
• A patient with severe acute asthma is considered
fit for discharge when
• He/she is able to return to the previous state of
health and in general should be clinically stable
for at least 24 hours.
• The patient should be able to eat and get
adequate sleep
• Should be able to comfortably use the inhaled
medication with requirement of inhaled
short-acting drugs no more than every 4 hours.

48. FOLLOW UP CARE
• Exacerbations often represent failures in chronic
asthma care, and hence all patients must be
followed up regularly by a health care provider
until symptoms and lung function return to
normal.
• Take the opportunity to review:
• Modifiable risk factors for exacerbations, e.g.
smoking
• Understanding of purposes of medications, and
inhaler technique skills

49. FOLLOW UP…
• Review and revise written asthma action plan
• Discuss medication use, as adherence with ICS
and OCS may fall after discharge.
• Comprehensive post-discharge programs that
include :
• optimal controller management
• Inhaler technique
• Self-monitoring written asthma action plan and
regular review.

50. WRITTEN ASTHMA ACTION PLAN