The document discusses bronchial asthma, including its pathophysiology, causes, symptoms, diagnosis and management in the emergency department setting. It covers assessing severity, providing treatments like bronchodilators and steroids, determining need for ventilation or ICU admission, and discharge criteria. The goal of ED treatment is to reverse airflow obstruction through oxygen, inhaled bronchodilators, and steroids to relieve inflammation.

1. Bronchial Asthma
DR. A. SAJJAD PATHAN MBBS MHA
DEPARTMENT OF ACCIDENT & EMERGENCY MEDICINE
KOKILABEN DHIRUBHAI AMBANI HOSPITAL & MEDICAL
RESEARCH INSTITUTE, MUMBAI

2. Objectives
 Review the Diagnosis & ED Management of
Bronchial Asthma

3. Introduction
Reactive airway disease
 Airway Inflammation
 Bronchial Hyperresponsiveness/Narrowing
 Reversible airflow obstruction

4. Pathophysiology
Reduction in airflow diameter
 Smooth Muscle contraction
 Vascular Congestion
 Bronchial wall edema
 Thick secretions

5. Causes
Common Triggers include respiratory infections,
environmental allergens, change in weather, and
exercise. In some cases it is associated with NSAID/ASA
use, beta blocker use, and emotional stressors.
Risk Factors for Death
 Previous ICU admission/intubation
 >2 hospitalizations/ >3 ED visits in last year
 > 2 canisters of SABA usage
 Poor socio economic status
 Drug Abusers
 Other Co morbidities

6. Symptoms/Exam
 Triad of Dyspnea, Wheezing, and Cough.
 Early in the attack: Chest Tightness
 Wheezes may be absent at both ends of spectrum
 As the severity progresses:
 Wheezing becomes apparent
 Expiration is prolonged
 Use of accessory muscles become evident (Diaphragmatic
Fatigue)
 Silent Chest “No Wheeze” means think about the worst
 Pulses Paradoxus & Paradoxical Respiration
 Change in Mental Status

7. Differential
 “All that wheezes is not asthma”
 CHF
 Upper Airway Obstruction
 COPD
 Aspiration
 Bronchiectasis

8. Classification of Severity
 Mild Dyspnea with only activity
PEF > 70 % predicted/personal best
 Moderate Dyspnea interferes with or limits usual
activity
PEF > 40 – 69 %
 Severe Dyspnea at rest, interferes with
conversation
PEF < 40 %
 Life Threatening Severe + Perspiration
PEF < 25 %
(Source: Tintinalli, 2010)

9. Diagnosis & Patient Monitoring
 Best Initial Test: PEFR
 Most Accurate Test: FEV1 pre & post Broncho-
dilation (NAEPP Report 3, 2007)
“These tests provide rapid, objective assessment of patients
and serves as a guide to the effectiveness of therapy”
(Tintinalli, 2010)
 Pulse Oximetry: To assess and monitor oxygen
saturation during treatment
 Capnography is the non-invasive method of choice for
monitoring ventilation

10. ABG in Asthmatics
 ABG is not indicated in most mild to moderate
cases. It does not predict clinical outcome and
should not supersede clinical findings to
determine the need for intubation
Severity pH PCO2 PO2
Mild Increased Decreased Normal
Moderate Normal Normal Normal/
Decreased
Severe Decreased Increased Decreased

11. ABG in Asthmatics

12. Investigations
 Routine CXR is not indicated: Would be normal or would
show hyperinflation
 Is indicated if there is suspicion of pneumonia, CHF,
pneumothorax, or other medical concern
 Routine CBC is not indicated: Slight Leucocytosis sec. to β2
agonist or steroid use
 Theophylline levels
 ECG: May show RV Strain, non specific ST-T abnormalities
 Cardiac Monitoring for all elderly and/or cardiac patients

13. Treatment
 The Goal of treatment of acute asthma in ED is “to
reverse airflow obstruction”
 Use of β2 agonist
 Adequate oxygenation
 Relieve inflammation

14. Treatment
 O2 Therapy to keep saturation > 90%
 Inhaled β2 –agonist
 Albuterol or levo-albuterol (no specific advantage
proven)
 Continuous or intermittent
 By handheld MDIs or nebulizer (drug delivery is
equivalent)
 Can combine with Ipratropium (Anticholinergics:
Alone is not a first line therapy)
 Parentral β2 agonist (Epinephrine/Terbutaline S/C) has
no proven advantage over aerosol

15. Treatment
 Systemic Steroids:
 Oral or IV equally effective
 Requires 4 hours to show effect so administer early
 Decreases the need for hospitalization and subsequent
relapses
 Patients should continue oral therapy for 3 – 10 days
 Oral burst (40 – 80 mg ) or IV Prednisolone 1-2 mg/kg /
d; IV Methyprednisolone (1 mg/kg qid)
 No known advantage for higher doses

16. Treatment
 Magnesium Sulfate IV in dose of 1- 2 gms over 30
mins is indicated in acute, very severe asthma with a
PEF <25%
 Heliox (80% Helium + 20% Oxygen) lowers airway
resistance and acts as an adjunct in care of severe
cases. (Insufficient data on whether its use can avert
intubations, ICU admissions, and improves
morbidity/lowers mortality)
 Antibiotics are only indicated if underlying
bacterial pneumonia is suspected

17. Treatment (What not to use)
 Theophylline: No longer used, infact dangerous with
β2 agonists. At levels >30 mg/ml , can cause
seizures and arrythmias
 Mast Cell Modifiers: Nedocromil or Cromolyn
 Leukotriene Modifiers: Zafirlukast/ zileuton.

19. Ventilation
 Initiate when there are s/o
acute ventilatory failure
 NPPV (NIV): The role of its use
in patients with severe asthma is
still uncertain
It may be helpful but not as well
as in CHF and COPD
Do not initiate in patients with
suspected pneumothorax

20. Mechanical Ventilation
 If Progressive hypercarbia and acidosis or mental
deterioration, intubate and ventilate.
 Inducing Agent: Ketamine is the preffered inducing
agent, do not use in elderly and patients with
potential for cardiac ischemia
 “Mechanical ventilation does not relieve the airflow
obstruction – it merely eliminates the work of
breathing and enables the patient to rest while the
airflow obstruction is resolved”

21. Mechanical Ventilation
• Goal: Maintenance of adequate oxygenation (>90%)
without the concern of normalizing the PCO2
• Achieved through “Controlled mechanical
hypoventilation or permissive
hypoventilation”
• Reduced frequency (12 or 14/min), low tidal volumes
(6 to 8 ml/kg) and prolonged expiratory phase.
• Provide deep sedation: Propofol is useful in such
cases but watch for hypotension
• NM blockers may be required but their use is
associated with post extubation muscle weakness.

22. Disposition & Follow Up
 Take into account
Subjective Measures: Resolution of wheezing,
improvement of air exchange, ptient opinion
Objective Measures: FEV1 or PEFR nomalization
Historical Factors: Compliance, ED visit history,
hospitalizations in past (Patients with a history of
relapse will have a relapse regardless of
management)

23. Disposition Checklist
 Good response: PEF > 70%, No Distress, Normal
PE  Goes Home:
 Inhaled SABA + Oral Steroids (5 – 7 Days)
 Teach MDI Technique, Emphasize use of spacer or
holding chamber
 Peak Flow Meter (Teach technique), Keep PEF Diary
 Arrange Close Follow Up in 1 - 4 weeks (Ideally 1
Week)

24. Disposition Checklist
 Incomplete Response:
PEF 40 – 69%
Admit to Ward: Oxygen, Inhaled SABA, Oral or IV
Steroids, Monitor vitals, PEF, SaO2
 Poor Response:
 PEF <40%, Severe symptoms, mental confusion and
agitation, PCO2 > 45
 Oxygen, Inhaled SABA, IV Steroids, Adjunct Therapy
 Intubation and Mechanical ventilation
 Admit in ICU