Occupational asthma is a form of asthma caused or aggravated by substances in the workplace. Common triggers include isocyanates, animal antigens, anhydrides, and various dusts and metals. It is characterized by narrowing of the airways and breathing difficulties. While not all workers exposed will develop it, risk factors include a history of asthma/allergies, family history, smoking, and low fitness. Early diagnosis is important as occupational asthma can be prevented or potentially cured by avoiding exposure.

1. OCCUPATIONAL
asthma

2. WHAT IS ASTHMA?WHAT IS ASTHMA?
• Asthma is described as a diseaseAsthma is described as a disease
that causes narrowing of thethat causes narrowing of the
airways and constricted breathing.airways and constricted breathing.
• The usual symptoms of asthmaThe usual symptoms of asthma
include wheezing, shortness ofinclude wheezing, shortness of
breath, tightness in the chest etc.,breath, tightness in the chest etc.,
ranging in severity to a liferanging in severity to a life
threatening condition.threatening condition.

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Definition of
asthma
Asthma is a chronic inflammatory disorder of the airways
in which many cells play a role.
The chronic inflammation causes an associated increase in
airway hyperresponsiveness that leads to recurrent episodes
of wheezing, breathlessness, chest tightness and coughing
particularly at night or early morning.
These episodes are usually associated with widespread but
variable airflow obstruction that is often reversible either
spontaneously or with treatment.

4. WHATWHAT ISIS OCCUPATIONOCCUPATION ALASTHMA?ALASTHMA?
Occupational asthma is a form ofOccupational asthma is a form of
asthma in which the symptoms areasthma in which the symptoms are
caused or aggravated by the workplacecaused or aggravated by the workplace
environment. Unlike other forms ofenvironment. Unlike other forms of
asthma, occupational asthma isasthma, occupational asthma is
preventable and possibly curable ifpreventable and possibly curable if
diagnosed early.diagnosed early.

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6. What is OccupationalWhat is Occupational
Asthma?Asthma?
Some substances canSome substances can
cause allergies if youcause allergies if you
breathe them in. Theybreathe them in. They
are called sensitisers.are called sensitisers.
They can causeThey can cause
permanent damage topermanent damage to
your nose, throat andyour nose, throat and
lungs.lungs.

7. What Causes it?What Causes it?
• IsocyanatesIsocyanates
• Animal antigensAnimal antigens
• AnhydridesAnhydrides
• Paper dustPaper dust
• FluxesFluxes
• MetalsMetals
• FlourFlour
• Wood dustWood dust
• DrugsDrugs
Spray painters, foam & insulation workersSpray painters, foam & insulation workers
Laboratory animal workersLaboratory animal workers
Plastic industry workersPlastic industry workers
Librarians, bookkeeper, post office clerkLibrarians, bookkeeper, post office clerk
Electronic workersElectronic workers
Welders, metal plating workersWelders, metal plating workers
Bakers, millersBakers, millers
Carpenters, saw mill workersCarpenters, saw mill workers
Pharmaceutical workersPharmaceutical workers

8. What Causes it?What Causes it?

9. WHO MAY DEVELOPWHO MAY DEVELOP
WORKPLACE INDUCEDWORKPLACE INDUCED
ASTHMA?ASTHMA?• Certainly not all workers exposed to irritant chemicals, fumes,Certainly not all workers exposed to irritant chemicals, fumes,
dusts, allergens etc at their workplace will develop occupationaldusts, allergens etc at their workplace will develop occupational
asthma. A number of factors are known to increase the risk andasthma. A number of factors are known to increase the risk and
these include:these include:
– past history of asthma and/or allergy;past history of asthma and/or allergy;
– family history of asthma;family history of asthma;
– smoking; andsmoking; and
– low physical fitness.low physical fitness.
• Other factors such as respiratory infections and seasonalOther factors such as respiratory infections and seasonal
reactions to environmental allergens (pollens, mould spores) canreactions to environmental allergens (pollens, mould spores) can
make a worker more susceptible to the danger of air pollutants inmake a worker more susceptible to the danger of air pollutants in
the workplacethe workplace

10. PathophysiologyPathophysiology
• Hallmark is narrowing of bronchial airwayHallmark is narrowing of bronchial airway
diameter secondary to:diameter secondary to:
a. Smooth muscle contractiona. Smooth muscle contraction
b. Airway edemab. Airway edema
c. Respiratory vascular congestionc. Respiratory vascular congestion
d. Increase in airway secretionsd. Increase in airway secretions
e. Hypertrophy of basement membranee. Hypertrophy of basement membrane
• Other respiratory changes include:Other respiratory changes include:
a. Decrease in expiratory flow ratesa. Decrease in expiratory flow rates
b. Increased respiratory workload and muscleb. Increased respiratory workload and muscle
fatiguefatigue
c. Ventilation-perfusion mismatchc. Ventilation-perfusion mismatch
d. Arterial blood gas abnormalitiesd. Arterial blood gas abnormalities
e. Pulmonary hypertensione. Pulmonary hypertension

11. What is the Pathophysiology?What is the Pathophysiology?
• Trigger FactorTrigger Factor
• Mast cellMast cell
• Mediators :Mediators :
histamine,prostaglandin,leukotrienes,as well ashistamine,prostaglandin,leukotrienes,as well as
cytokines.cytokines.
• Inflammatory cellsInflammatory cells
• Sustained Inflammatory responseSustained Inflammatory response
• Contraction of airway smooth musclesContraction of airway smooth muscles
(Bronchoconstriction)(Bronchoconstriction)

12. Pathophysiology (Cont.)Pathophysiology (Cont.)
• Airway wall swelling (mucosal edema)Airway wall swelling (mucosal edema)
• Airway hyper responsivenessAirway hyper responsiveness
• Chronic changesChronic changes
• Hypertrophy of the smooth muscles, thickening ofHypertrophy of the smooth muscles, thickening of
the basement membranethe basement membrane
• Airway remodelingAirway remodeling
• There is good evidence that asthma occurs inThere is good evidence that asthma occurs in
families.families.

13. What are the Triggering Factors?What are the Triggering Factors?
• Domestic dust mitesDomestic dust mites
• Air pollutionAir pollution
• Tobacco smokeTobacco smoke
• Occupational irritantsOccupational irritants
• CockroachCockroach
• Animal with furAnimal with fur
• PollenPollen

14. Triggering Factors ( cont.)Triggering Factors ( cont.)
• Respiratory (viral)Respiratory (viral)
infectionsinfections
• Chemical irritantsChemical irritants
• Strong emotionalStrong emotional
expressionsexpressions
• Drugs ( aspirin, betaDrugs ( aspirin, beta
blockers)blockers)

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bronchial hyperresponsivenessSaAICSaAIC
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The clinical consequences of bronchial
hyperresponsiveness
include increased variation in airway caliber within and
between days
Exaggerated
bronchoconstrictor response to a
wide variety NON SPECIFIC
of exogenous stimuli (ex cold air, irritants....)
and
endogenous stimuli (ex physical exercise, laughter....)

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bronchial hyperresponsiveness
measurement
Stimuli
methacholine
histamine
………….
AMPc
hypotonic
hypertonic
cold air
physical exercise
………...
Effect
FEV1
smooth
muscle
contraction
Mechanism
direct
indirect

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inflammationinflammation
measurementmeasurement
MacrophageNeutrophil
s
Limphocyt
es
Eosinohils
Squamous
cells
Epithelial
cells
induced
sputum
brushing
bronchial biopsy
more invasive
less invasive

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inflammation
measurement
FeNO
Exhaled Breath Condensate
ATSERS
task force.....2005
ATSERS
recommendations.....2005
safe
simple

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bronchial asthma
many parameters. any correlations
inflammation
bronchial obstruction
symptoms
signs
hyperresponsiveness
compliance
allergy
quality of life
reliever drugs
environment
work
remodeling
exacerbation
drug adverse reactions
?
?
?
controller drugs

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patient report
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symptoms
3. Nat ura dei sintomi
3.1. Respiratori :
Tosse Si No ND
Espettorazione Si No ND
Oppressione toracica Si No ND
Sibili/fischi Si No ND
Difficolta’ respiratoria a riposo Si No ND
Difficolta’ respiratoria da sforzo Si No ND
Disfonia Si No ND
3.2. Generali :
Febbre Si No ND
Brividi Si No ND
Dolori muscolari o articolari Si No ND
Altri : …………………………………………………………………………………………………………………..
3.3. Rinite :
Ostruzione nasale Si No ND
Rinorrea Si No ND
Starnutazione Si No ND
Prurito nasale/ faringeo Si No ND
3.4. Congiuntivite :
Prurito oculare Si No ND Lacrimazione
Si No ND
Eritema congiuntivale Si No ND
3.5. Cutanei :
Orticaria / eritema cutaneo Si No ND
Eczema (delle mani) Si No ND
1. Cronologia dei sintomi respiratori
-Intervallo tra l’inizio dell’esposizione professionale e l’inizio dei sintomi : ……… mesi
- Intervallo tra l’inizio dei sintomi e il presente questionario : ……… mesi
- Intervallo tra l’ultima esposizione professionale e il presente questionario : ……… mesi
5. Relazione “lavoro-sintomi respiratori” :
- « Come sta dal punto di vista respiratorio nei giorni in cui lavora rispetto ai giorni in cui non lavora ?»:
Meglio Nello stesso modo Peggio
Se Peggio o Meglio, precisi (sono possibili piu’ risposte):
questionnaire
wheezing
breathlessness
chest tightness
coughing
...............

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Physical examination
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signs
wheezing
tachypnea
cyanosis
..............
Often normal Needs repeating

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airflow obstruction
spirometry
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One week
Peak Flow Meter
One second
edema etc.
smooth muscle
contraction

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bronchial obstruction
reversibilitySaAICSaAIC
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spontaneous
formoterol etc.
steroids
5 min
1 week
edema etc.
smooth muscle
contraction
Significant response = FEV1 increase > 12%

25. ClassificationClassification
• Mild intermittent asthmaMild intermittent asthma
a. Mild asthma symptoms once or twicea. Mild asthma symptoms once or twice
weeklyweekly
b. Nighttime asthma two or fewer timesb. Nighttime asthma two or fewer times
per monthper month
c. Pulmonary function tests are 80% orc. Pulmonary function tests are 80% or
more of predicted normalmore of predicted normal
d. PEF variability less than 20%d. PEF variability less than 20%

26. ClassificationClassification
• Mild persistent asthmaMild persistent asthma
a. Symptoms more than two times pera. Symptoms more than two times per
week but less than once per dayweek but less than once per day
b. Nighttime asthma more than two timesb. Nighttime asthma more than two times
per monthper month
c. Pulmonary function tests 80% or morec. Pulmonary function tests 80% or more
of predicted normalof predicted normal
d. PEF variability 20 to 30%d. PEF variability 20 to 30%

27. ClassificationClassification
• Moderate persistent asthmaModerate persistent asthma
a. Daily asthma symptoms with two ora. Daily asthma symptoms with two or
more exacerbations per weekmore exacerbations per week
b. Nighttime asthma more than once perb. Nighttime asthma more than once per
weekweek
c. Pulmonary function tests more 60 andc. Pulmonary function tests more 60 and
less than 80% predicted normalless than 80% predicted normal
d. PEF variability more than 30%d. PEF variability more than 30%

28. ClassificationClassification
• Severe persistent asthmaSevere persistent asthma
a. Continual symptoms with frequenta. Continual symptoms with frequent
exacerbationsexacerbations
b. Frequent nighttime asthmab. Frequent nighttime asthma
c. Pulmonary function tests 60% or lessc. Pulmonary function tests 60% or less
predicted normalpredicted normal
d. PEF variability more than 30%d. PEF variability more than 30%

29. Confirming the
diagnosis of
occupational asthma
• Specific challenge testsSpecific challenge tests
= international golden standard for diagnosis= international golden standard for diagnosis
of occupational asthmaof occupational asthma
• to prove the cause-effect relationshipto prove the cause-effect relationship
between the agent from the workplacebetween the agent from the workplace
and the asthmatic reaction in individualand the asthmatic reaction in individual
levellevel

30. TestsTests
• Pulmonary function tests; increase in FEVPulmonary function tests; increase in FEV11 afterafter
aa ββ--agonist or PEFagonist or PEF
• CBC: detect eosinophilia in atopic patientsCBC: detect eosinophilia in atopic patients
• IgEIgE
• Sputum exam: May show eosinophilia orSputum exam: May show eosinophilia or
Curschmann’s spiralsCurschmann’s spirals
• Wright peak flow measurementWright peak flow measurement
• Pulse oximetryPulse oximetry
• Chest filmChest film
• Arterial blood gas measurementArterial blood gas measurement

31. Occupational asthma,Occupational asthma,
diagnosticsdiagnostics
• Work related asthmatic symptomsWork related asthmatic symptoms
• Exposure to a sensitizing agent atExposure to a sensitizing agent at
workwork
• Cause-effect relationship between theCause-effect relationship between the
exposure material and asthmaexposure material and asthma
– Sensitization (skin prick tests/specific IgESensitization (skin prick tests/specific IgE
antibodies)antibodies)
– Positive provocation testPositive provocation test

32. Diagnostics ofDiagnostics of
occupational asthmaoccupational asthma
• PEF-surveillance at home andPEF-surveillance at home and
at the workplace always, ifat the workplace always, if
possiblepossible
– Positive finding supports the diagnosisPositive finding supports the diagnosis
– Negative finding does not exclude theNegative finding does not exclude the
diagnosisdiagnosis

33. Prerequirements forPrerequirements for
challenge testschallenge tests
1. Clinical picture fits with occupational1. Clinical picture fits with occupational
asthma, but the diagnosis has not yetasthma, but the diagnosis has not yet
been verifiedbeen verified
2. Asthma is stable. Inhaled steroid may be2. Asthma is stable. Inhaled steroid may be
used, stable dose every evening.used, stable dose every evening.
3. Differential diagnostics done.3. Differential diagnostics done.
4. No contraindications to challenge tests.4. No contraindications to challenge tests.

34. Prerequirements forPrerequirements for
challenge testschallenge tests
1. Clinical picture fits with occupational1. Clinical picture fits with occupational
asthma, but the diagnosis has not yetasthma, but the diagnosis has not yet
been verifiedbeen verified
2. Asthma is stable. Inhaled steroid may be2. Asthma is stable. Inhaled steroid may be
used, stable dose every evening.used, stable dose every evening.
3. Differential diagnostics done.3. Differential diagnostics done.
4. No contraindications to challenge tests.4. No contraindications to challenge tests.

35. Contraindications toContraindications to
challenge testschallenge tests
• Acute infectionsAcute infections
• Unstable asthma or some other diseaseUnstable asthma or some other disease
• Poor lung functionPoor lung function
• Facts, that prevent proper interpretation of theFacts, that prevent proper interpretation of the
challenge tests (e.g. non co-operating patient)challenge tests (e.g. non co-operating patient)
• Highly toxic or irritative substancesHighly toxic or irritative substances
• Anaphylactic or otherwise very strong reactionAnaphylactic or otherwise very strong reaction
to the challenge material in historyto the challenge material in history

36. Requirements, whenRequirements, when
performing challengeperforming challenge
teststests
• 24-hour follow up and facilities to treat24-hour follow up and facilities to treat
acute and late asthmatic ( and other)acute and late asthmatic ( and other)
reactionsreactions
• Aduquate challenge chamber and wellAduquate challenge chamber and well
trained stafftrained staff

37. Challenge chamberChallenge chamber
• Adequate ventilationAdequate ventilation
• Safety of the patientSafety of the patient
• Safety of the personnelSafety of the personnel
– exhaust ventilationexhaust ventilation
– easy to cleaneasy to clean
• Facilities for generation of dusts, vaporsFacilities for generation of dusts, vapors
and aerosols in controlled concentrationsand aerosols in controlled concentrations

38. Challenge test withChallenge test with
active agentactive agent
• Commercial allergen extractsCommercial allergen extracts
• Tests simulating work tasksTests simulating work tasks
(patient handles the material from(patient handles the material from
workplace)workplace)
– Individual planning: challenge materia,Individual planning: challenge materia,
concentration, duration of test e.g.concentration, duration of test e.g.
– Occupational hygienist/chemistOccupational hygienist/chemist
consultations when neededconsultations when needed
– Controlled concentrationsControlled concentrations

39. Criteria for aCriteria for a
positive provocationpositive provocation
test reactiontest reaction
• minimum 20% FEVminimum 20% FEV11 /PEF decrease/PEF decrease
compared to baseline before exposurecompared to baseline before exposure
and to control testand to control test
• tests with allergen extractstests with allergen extracts
– minimum 15% decrease in immediateminimum 15% decrease in immediate
reactionreaction
(during one hour after challenge)(during one hour after challenge)

40. Criteria for aCriteria for a
positive provocationpositive provocation
test reactiontest reaction
• Findings supporting positive challenge test:Findings supporting positive challenge test:
– symptomssymptoms
– wheezing raleswheezing rales
– dose-responsedose-response
– increase in hyperreactivityincrease in hyperreactivity
– recovery of the reaction on the following dayrecovery of the reaction on the following day
– increase in exhaled nitric oxide?increase in exhaled nitric oxide?
– increase in peripheral resistance (impulseincrease in peripheral resistance (impulse
oscillometry)oscillometry)

41. Diagnostics ofDiagnostics of
occupational asthmaoccupational asthma
• Provocation tests not necessaryProvocation tests not necessary
– typical work related asthmatic symptomstypical work related asthmatic symptoms
– exposure to a known sensitizerexposure to a known sensitizer
– sensitization confirmedsensitization confirmed
– asthma and work related bronchoconstrictionasthma and work related bronchoconstriction
confirmed (asthma diagnosis done, PEF-confirmed (asthma diagnosis done, PEF-
surveillance at home and at the workplacesurveillance at home and at the workplace
typical for occupational asthma)typical for occupational asthma)

42. Procedures afterProcedures after
diagnosing occupationaldiagnosing occupational
asthmaasthma
• Statements neededStatements needed (medical certificates,(medical certificates,
Announcement of a new occupational disease to theAnnouncement of a new occupational disease to the
Register of Occupational Diseases as well to localRegister of Occupational Diseases as well to local
officials in Finland e.g.)officials in Finland e.g.)
• Stopping/minimizing exposure at theStopping/minimizing exposure at the
workplaceworkplace
• Treatment and follow up of asthmaTreatment and follow up of asthma
Aim:Aim: To discontinue exposure in order toTo discontinue exposure in order to
prevent the disease from worsening/gettingprevent the disease from worsening/getting
chronic or make it possible for the disease tochronic or make it possible for the disease to
heal totallyheal totally

43. Procedures after diagnosingProcedures after diagnosing
occupational asthmaoccupational asthma
How to discontinue/minimizeHow to discontinue/minimize
exposure?exposure?
• Changing agents used in the workplaceChanging agents used in the workplace
• Changing work tasks/working area/environmentChanging work tasks/working area/environment
(replacement in another kind of work task or working(replacement in another kind of work task or working
environment)environment)
• Changing the work tasksChanging the work tasks
• Restrictions to the workerRestrictions to the worker
• Use of respiratory protective deviceUse of respiratory protective device
• Re-education to another occupation ( in FinlandRe-education to another occupation ( in Finland
legally set that the insurance company of thelegally set that the insurance company of the
employer is responsible for re-education)employer is responsible for re-education)
• RetirementRetirement

44. Differential DiagnosisDifferential Diagnosis
• Upper respiratory obstructionUpper respiratory obstruction
• Bronchitis/pneumonia/bronchilolitisBronchitis/pneumonia/bronchilolitis
• Tumor/neoplasmTumor/neoplasm
• Pulmonary embolismPulmonary embolism
• Congestive heart failureCongestive heart failure
• Vocal cord dysfunctionVocal cord dysfunction
• Viral lower respiratory tract infectionViral lower respiratory tract infection

45. TreatmentTreatment
Mild intermittent asthmaMild intermittent asthma
a. No daily medication for long-terma. No daily medication for long-term
controlcontrol
b. Short-acting: bronchodilatorb. Short-acting: bronchodilator
(inhaled(inhaled ββ2-agonist) as needed for2-agonist) as needed for
symptomssymptoms

46. TreatmentTreatment
Mild persistent asthmaMild persistent asthma
a. One of the following as a daily medicationa. One of the following as a daily medication
for long-term control:for long-term control:
1. Anti-inflammation medication (inhaled1. Anti-inflammation medication (inhaled
Corticosteroid 200-500Corticosteroid 200-500μμgg
2. Sustained-release Theophylline2. Sustained-release Theophylline
3. Disodium cromoglycate3. Disodium cromoglycate
4. Nedocromil sodium4. Nedocromil sodium
b. Short-acting: inhaledb. Short-acting: inhaled ββ2-agonist2-agonist

47. TreatmentTreatment
Moderate persistent asthmaModerate persistent asthma
a. Daily medication for long-term contrala. Daily medication for long-term contral
1. Inhaled Corticosteroid 500-8001. Inhaled Corticosteroid 500-800μμgandgand
long-acting bronchodilator (long-actinglong-acting bronchodilator (long-acting
inhaledinhaled ββ2-agonist, sustained-release2-agonist, sustained-release
Theophylline, orTheophylline, or long-actinglong-acting ββ2-agonist2-agonist
tablettablet
b. Short-acting: inhaledb. Short-acting: inhaled ββ2-agonist as2-agonist as
needed for symptomsneeded for symptoms

48. TreatmentTreatment
Severe persistent asthmaSevere persistent asthma
a. Daily medications for long-term controla. Daily medications for long-term control
1. Inhaled Corticosteroid 800-20001. Inhaled Corticosteroid 800-2000 μμgg
2. Long-acting2. Long-acting ββ2-agonist, sustained-2-agonist, sustained-
release Theophylline, or long-actingrelease Theophylline, or long-acting
ββ2-agonist tablets2-agonist tablets
3. Corticosteroid tablets or syrup3. Corticosteroid tablets or syrup
b. Short-acting: inhaledb. Short-acting: inhaled ββ2-agonist as2-agonist as
needed for symptomsneeded for symptoms

49. How to Control ExposureHow to Control Exposure
EmployerEmployer
• Minimise ExposureMinimise Exposure
• Provide informationProvide information
• Provide trainingProvide training
• Supply PPESupply PPE
• Supply ventilationSupply ventilation
• Comply with the lawComply with the law
EmployeeEmployee
• Be aware of asthmaBe aware of asthma
• Take care withTake care with
substancessubstances
• Use PPEUse PPE
• Maintain PPEMaintain PPE
• Report symptomsReport symptoms

50. OccupatiOnal asthmaOccupatiOnal asthma
checklistchecklist
• Remember, if you have trouble withRemember, if you have trouble with
wheezing, coughing or shortness of breath atwheezing, coughing or shortness of breath at
work, you could have occupational asthma:work, you could have occupational asthma:
• Consult your physician. He or she may suggest aConsult your physician. He or she may suggest a
pulmonary function test.pulmonary function test.
• See your work supervisor for details about potentialSee your work supervisor for details about potential
hazards in your work environment.hazards in your work environment.
• Have the tests and evaluation required to prove theHave the tests and evaluation required to prove the
suspected occupational asthma and its cause.suspected occupational asthma and its cause.
• Seek your physician's advice about therapy forSeek your physician's advice about therapy for
occupational asthma.occupational asthma.

51. Emergency boxEmergency box
Treatment of severe asthmaTreatment of severe asthma
At homeAt home
• The patient is assessed. Tachycardia, a highThe patient is assessed. Tachycardia, a high
respiratory rate and inability to speak in sentencesrespiratory rate and inability to speak in sentences
indicate a severe attack.indicate a severe attack.
• If the PEF is less than 150L/min (in adult), anIf the PEF is less than 150L/min (in adult), an
ambulance should be called. (All doctors should carryambulance should be called. (All doctors should carry
peak flow meters.)peak flow meters.)
• Nebulized salbutamol 5 mg or terbutaline 10 mg isNebulized salbutamol 5 mg or terbutaline 10 mg is
administered.administered.
• Hydrocortisone sodium succinate 200 mg i.v. is given.Hydrocortisone sodium succinate 200 mg i.v. is given.
• Oxygen 40-60% is given if available.Oxygen 40-60% is given if available.
• Prednisolone 60 mg is given orally.Prednisolone 60 mg is given orally.

52. Emergency boxEmergency box
At hospitalAt hospital
• The patient is reassessed.The patient is reassessed.
• Oxygen 40-60%is given.Oxygen 40-60%is given.
• The PEF is measured using a low-reading peak flow meter, as an ordinaryThe PEF is measured using a low-reading peak flow meter, as an ordinary
meter measures only from 60L/min upwards. Measure Ometer measures only from 60L/min upwards. Measure O22 saturation with asaturation with a
pulse oximeter.pulse oximeter.
• Nebulized salbutamol 5 mg or terbutaline 10 mg is repeated andNebulized salbutamol 5 mg or terbutaline 10 mg is repeated and
administered 4-hourly.administered 4-hourly.
• Add nebulized ipratropiun bromide 0.5 mg to nebulizedAdd nebulized ipratropiun bromide 0.5 mg to nebulized
salbutamol/terbutaline.salbutamol/terbutaline.
• Hydorcortisone 200 mg i.v. is given 4-hourly for 24 hours.Hydorcortisone 200 mg i.v. is given 4-hourly for 24 hours.
• Predisolone is continued at 60 mg orally daily for 2 wks.Predisolone is continued at 60 mg orally daily for 2 wks.
• Arterial blood gases are measured; if the PaCOArterial blood gases are measured; if the PaCO22 is greater than 7 kpa,is greater than 7 kpa,
ventilation should be considered.ventilation should be considered.
• A chest x-ray is performed to exclude pneumothorax.A chest x-ray is performed to exclude pneumothorax.
• One of the following intravenous infusions is given if no improvement isOne of the following intravenous infusions is given if no improvement is
seen:seen: salbutamol 3-20salbutamol 3-20 μμg/min, or terbutaline 1.5-5.0g/min, or terbutaline 1.5-5.0 μμg/min.g/min.