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Acute Asthma Exacerbation

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Acute Asthma Exacerbation

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Immediate
1. ABCs a. Airway: is patient able to talk? If not: head-tilt, chin-lift or jaw thrust +/- adjunct airway if unconscious b. Breathing: RR & O2 saturation i. Supplemental oxygen ii. Give bronchodilator (salbutamol; Ventolin) c. Circulation: i. Pulse, BP ii. IV line, keep open with saline and take blood sample CBC, U&E, blood culture d. Level of consciousness

History & Examination


History
HPI: 1. Dyspnea a. Duration b. Onset (triggers) c. Progression d. Severity (grade it) e. Associated: fever, cough, sputum (color, amount), hemoptysis, wheezing, hyperventilation, hoarseness, chest pain 2. Asthma: a. Duration of asthma b. Follow-up c. Hospitalization d. ICU admission (previous intubation) e. Inhaler refills f. Attacks per month g. Night symptoms h. Current medications (corticosteroids, oxygen etc) & compliance 3. Risk factors/Triggers: recent URTI, allergies, smoking, exercise, aspirin, occupational 4. Other: pregnancy

Examination
1. Vital signs: tachycardia, tachypnea, fever? severe: tachycardia >130, pulsus paradoxus 2. General appearance: drowsiness, cyanosis, respiratory distress (use of accessory muscles), inability to speak 3. Chest examination:

a. Inspection: hyperinflation b. Auscultation: biphasic wheezes, severe: silent chest

Investigations
1. Blood: a. CBC: WBC b. U&E 2. ABGs: should be hyperventilation picture (respiratory alkalosis), if acidosis = pending respiratory failure 3. CXR: determine extent of infection if present, exclude pneumothorax 4. PEFR: prolonged; peak flow, FEV1 5. Blood & sputum cultures

Management
1. 2. 3. 4. 5. 6. 7. Admit 1st line: Ventolin (albuterol) Atrovent (ipratropium) 2nd line: Systemic steroids (# in pregnancy) 3rd line: theophylline (cardiac toxicity), magnesium sulphate Antibiotics (if infection suspected) If no improvement: consider ICU admission & intubation

Things You Must Know


1. Classifying severity: 33, 92 CHEST a. Life-threatening: i. PEFR <33% of predicted ii. O2 saturation <92% iii. Cyanosis iv. Hypotension v. Exhaustion vi. Silent chest vii. Tachycardia b. Severe: i. PEFR <50% ii. RR >25 iii. PR >110 c. Moderate: PEFR <75% d. Mild: PEFR >75%

History, P/E (HR, RR, O2 sat, use of accessory muscles, auscultation), tests (PEF, ABGs) 1) Supplemental oxygen (until O2 sat >90%) 2) Inhaled B-agonist for 1 hour 3) Systemic steroids (if no response, on oral steroids or very severe)

Initial Assessment

Initial Treatmant

P/E, O2 saturation, PEF

Reassess in 1 hour

Moderate episode: -Moderate symptoms, PEF 60-80%

Severe episode: -Severe symptoms at rest, PEF <60% -Hx of risk factors for near fatal asthma -No improvement with initial Rx

Continue above treatment for 1-3 hrs

-Oxygen, inhaled B-agonist, systemic steroids -IV magnesium sulphate

Reassess after 1-2 hours

Good response: - Sustained response - Normal P/E - PEF >70%, O2 Sat >90%

Incomplete response: - Risk factors - Mild-moderate signs - PEF <60% - O2 sat not

Poor response: - Risk factors - Severe symptoms - PEF <30% - PO2 <65, PCO2 >45

Discharge

Admit & monitor

Admit to ICU & consider mechanical ventilation

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