Acute Exacerbation of Asthma

Acute exacerbation of
Asthma
Definition:
GINA defines asthma as: An acute or subacute worsening of symptoms
and lung function from the patient’s usual status. Occasionaly which
may be the initial presentation of asthma itself.
Clinically, acute exacerbations or “Flare up” areepisodes of progressive

increase in the shortness of breath, cough, wheeze, or chest tightness
or a combination of these symptoms.
Assesment of exacerbation
• A breif focused history and relevant physical examination should be
conducted concurruntly with the promp initiation of therapy, and
findings should be documented.
• Assesment is done at first look (static) and as a comparison with
previous examination findings to look for patient’s response to
therapy (dynamic).
History
• Timing of onset and cause of the present exacerbation should be
determined.
• Severity of the asthma symptoms
• Any symptoms of anaphylaxis.
• Any risk factors of asthma related death.
• All current reliever and controller medications, including dose and
devices prescribed, adherence pattern, any recent dose changes and
response to current therapy should be noted.
Physical Examination
• Signs of exacerbation severity and vital signs.
• (eg: level of conciousness, temperature, pulse rate, respiratory rate,
B.P., ability to complete sentences, use of accessory muscles,
wheeze)
• complicating factors (eg: anaphylaxis, pnumonia, pnumothorax)

• sings of alternative conditions that could explain acute
breathlessness(eg: cardiac failure, inhaled foreign body, pulmonary
embolism)
• objective easurements:
• pulse oximetry. Saturation levels
less than 90% in children suggest
the need of aggressive therapy
• PEF in patients older than 5 years.
Asthma Action plan
• All patients should be provided with a written asthma action plan
appropriate for theirlevel of asthma control and health literacy, so
that they know how to recognize and respond to worsening asthma.
• The written asthma action plan should include:

• the patient's usual asthma medications
• when and how to increase medications, and start OCS
• how to access medical care if symptoms fail to respond
Medication changes for action plan
• Increased frequency of inhaled reliever (low dose ICS formeterol or
SABA)
• add spacer for pMDI.
• advice to seek medical care immediately if they need SABA reliever again
within 3 hours.
• Increase controller
• Oral corticosteroid:
• 1-2 mg/kg/day upto 40mg/day usually for 3-5 days.
• Tapering not needed if OCS has been given for less than 2 weeks.
Asthma exacerbation severity grading:
Reviewing response:-
• Monitor patients closely and frequently during treatment
• titrate the treatmnet as per the response.
• transfer the patient to higher center if the patient is worsening or failing to respond
• decide on need for hospitalization depending on the clinical status, symptoms and
lung function, response to treatment, recent and history of exacerbation, ability to
manage at home.
• Before discharge, arrange ongoing treatment:
• Most patients should be prescribed regular controller therapy (or increase current
dose) to reduce the risk of further exacerbations.
• continue increased controller dose for 2-4 weeks and reduce reliever dosing to as-
needed dosing.
• recheck inhaler technique and adherence and provide interim asthma action plan.
• Arrange early follow up
• preferably within 1-2 working days for children.
• consider early referral for specialist advice after hospitalization, or for patients
with repeated presentation at Emergency department.
• patients who have had more than 1-2 exacerbations/year despite medium or
high dose ICS-LABA should be referred.
• All patients should be followed up regularly by a health care provider
until the symptoms and lung function return back to normal.
Treatment:-
1. Propped up position
2. Nebulize with Salbutamol and normal saline, repeat 3 times at 20 min
interval.
3. High flow oxygen is necessary in between the nebulization.
4. IV channel should be opened. Blood drawn for necessary investigations.
5. Inj. Hydrocortisone(5mg/kg), 6-8 hourly if no improvement.
5. Inj aminophylline(5mg/kg, loading dose, followed by 0.7mg/kg/hr)
6. Assess the patient’s ABG for PaO2. If still no improvement, ICU care
with/without mechanical ventilation.
Indications for mechanical ventilation:
Sources:-
• GINA 2021 Pocketbook.
• Nelson Textbook Of Pediatrics 21st edition.
• CMDT 2022

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Acute exacerbation of

Clinically, acute exacerbations or “Flare up” areepisodes of progressive

• complicating factors (eg: anaphylaxis, pnumonia, pnumothorax)

• The written asthma action plan should include:

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