Managing Acute Asthma Exacerbations

1. Managing Acute Asthma Exacerbations Cathryn Caton, MD, MS

2. Objectives • Review assessment of patients with asthma exacerbation • Review components of brief history and physical exam • Describe findings associated with mild, moderate and severe exacerbations • Treatment of moderate and severe exacerbations • Review discharge planning for patients with an asthma exacerbation

3. Assessment of Asthma Exacerbation • In ER – evaluate and triage patients immediately • Start treating immediately • Obtain brief, focused history • Focused physical examination • Once initial treatment is completed, then do detailed history and physical exam

4. Brief History • Time of onset and potential causes of current exacerbations • Severity of symptoms compared with previous exacerbations • Current medications and time of last dose (asthma medications) • Estimation of number of times care sought for asthma related issues • Any prior episodes of LOC or intubation, and mechanical ventilation • Other potentially complicating illness – lung or cardiac; others that may be aggravated by systemic steroids

5. Brief Physical Exam • Assess severity of asthma exacerbation • Assess overall patient status – level of alertness, fluid status, presence of cyanosis, respiratory distress and wheezing • Identify possible complications – pneumonia or pneumothorax • Evaluate for upper airway obstruction • Don’t wait on labs to start therapy

6. Assessing severity of symptoms • Mild exacerbation • Moderate exacerbation • Severe exacerbation

7. Mild Exacerbation • Breathlessness while walking • Able to lie down • Talks in complete sentences • May be agitated • Increased respiratory rate • No accessory muscle use • Moderate wheezing, often only end expiratory • Pulse <100 • Peak flow 50-80% of predicted / personal best

8. Moderate Exacerbation • Breathlessness while talking • Prefers sitting • Talks in phrases • Usually agitated • Increased respiratory rate • Commonly uses accessory muscles • Loud wheezes throughout exhalation • Pulse 100-120

9. Severe Exacerbation • Breathlessness at rest • Sits upright • Talks in words • Usually agitated • Respiratory rate often >30/min • Usually uses accessory muscles • Wheezes usually loud throughout inhalation and exhalation • Pulse >120 • Peak flow <50% predicted / personal best

10. Respiratory Arrest Imminent • Drowsy or confused • Paradoxical thoracoabdominal movement • Absence of wheeze • Bradycardia

11. Treatment of Moderate Exacerbation • Inhaled Beta2 – agonists • Supplemental O2 to keep sats >90% • Oral systemic if no immediate response • Monitor for improvement in peak flow • Continue treatment for 1-3 hours as long as patients are showing signs of improvement • If peak flow >70% and response is sustained 60 mins after last treatment then D/C patient home

12. Treatment of Severe Exacerbation • Inhaled short acting Beta2–agonist + inhaled anticholinergic administered hourly or continuous • Supplemental oxygen • Systemic steroids • If Peak flow > 50% but < 70% patient should be admitted • Continue steroids either oral or IV • Monitor for improvement in peak flow

13. Treatment of Severe Exacerbation • Inhaled short acting Beta2–agonist + inhaled anticholinergic administered hourly or continuous • Supplemental oxygen • Systemic steroids • If peak flow remains less than 50%; drowsiness, confusion then admit to ICU • IV steroids • Possible intubation and mechanical ventilation • Consider use of magnesium sulfate and heliox-driven albuterol neb

14. When is it safe to discharge? • Significant improvement in symptoms • Significant improvement in peak flow – should be at least 70% of predicted / personal best

15. Discharge • Continue treatment with inhaled Beta2-agonist • Continue course of oral systemic steroid • Patient education • Review medication use • Review / initiate action plan • Recommend close medical follow up