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The Saudi Initiative for Asthma. On behalf of the SINA group Mohamed S. Al-Moamary, FRCP (Edin) FCCP King Abdulaziz Medical City-Riyadh King Saud bin Abdulaziz Uinversity for Health Scinces. June 2010. Asthma Diagnosis & Management . Enter presenter name Enter the presenter’s institute .

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the saudi initiative for asthma

The Saudi Initiative for Asthma

On behalf of the SINA group

Mohamed S. Al-Moamary, FRCP (Edin) FCCP

King Abdulaziz Medical City-Riyadh

King Saud bin Abdulaziz Uinversity for Health Scinces

June 2010

asthma diagnosis management

Asthma Diagnosis & Management

Enter presenter name

Enter the presenter’s institute

what is sina
What is SINA?
  • SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society
  • SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist.
  • International recommendations were customized to the local setting for asthma diagnosis and management
  • Directed to HCW dealing with asthma who are not specialists in the field.
purpose of sina
Purpose of SINA
  • To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians
where do you find sina
Where do you find SINA?
  • The SINA guideline was published in the Annals of Thoracic Medicine:

Al-Moamary MS, Al-Hajjaj MS, Idrees MM, Zeitouni MO, Alanezi MO, Al-Jahdali HH, Al Dabbagh M. The Saudi Initiative for asthma. Ann Thorac Med 2009;4:216-33

(www.thoracicmedicine.org):

  • The SINA guidelines booklet is available at: www.sinagroup.org
saudi thoracic society commitment
Saudi Thoracic Society commitment
  • The STS is committed to improve the care of asthma by a long term plan:
    • Periodic scientific meetings
    • Annual asthma meeting (since 2001)
    • Frequent asthma courses
    • Educational brochures
    • Publishing new and updated asthma guidelines
sina task force
SINA Task Force
  • Mohamed S. Al-Moamary (Head), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
  • Mohamed S. Al-Hajjaj, College of Medicine, King Saud University, Riyadh
  • Majdy M. Idrees, Military Hospital, Riyadh
  • Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh
  • Mohammed O. Alanezi, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
  • Hamdan H. Al-Jahdali, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
  • Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah
acknowledgment
Acknowledgment

The Saudi Initiative for Asthma group would like to thank the following reviewers :

  • Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa
  • Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada
  • Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada.
sina documents
SINA Documents
  • Published manuscript
  • Booklet
  • Electronic version
  • Slides kit
  • Flyers
  • Website: www.sinagroup.org
sections of sina
Sections of SINA
  • Epidemiology
  • Pathophysiology
  • Diagnosis
  • Medications
  • Approach to Management
  • Treatment Steps
  • Special Situations
  • Acute Asthma
prevalence
Prevalence
  • Prevalence of asthma has increased between 1986 – 1995

Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296

burden of asthma
Burden of Asthma
  • Asthma is among the most common chronic illnesses in Saudi Arabia
  • 53% had missed school or work (AIRKSA-2007)
  • 35% attempted Unconventional therapy (Al Moamary, ATM 2008)
  • 46% were controlled in Riyadh (AIRKSA-2007)
  • 36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008)
  • 48% were controlled in one center (Al Moamary, ATM 2008)
airksa report ministry of health
AIRKSA report (Ministry of Health)
  • 78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA)
  • 54 % of adults & 80% of kids reported ER over 12 months (AIRKSA)
  • 45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA)
  • 76 % of adults & 78% of kids never had spirometry(AIRKSA)
pattern of asthma treatment
Pattern of asthma treatment

Ann Thorac Med 2006;1:20-5

pathology of asthma
Pathology of Asthma

Inflammation

Airway Hyper-responsiveness

Airway Obstruction

Symptoms of Asthma

inflammation remodeling
Inflammation  Remodeling
  • Inflammation
  • Airway Hypersecretion
  • Subepithelial fibrosis
  • Angiogenesis
diagnosis history
Diagnosis - History
  • Episodic attacks:
    • Cough
    • Breathlessness
    • Wheezing
    • Nocturnal symptoms
  • Patient could be asymptomatic between attacks
  • co-existent conditions: GERD, rhinosinusitis.
physical examination
Physical Examination
  • Normal between attacks
  • Bilateral expiratory wheezing
  • Examination of the upper airways
  • Other allergic manifestations: e.g., atopic dermatitis/eczema
  • Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing
investigations
Investigations
  • Measurements of lung function:
    • Spirometry
    • Peak expiratory flow (PEF)
  • Normal Spirometry does not role out asthma
  • Spirometry is superior to PEF
clinical assessment
Clinical Assessment
  • Measurements of allergic status to identify risk factors (if indicated)
  • Chest X-ray is not routinely recommended
  • Routine blood tests are not routinely recommended
  • IgE measurement is indicated in severe cases
slide24

Level of Control:

  • Control: 20-24
  • Partial control: 16-19
  • Uncontrolled: < 16
differential diagnosis
Differential Diagnosis
  • Upper airway diseases
    • Allergic rhinitis and sinusitis
  • Obstructions involving large airways
    • Foreign body in trachea or bronchus
    • Vocal cord dysfunction
    • Vascular rings or laryngeal webs
    • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
    • Enlarged lymph nodes or tumor
  • Obstructions involving small airways
    • Viral bronchiolitis or obliterative bronchiolitis
    • Cystic fibrosis
    • Bronchopulmonary dysplasia
    • Heart disease
  • Other causes
    • Recurrent cough not due to asthma
    • Aspiration from swallowing mechanism dysfunction or GERD
differential diagnosis26
Differential Diagnosis
  • COPD (e.g., chronic bronchitis or emphysema)
  • Congestive heart failure
  • Pulmonary embolism
  • Mechanical obstruction of the airways (benign and malignant tumors)
  • Pulmonary infiltration with eosinophilia
  • Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors)
  • Vocal cord dysfunction
asthma in children 5 years
Asthma in children < 5 years
  • The diagnosis is challenging
  • Asthma must be distinguished from other causes of persistent and recurrent wheezing
  • The earlier the onset of a wheeze, the better the prognosis
  • A family history of atopy and asthma and maternal atopy are strongly associated with persistent childhood asthma
asthma in children 5 years28
Asthma in children < 5 years
  • Three categories of wheezing:
    • Transient early wheezing:
      • It outgrown in the first three years
      • It associated with prematurity and parental smoking.
    • Persistent early-onset wheezing:
      • Symptoms continue beyond the age of six
      • Associated with acute viral respiratory infections and have no evidence of atopy
    • Late-onset wheezing/asthma:
      • Symptoms persist into childhood and adult life.
      • Atopic background, often with eczema
asthma in children 5 years29
Asthma in children < 5 years
  • No tests can diagnose asthma with certainty.
  • Lung function testing is not very helpful
  • CXR may help to exclude structural abnormalities of the airway.
  • A trial of treatment with short-acting bronchodilators and inhaled corticosteroids (ICS) for at least 8 to 12 weeks may provide some guidance as to the presence of asthma.
patient dr partnership
Patient/Dr Partnership
  • Enhance the chance of disease control
  • Agreed goals of management
  • Guided self-management plan
non adherence
Drugs:

Poor technique of inhaler devices.

Regimen with multiple drugs.

Occurrence of Side effects from the drugs.

Cost of medications.

Non-drugs

Lack of knowledge about asthma.

Lack of partnership in the management.

Inappropriate expectations.

Underestimation of severity.

Cultural issues.

Non-Adherence
precipitating factors
Precipitating Factors
  • Indoor Allergens and Air Pollutants
  • Outdoor Allergens
  • Occupational Exposure
  • Food and Drugs
slide35

Self-management plan

لكل مريض خطة علاجية ذاتية خاصة به توضع تحت إشراف الطبيب المختص حسب حالته

asthma medications
Asthma Medications
  • Controllersare medications taken daily on a long-term basis to keep asthma under clinical control chiefly through their anti-inflammatory effects.
  • Relieversare medications used on an as-needed basis that act quickly to reverse
  • bronchoconstriction and relieve symptoms.
controller medications
Controller Medications
  • Inhaled glucocorticosteroids
  • Leukotriene modifiers
  • Long-acting inhaled B2-agonists
  • Theophylline
  • Anti-IgE
  • Systemic glucocorticosteroids
inhaled corticosteroids
Inhaled Corticosteroids
  • The most effective antiinflammatory medications for the treatment of asthma
  • Benefits of ICS:
  • Reduce symptoms:
    • improve quality of life
    • improve lung function
    • decrease airway hyperresponsiveness
    • control airway inflammation
    • reduce frequency and severity of exacerbations, and reduce mortality.
inhaled corticosteroids39
Inhaled Corticosteroids
  • When ICS discontinued, deterioration of clinical control follows within weeks to months in most patients
  • Most of the benefits from ICS are achieved in adults at relatively low doses
  • Increasing to higher doses may provide further benefits in terms of asthma control but increases the risk of side effects
  • Tobacco smoking reduces the responsiveness to ICS
inhaled corticosteroids40
Inhaled Corticosteroids
  • To reach control, add-on therapy with another class of controller is preferred to increasing the dose of ICS
  • ICS are generally safe and well-tolerated
  • Though low-medium dose of ICS may affect growth velocity, this effect is clinically insignificant and may be reversible.
inhaled corticosteroids41
Inhaled Corticosteroids
  • Local adverse effects:
    • oropharyngeal candidiasis
    • Dysphonia – may be e reduced by using MDI + spacer devices and mouth washing
  • Systemic side effects are occasionally reported with high doses and long-term treatment
leukotriene modifiers ltra
Leukotriene modifiers (LTRA)
  • LTRA reduce airway inflammation and improve asthma symptoms and lung function but with a less consistent effect on exacerbations, especially when compared to ICS.
  • Alternative treatment to ICS for patients with mild asthma, especially in those who have clinical rhinitis
  • Some patients with aspirin-sensitive asthma respond well to the LTRA
leukotriene modifiers ltra44
Leukotriene modifiers (LTRA)
  • Available as Montelokast in Saudi Arabia
  • Their effects are generally less than that of low dose ICS
  • When added to ICS, LTRA may reduce the dose of ICS required by patients with uncontrolled asthma, and may improve asthma control
  • LTRA are generally well-tolerated. There is no clinical data to support their use under the age of six months.
slide45
LABA
  • LABA: (formoterol and salmeterol)
  • Should not be used as monotherapy
  • Combination with ICS lead to:
    • improves symptoms
    • decreases nocturnal asthma
    • improves lung function
    • decreases the use rapid-onset inhaled B2-agonists
    • reduces the number of exacerbations
    • achieves clinical control of asthma in more patients, more rapidly, and at a lower dose of ICS
combination devices
Combination devices
  • Sympicort turbohaler:
    • Budesonide/Formeterol: 160/4.5
  • Seretide:
    • Fluticasone/Salmeterol
    • Evohaler: 50/8 125/8 250/8
    • Diskus: 100/16 250/16 500/16
theophylline
Theophylline
  • Weak bronchodilator with modest anti-inflammatory properties.
  • It may provide benefit as add-on therapy in patients who do not achieve control on ICS alone
  • Less effective than LABA and LTR.
  • Side effects:
    • gastrointestinal symptoms
    • cardiac arrhythmias
    • seizures, and even death
    • Drug interaction
anti ige
Anti-IgE
  • Omalizumab (Xolair) indication:
    • Uncontrolled severe allergic asthma on high dose ICS and other controllers.
    • Needs specialist consultation.
  • Side effects:
    • Pain and bruising at injection site and very rarely anaphylaxis (0.1%).
oral glucocorticosteroids
Oral glucocorticosteroids
  • Long-term oral glucocorticosteroid therapy may be required for uncontrolled asthma despite maximum standard therapy.
  • It is limited by the risk of significant adverse effects.
  • Side effects:
    • Osteoporosis, hypertension, diabetes, adrenal insufficiency, obesity, cataracts, glaucoma, skin thinning, and muscle weakness. Withdrawal can elicit adrenal failure.
    • In patients prescribed long-term systemic glucocorticosteroids, prophylactic treatment for osteoporosis should be considered.
reliever medications
Reliever Medications
  • Short-acting inhaled B2-agonists
  • Anticholinergics
  • Theophylline
short acting b2 agonists
Short-acting B2-agonists
  • The medications of choice for symptoms relief
  • Pretreatment for exercise-induced bronchoconstriction.
  • Formoterol is used for symptom relief because of its rapid onset of action.
  • Increased use, especially daily use, is a warning of deterioration of asthma control
  • Side effects: B2-agonists are associated with adverse systemic effects such as tremor and tachycardia.
anticholinergics
Anticholinergics
  • Less effective than SABA.
  • Used in combination in acute asthma.
  • An alternative bronchodilator for patients with adverse effects from rapid acting B2agonists.
  • Side effects: can cause a dryness of the mouth and a bitter taste.
principles of management
Principles of management
  • Initiation
  • Adjustment
  • Maintenance
initiation of treatment
Initiation of treatment
  • Step 1 SABA on as needed bases
  • Step 2  For patients who are not currently taking long-term controller medications.
  • Step 3 If the initial symptoms are more frequent.
initiation of treatment based on asthma control test
Initiation of treatment based on Asthma Control Test
  • The consensus among SINA panel is to simplify the approach to initiate asthma therapy by using ACT
    • ACT Score ≥ 20  Step 1
    • ACT Score 16–19  Step 2
    • ACT Score 16  Step 3
principles of asthma treatment
Principles of Asthma Treatment
  • Daily long-term controller medication is needed
  • ICS are considered as the most effective controller
  • Relievers or rescue medications must be available to all patients at any step
  • SABA or rapid onset LABA should be taken as needed to relieve symptoms
  • Increasing use of reliever treatment is usually an early sign of worsening asthma control
principles of asthma treatment63
Principles of Asthma Treatment
  • Treat patients who may have seasonal asthma as having uncontrolled asthma during the season at step 1 for the rest of the year
  • Patients who had two or more exacerbations requiring oral corticosteroids or hospital admissions in the past year should be treated as patients with uncontrolled asthma, even if the level of control seems good in between the exacerbations
step 1 recommendations
Step 1 - Recommendations
  • The symptoms are usually mild and infrequent
  • If patient may experience sudden, severe, and life-threatening exacerbations, treat these exacerbations accordingly
  • Consider rapid onset B2-agonist to be taken “as needed” to treat symptoms
  • If B2-agonist use increases to more than two days a week, treate as partially controlled asthma
step 2 recommendations
Step 2 - Recommendations
  • The preferred recommendation is daily ICS at a low dose (< 500 μg of beclomethasone equivalent/day
  • Alternative treatments include LTRA (montelukast)
step 3 recommendations
Step 3 – Recommendations
  • Add a LABA to a low-medium dose ICS for patients whose asthma is not controlled on a low dose ICS alone, such as:
    • Fluticasone/Salmeterol (Seretide)
    • Budesonide/Formoterol (Symbicort)
  • Use a maintenance dose of the combination drugs twice daily
  • Use the rapid onset B2-agonist as a reliever treatment (Evidence A).[129]
step 3 s m a r t approach
Step 3 - S.M.A.R.T® approach
  • S.M.A.R.T® approach: Use of Formoterol/Budesonide for both rescue and maintenance
    • Maintenance dose single inhaler (1–2 puff 160/4.5 BID) is selected plus extra puffs from the same inhaler up to a total of 12 puffs per day.
    • Those patients who require such high dose should seek medical advice to step up therapy that may include use of short course of oral prednisone.
step 3 goal study
Step 3 - GOAL study
  • GOAL study has shown that an escalating dose of combination of Fluticasone/ Salmeterol (Seretide) achieves
    • Well controlled asthma in 85% of patients
    • Totally controlled asthma in 30% of patients
step 3 alternative therapy
Step 3 – Alternative therapy
  • Increasing the dose ICS to the medium to high dose range as a monotherapy
  • Adding LTRA to a low-medium dose ICS, especially with concomitant rhinitis
  • Adding sustained release theophylline to a low-medium dose ICS
  • Consultation with a specialist is recommended for patients whenever there is a difficulty in achieving control
step 4 recommendations
Step 4 – Recommendations
  • Maximizing treatment is recommended by combining high-dose ICS with LABA
  • Adding LTRA or theophylline to high-dose ICS and LABA should be considered
  • Omalizumab may be considered:
    • Allergic asthma (as determined by skin test or RAST study) and still uncontrolled.
    • Special knowledge about the drug
  • Consultation is recommended
step 5 recommendations
Step 5 - Recommendations
  • Omalizumab to be considered for patients who have allergic asthma and persistent symptoms despite the maximum therapy mentioned above
  • lowest possible dose of long-term oral corticosteroids for patient who:
  • Does not have allergic asthma
  • Omalizumab is not available or not adequately controlling the disease
step 5 long term steroids
Step 5 – long term steroids
  • Long-term systemic corticosteroids:
    • lowest possible dose to maintain control
    • Monitor for the development of side effects
    • Continue attempts to reduce the dose
    • Maintaining high-dose of ICS therapy
    • Strongly consider concurrent treatments with calcium supplements and vitamin D
  • Consultation is mandatory
children younger than 5 years
Children younger than 5 years
  • The most effective bronchodilator available is SABA
  • If control is not achieved and controller treatment commenced, the lowest dose of ICS delivered by MDI and a spacer
  • LTRA is considered as an alternative therapy especially when there is concomitant rhino-sinusitis.
  • Doubling the dose of ICS If asthma control is not achieved on low dose ICS
children younger than 5 years75
Children younger than 5 years
  • If asthma is not controlled, increase ICS dose to the maximum, and/or adding a LTRA or theophylline
  • Low dose of oral corticosteroids for a few weeks should be limited to severe uncontrolled cases
  • Seasonal symptoms: discontinue daily controller therapy after the season
  • Frequent episodes by severe viral infection may justify a trial of ICS
maintaining control
Maintaining Control
  • Regular follow-up is essential
  • Follow-up at 1- to 6- month intervals is recommended, depending on the level of control
  • Consider 3- month intervals, if a step down in therapy is anticipated.
allergen immunotherapy ait
Allergen Immunotherapy (AIT)
  • gradual immunization by increasing doses of standardized allergen responsible for causing allergic symptoms either subcutaneously or sublingually
  • This will induce increased tolerance to the allergen that may provide long-term relief of symptoms during subsequent exposure to the same allergen
allergen immunotherapy ait78
Allergen Immunotherapy (AIT)
  • AIT is more effective in seasonal asthma than in perennial asthma particularly when used against a single allergen
  • AIT may be considered if strict environmental avoidance and pharmacologic intervention have failed to control asthma
  • Side effects include systemic allergic reactions, occasional anaphylaxis and, even, rare fatalities
asthma and pregnancy
Asthma and pregnancy
  • Present in up to 8% of pregnant women.
  • Unpredictable course: one third will have worsening of their of asthma control
  • Maintaining adequate control of asthma during pregnancy is essential for the health and well-being of both the mother and her baby.
  • Identifying and avoiding triggering factors should be the first step of therapy for asthma during pregnancy
asthma and pregnancy81
Asthma and pregnancy
  • Same stepwise approach as in the nonpregnant patient.
  • Salbutamol is the preferred SABA
  • ICSs are the preferred controllers
  • Use of ICS, theophylline, antihistamines, B2-agonists, and LTRA is generally safe
  • Acute exacerbations of asthma during pregnancy should be treated on the same outlines as in nonpregnant patients
cough variant asthma
Cough-variant asthma
  • Cough is the main symptom
  • It is common in children, and is often more problematic at night
  • Other diagnoses to be considered are:
    • Drug-induced cough caused by angiotensin-converting-enzyme inhibitors
    • GERD
    • Postnasal drip and chronic sinusitis
  • Treatment is similar to long-term management of asthma
exercise induced asthma
Exercise-induced Asthma
  • Bronchoconstriction peaks within 10 to 15 minutes after completing the exercise and resolves within 60 minutes.
  • Prevention:
    • SABA before exercise
    • Warm-up period before exercise
    • Some patients may need maintenance therapy
    • Regular use of LTRA may help in this condition especially in children
aspirin nsaid induced asthma
Aspirin/NSAID induced Asthma
  • Occurs in 10–20% of adults with asthma
  • The majority experience first symptoms during the third to fourth decade.
  • Once aspirin or NSAID hypersensitivity develops, it is present for life.
  • Within 1-2 hours following ingestion of aspirin, an acute, severe attack develops, and is usually accompanied by rhinorrhea, nasal obstruction, conjunctival irritation, and scarlet flush of the head and neck
aspirin nsaid induced asthma85
Aspirin/NSAID induced Asthma
  • Prevention by avoidance of aspirin/NSAID
  • Patients for whom aspirin is considered essential, they should be referred to an allergy specialist for aspirin desensitization
  • Aspirin and NSAID can be used in asthmatic patients who do not have aspirin induced asthma
gerd triggered asthma
GERD triggered asthma
  • GERD is more prevalent in asthmatics
  • Mechanisms of GERD triggered asthma:
    • vagal mediated reflex
    • reflux of micro-aspiration of gastric contents into the upper airways
  • If GERD symptoms presents, a trial of GERD therapy for 6–12 weeks and lifestyle modifications may be considered
  • Asymptomatic patients with uncontrolled asthma may not benefit from GERD therapy
management of acute asthma
Management of Acute Asthma
  • Mortality reported in patients who have received inadequate treatment or poor education
  • The following should be carefully checked:
    • Previous history of near fatal asthma
    • Patient on three or more medications
    • Heavy use of SABA
    • Repeated visits to emergency department
    • Brittle asthma
oxygen
Oxygen
  • High concentration of inspired oxygen should be used to correct hypoxemia
  • Pulse oximetry should be used to tailor oxygen therapy
  • Failure to achieve oxygen saturations of more than 92% is a good predictor of the need for hospitalization
  • Normal or high PaCO2 is an indication of a severe attack, and the need for specialist consultation
bronchodilators
Bronchodilators
  • Inhaled salbutamol is the preferred choice
  • Repeated doses should be given at 15–30 minute intervals.
  • Alternatively, continuous nebulization (Salbutamol at 5–10 mg/hour) may be used for one hour if there is an inadequate response to initial treatment.
bronchodilators93
Bronchodilators
  • In patients who are able to use the inhaler devices, 6–12 puffs of MDI with a spacer are equivalent to 2.5 mg of Salbutamol by nebulizer
  • In moderate to severe acute asthma, combining ipratropium bromide with Salbutamol has some additional bronchodilation effects, in reducing hospitalizations and greater improvement in PEF or FEV1
steroid therapy
Steroid therapy
  • Systemic steroids: reduce relapses and subsequent hospital admission
  • Oral steroid = injected steroids
  • Oral prednisolone: 40–60 mg daily
  • Parenteral steroids:
    • Hydrocortisone: 300–400 mg/day
    • Methylprednisolone: 60–80 mg/day
  • Systemic steroids should be given for seven days for adults and three to five days for
magnesium sulphate
Magnesium sulphate
  • A single dose of IV magnesium sulphate (1.2–2 gm IV infusion over 20 mins) is safe and effective
  • Routine use of IV magnesium sulphate in patients with acute asthma presenting to emergency department is not recommended.
  • Its use should be limited to those with sever exacerbation who fail to respond to treatment after an hour
intravenous aminophylline
Intravenous aminophylline
  • In acute asthma, the use of intravenous aminophylline did not result in any additional bronchodilation compared to standard care with B2-agonists
antibiotics
Antibiotics
  • Viral infection is the usual cause of asthma exacerbation
  • The role of bacterial infection has been probably overestimated, and routine use of antibiotics is strongly discouraged
  • They should be used when there is associated pneumonia or bacterial bronchitis
referral to a specialist center
Referral to a specialist center
  • Status asthmatics
  • Deteriorating PEF
  • Persisting or worsening hypoxia
  • Hypercapnea, respiratory acidosis (pH <7.3)
  • Severe exhaustion
  • Increase work of breathing
  • Drowsiness
  • Confusion
  • Coma
  • Respiratory arrest
criteria for admission
Criteria for admission
  • Patients whose peak flow is ≥ 60% best or predicted one hour after initial treatment can be discharged from the emergency department
  • Criteria for admission:
    • Any feature of a life threatening, near fatal attack
    • Any feature of a severe attack that persists after initial treatment.
    • unless any of the following is present:
    • still suffering from significant symptoms
    • previous history of near fatal or brittle asthma
    • concerns about compliance and pregnancy
acute asthma in children 5 years
Acute asthma in children < 5 years
  • Early symptoms of an acute exacerbation would usually follow an upper respiratory infection.
  • Ssymptoms: shortness of breath, wheeze, nocturnal cough, exercise intolerance .
  • Initiation of treatment: two puffs (200 μg) of salbutamol via spacer is recommended
acute asthma in children 5 years101
Acute asthma in children < 5 years
  • Immediate medical attention should be taken in case of children less than two year who had a history of poor response to three doses of SABA within 1–2 hours, saturation less than 92%, or the child is acutely distressed.
  • In this age group, the risk of fatigue, respiratory compromise and dehydration is considerable