Acute Asthma

• Onset of severe symptoms is known as an acute exacerbation of asthma or an asthma attack

• How do we assess severity?– Wheeze and respiratory rate?– Accessory muscle use?– Pulse rate?– Presence of pulsus paradoxus?– Breathlessness?– Cyanosis?

Acute Asthma - Classification

• Mild: <7• Moderately severe: 7 - 11• Severe: >12

Acute Asthma - Classification

Severe• Too breathless to talk or

feed• Some accessory muscle use• RR > 50/min• Pulse > 140/min

Life-threatening• Fatigue, agitation,

drowsiness• Unable to talk• Marked accessory muscle

use• Cyanosis, silent chest or

poor respiratory effort

Acute Asthma - Management

• Mild– Short Acting Beta 2 Agonists (SABA) as a nebulizer

(0.15 mg/kg; min 2.5 mg and max 5 mg per dose) or MDI ( 1/4 to 1/3 puff/kg; min 2 puffs and max 8 puffs per dose)

– If do not improve Oral systemic glucocorticoids (dexamethasone, prednisolone, or prednisone)

Acute Asthma - Management• Moderate

– Supplemental oxygen if oxygen saturation is ≤92%– Inhalation therapy with a SABA– Ipratropium bromide. Administer with each of the first three

beta agonist nebulizer treatments or continuously OR administer with the second and third treatments.

– Systemic oral glucocorticoids soon after arrival in the emergency department (ED) or after the first inhalation therapy is initiated

– IV magnesium sulfate if there is clinical deterioration despite treatment with beta agonist, ipratropium, and systemic glucocorticoids

Acute Asthma - Management

• Severe– Supplemental O2 if saturation ≤92%– Nebulized SABA OR SC/IM beta-agonist (terbutaline,

epinephrine) for children with poor respiratory flow, uncooperative, suboptimal response

– Ipratropium bromide– IV systemic glucocorticoids

• If good response procede as moderate• Poor response IV magnesium sulfate, IV

terbutaline

Acute Asthma – Hospital Admission

• Criteria for hospital admission:– Little improvement to Beta agonists and systemic

corticosteroids– Beta agonist therapy required more often than 4

hours– O2 Saturation < 92%– History of life-threatening asthma– Lack of health facilities– Poor outpatient compliance

Acute Asthma – Hospital Admission

• Management– Continue Beta-blockers, systemic corticosteroids,

O2 and magnesium sulfate– Ipratropium bromide discontinued– Monitor patient ( every 15 minutes to 4 hours)– Consult asthma specialist– Patient Education– Failure to respond ICU– Symptoms regress discharge

References

• http://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-emergency-department-management#H14

• http://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-inpatient-management?source=see_link

• http://www.rch.org.au/clinicalguide/guideline_index/Asthma_Acute/