Asthma exacerbation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]; Vidit Bhargava, M.B.B.S [3]; Rim Halaby, M.D. [4]

Overview

Asthma exacerbations are acute or subacute episodes of progressively worsening symptoms of cough, wheezing and dyspnea accompanied by a measurable decrease in peak expiratory airflow.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Asthma exacerbation is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

  • Occupational irritants and sensitizers

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to asthma exacerbation based on directives issued by the National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma.[7]

 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
Dyspnea
Wheezing
❑ Chest tightness
Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a focused history:
❑ Onset
❑ Severity compared to previous episodes
❑ Possible causes
❑ Current medications
❑ Time since the last dose of asthma medications
❑ Exacerbations in previous 1 year
❑ Concurrent illness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Agitation
Tachypnea
Tachycardia
❑ Use of accessory muscles
❑ Speech (full sentences, words)
❑ Level of alertness
❑ Hydration status
❑ Cyanosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:
Spirometry (FEV1, Peak expiratory flow PEF)*
❑ O2 saturation (pulse oximetry)
❑ Arterial blood gas (not routine)
❑ Order additional tests if needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
COPD exacerbation
Aspiration pneumonia
Allergy or hay fever
❑ Vocal cord dysfunction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify the severity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild:
Symptoms:
❑ Breathlessness while walking
❑ Speaking full sentences

Signs:
Tachypnea
❑ End expiratory wheezing
Pulse < 100/min


❑ FEV1 ≥ 70%
Pulse oximetry > 95 %

ABG Normal
 
Moderate:
Symptoms:
❑ Breathlessness at rest, sitting is preferred
❑ Speaking phrases
❑ Agitation

Signs:
Tachypnea
❑ Using accessory muscles of respiration
❑ Expiratory wheezing
Pulse 100-120/min
Pulsus paradoxus


❑ FEV1 40-69 %
❑ Pulse oximetry 90-95 %
❑ ABG: ♦ PaO2 ≥ 60 mm Hg

♦ PCO2 < 42 mm Hg
 
 
 
 
 
Severe:
Symptoms:
❑ Breathlessness at rest, sitting is preferred
❑ Speaking words
❑ Agitation

Signs:
Tachypnea ≥ 30/min
❑ Use of accessory muscles of respiration
❑ Wheezing during inhalation and exhalation
Pulse > 120/min
❑ Pulsus paradoxus


❑ FEV1 < 40 %
❑ Pulse oximetry < 90 %
❑ ABG: ♦ PaO2 < 60 mm Hg

♦ PCO2 ≥ 42 mm Hg
 
Imminent respiratory arrest:
Symptoms:
❑ Drowsiness or confusion

Signs:
❑ Paradoxical thoracoabdominal movement
❑ Absent wheezing
❑ Bradycardia
❑ Absent pulsus paradoxus due to respiratory fatigue


❑ FEV1 < 25 %
❑ < 10 % in FEV1 after treatment

 
 
 
 
 
 

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to asthma exacerbation based on directives issued by the National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma.[7]

 
 
 
 
 
 
 
 
 
 
Asthma exacerbation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild or moderate exacerbation
FEV1 or PEF ≥ 40-60%
 
 
 
 
 
Severe exacerbation
FEV1 or PEF ≤ 40%
 
 
Imminent or ongoing respiratory arrest
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer oxygen to reach a target SaO2 ≥ 90%
❑ Administer inhaled SABA by nebulizer or metered dose inhaler (MDI), maximum 3 doses in 1st hour
❑ Administer oral corticosteroid if no response or recent intake of oral steroid
 
 
 
 
 
❑ Administer oxygen to reach a target SaO2 ≥ 90%
❑ Administer high dose inhaled SABA plus ipratropium by either nebulizer of by MDI with valve holding chamber
♦ Every 20 minutes, OR
♦ For 1 continuous hour
❑ Administer oral corticosteroids
 
 
Intubate and mechanically ventilate with 100% O2
❑ Administer SABA and ipratropium via nebulizer
❑ Administer IV corticosteroids
❑ Consider adjunct therapies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassess the patient:
❑ Patient's subjective response
❑ Physical findings
❑ FEV1 and PEF
❑ Oxygen saturation
❑ Order additional tests if needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate exacerbation:
❑ FEV1 or PEF 40-69%
❑ Moderate signs and symptoms on physical exam
 
 
 
 
 
Severe exacerbation:
❑ FEV1 or PEF 40-69%
❑ High risk patient
❑ Severe signs and symptoms on physical exam
♦ Severe symptoms at rest
♦ Chest retraction
♦ Use of accessory muscle
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer inhaled SABA every 60 minutes
❑ Administer oral corticosteroids
❑ Treat for 1-3 hours
❑ Take a decision on whether to admit the patient or not within the first 4 hours based on the patient's improvement status
 
 
 
 
 
❑ Administer oxygen
❑ Administer nebulized SABA and ipratropium continuously or every hour
❑ Administer oral corticosteroids
❑ Consider adjunct therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassess the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Good response:
❑ FEV1 or PEF ≥ 70%
❑ Absence of distress
❑ Stable after 60 minutes of treatment
❑ Normal physical exam
 
Incomplete response:
❑ FEV1 or PEF 40-69%
❑ Mild-moderate symptoms
 
Poor response
❑ FEV1 or PEF < 40%
❑ PCO2 ≥ 42 mm Hg
❑ Confusion and severe symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Admission to ward:
❑ Administer oxygen
❑ Administer inhaled SABA
❑ Administer oral or IV corticosteroids
❑ Monitor the patient
 
Admission to ICU:
❑ Administer oxygen
❑ Administer inhaled SABA continuously or every hour
❑ Administer IV corticosteroids
❑ Consider adjunct therapies
Intubate the patient in case of:
❑ Inability to speak
❑ Altered mental status
❑ Progressing fatigue
❑ Intercostal retraction
❑ Increasing PaCO2 above 42 mmHg
Apnea
Coma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient discharge:
❑ Continue treatment with inhaled SABA
❑ Continue course of oral steroids
❑ Continue/initiate inhaled corticosteroids
❑ Educate the patient
❑ Schedule a follow up visit
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Asthma Exacerbation Drugs

Shown below is a table summarizing the dosage of drugs used to manage asthma exacerbation:

DrugAdult dosage
Inhaled Short Acting β Agonists (SABA)
Albuterol, bitolterol, pirbuterol
a) Nebulizer solution
b) MDI

♦ 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed or 10-15 mg/hour continuously.
♦ 4-8 puffs every 20 minutes up to 4 hours, then every 1-4 hours as needed.
Levalbuterol
a) Nebulizer solution
b) MDI

♦ 1.25-2.5 mg every 20 minutes for 3 doses, then 1.25-5 mg every 1-4 hours as needed.
♦ 4-8 puffs every 20 minutes upto 4 hours, then every 1-4 hours as needed.
Anticholinergics
Ipratropium bromide
a) Nebulizer solution
b) MDI

♦ 0.5 mg every 20 minutes for 3 doses, then as needed.
♦ 8 puffs every 20 minutes as needed for up to 3 hours.
Ipratropium with albuterol
a) Nebulizer solution (each 3 ml containing 0.5 mg ipratropium and 2.5 mg albuterol)
b) MDI (each puff contains 18 mcg ipratropium and 90 mcg albuterol)

♦ 3 ml every 20 minutes for 3 doses, then as needed.
♦ 8 puffs every 20 minutes as needed for 3 hours
Systemic corticosteroids
Prednisone, prednisolone, methylprednisolone ♦ 40-80 mg/day in 1 or 2 divided doses until peak expiratory flow (PEF) reaches 70%.
  • SABA: short acting beta agonist
  • FEV1: forced expiratory volume for the for the first second
  • PEF: peak expiratory flow

Do's

  • Use the percent predicted FEV1 and peak expiratory flow (PEF) as your main factors to classify the severity of asthma exacerbation.
  • Initiate the treatment of asthma exacerbation as soon as possible while obtaining a brief history and examining the patient.
  • Rule out on physical examination complications of asthma exacerbation such as pneumonia, pneumomediastinum and pneumothorax.
  • Administer oxygen through nasal cannula or a mask with a target of SaO2 >90%, except for pregnant women and patients with heart disease for whom the target oxygen saturation should be more than 95%.

Ordering labs:

  • Ordering additional labs should not hinder administering treatment.
  • Measure serum theophylline concentration in patients who have taken theophylline before presentation.
  • Order ABG in patients with severe respiratory distress or suspected hypoventilation.
  • Measure serum electrolytes in patients who have been taking diuretics regularly and in patients who have coexistent cardiovascular disease.
  • Obtain chest radiography for patients with suspected congestive heart failure, pneumothorax, pneumomediastinum, pneumonia, or lobar atelectasis.
  • Obtain electrocardiograms in patients older than 50 years of age with evidence of heart disease or COPD.
  • Order a CBC in patients presenting with elevated temperature.

Drug therapy:

  • Use only selective β agonists to mitigate cardiac risks.
  • Prescribe a 5-10 days course of corticosteroids to prevent early relapse.
  • Administer supplemental doses of corticosteroids among patients who have been on regular corticosteroids.

Adjunct therapies:

  • Adjunct therapies that may be considered (evidence not complete, further data is required):
  • Intravenous magnesium sulfate in patients who have life-threatening exacerbations and in those whose exacerbations remain in the severe category after 1 hour of intensive conventional therapy.
  • Heliox-driven albuterol nebulization for patients who have life-threatening exacerbations and for those patients whose exacerbations remain in the severe category after 1 hour of intensive conventional therapy.
  • Intravenous beta2-agonists
  • Noninvasive ventilation
  • Intravenous leukotriene receptor antagonists

Intubation:

  • Intubate patients presenting with apnea or coma immediately.
  • Use permissive hypercapniap or pcontrolled hypoventilation as a ventilator strategy.
  • Have a low threshold for intubation because the intubation of asthmatic patients can be complicated.
  • Consider administering IV magnesium sulfate or heliox-driven albuterol nebulization when the intubation of an asthmatic patient is difficult.

Discharge:

  • Educate the patient by reviewing the list of home medications, the appropriate technique used for the inhaler and the importance of follow up visits.
  • Consider issuing a PEF meter.

Don'ts

  • Don't measure FEV 1 and PEF in a patient presenting with severe asthma exacerbation and proceed directly to the initiation of the management.
  • The following treatments are not recommended during hospitalization or emergency care settings:
  • Methylxanthine
  • IV isoproterenol
  • Leukotriene modifiers
  • Antibiotics including macrolides (except for comorbid conditions)
  • Excessive hydration
  • Mucolytics
  • Chest physical therapy
  • Non invasive ventilation

References

  1. Camargo CA, Rachelefsky G, Schatz M (2009). "Managing asthma exacerbations in the emergency department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations". J Emerg Med. 37 (2 Suppl): S6–S17. doi:10.1016/j.jemermed.2009.06.105. PMID 19683665.
  2. Adler, VV.; Kiseleva, NP.; Kistanova, EN.; Klenova, EM.; Lobanenkov, VV.; Polotskaia, AV.; Tevosian, SG. "[Differences in expression and functional organization of the rat tyrosine aminotransferase gene in two lines of Morris hepatoma, 8994 and 7777]". Mol Biol (Mosk). 25 (2): 431–41. PMID 1679193.
  3. del Hoyo, N.; Pulido, JA.; Carretero, MT.; Pérez-Albarsanz, MA. (1990). "Comparison of linoleate, palmitate and acetate metabolism in rat ventral prostate". Biosci Rep. 10 (1): 105–12. PMID 2111190. Unknown parameter |month= ignored (help)
  4. Seggev, JS.; Lis, I.; Siman-Tov, R.; Gutman, R.; Abu-Samara, H.; Schey, G.; Naot, Y. (1986). "Mycoplasma pneumoniae is a frequent cause of exacerbation of bronchial asthma in adults". Ann Allergy. 57 (4): 263–5. PMID 3094410. Unknown parameter |month= ignored (help)
  5. Van Winkle, LJ.; Campione, AL.; Gorman, JM.; Weimer, BD. (1990). "Changes in the activities of amino acid transport systems b0,+ and L during development of preimplantation mouse conceptuses". Biochim Biophys Acta. 1021 (1): 77–84. PMID 2104753. Unknown parameter |month= ignored (help)
  6. Ikeda, H.; Mitsuhashi, T.; Kubota, K.; Kuzuya, N.; Uchimura, H. (1985). "Effects of phorbol ester on GH, TSH and PRL release by superfused rat adenohypophysis". Endocrinol Jpn. 32 (5): 759–65. PMID 2868885. Unknown parameter |month= ignored (help)
  7. 7.0 7.1 "Section 5, Managing Exacerbations of Asthma - Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma - NCBI Bookshelf". Retrieved 14 January 2014.