1. M ANAGING A CUTE A STHMA E XACERBATIONS Cathryn Caton, MD, MS

2. O BJECTIVES 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. A SSESSMENT OF A STHMA E XACERBATION 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. B RIEF H ISTORY 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. B RIEF P HYSICAL E XAM 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. A SSESSING SEVERITY OF SYMPTOMS Mild exacerbation Moderate exacerbation Severe exacerbation

7. M ILD E XACERBATION 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. M ODERATE E XACERBATION 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. S EVERE E XACERBATION 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. R ESPIRATORY A RREST I MMINENT Drowsy or confused Paradoxical thoracoabdominal movement Absence of wheeze Bradycardia

11. T REATMENT OF M ODERATE E XACERBATION Inhaled Beta 2 – agonists Supplemental O 2 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. T REATMENT OF S EVERE E XACERBATION Inhaled short acting Beta 2 –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. T REATMENT OF S EVERE E XACERBATION Inhaled short acting Beta 2 –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. W HEN IS IT SAFE TO DISCHARGE ? Significant improvement in symptoms Significant improvement in peak flow – should be at least 70% of predicted / personal best

15. D ISCHARGE Continue treatment with inhaled Beta 2 -agonist Continue course of oral systemic steroid Patient education Review medication use Review / initiate action plan Recommend close medical follow up