1. Acute severe asthma

2. Acute severe asthma : who is at most risk ?
Previous life-threatening attacks
Severe disease (3 or >3 drugs for control; emergency steroid in past ; ever admitted in last 1 year)
Psychiatric morbidity
Non-compliance
Requiring 2 or > 2 Bronchodilator inhalers monthly

3. Near fatal episodes Misuse of drugs/alcohol Psychiatric illness Denial
Non compliance
Learning difficulties
Previous admission to ICU for asthma
Brittle asthma
Social isolation, income and employment difficulties
Previous self discharge from hospital
Br Med J 2005;

4. What is acute severe asthma ?
ANYONE OF:
PEF 33-50% best or predicted
RR 25/min
Heart rate  110/min
Inability to complete sentences in one breath

5. What is life threatening asthma ?
ANYONE OF:
PEF < 33% best or predicted
Sat O2 < 92%
PaO2< 55 mm Hg
Normal PaCO2
Silent chest
Cyanosis
Feeble respiratory effort
Heart rate  110/min
Inability to complete sentences in one breath

6. Contd…….
Bradycardia
Dysrhythmia
Hypotension
Exhaustion
Confusion
Coma

7. What is near fatal asthma?
Increased PaCO2
Requiring mechanical ventilation

8. What is brittle asthma?
Type 1… > 40% diurnal variability in PEF for > 50% of the time over a period > 150 days despite intense therapy
Type 2 … sudden severe attacks on a background of apparently well controlled asthma

9. Criteria for hospital admission
Near fatal attack  ADMIT IN ICU
Life threatening attack  ADMIT IN ICU
Severe attack persisting after initial treatment
Previous near fatal or brittle attack
Concerns about compliance
Living alone
Psychological problems
Physical disability / learning difficulty
Pregnancy
Presentation at night

10. Hospital Treatment – Immediate action
CBC (to r/o infection)
Chest X-ray (to r/o pneumothorax)
Oxygen (40-60%)
β2 agonist –nebulised or MDI + spacer
Inhaled Ipratropium can be added if required
Systemic steroid (Prednisolone / Hydrocortisone)
Inhaled steroids to be continued or started as soon as posible
Avoid sedation

11. Nebulised salbutamol
5 mg or mg/kg salbutamol hourly (to a maximum of 10 mg per hour have been used in trials so far)
Nebulised Ipratropium bromide
mcg 6 hourly

12. Acute severe asthma…continues
Oxygen continues
Nebulised ß2-agonist (5 mg salbutamol every 20 minutes or continuously at 5-10mg/hr)
Nebulised ipratropium bromide (500 mcg 4-6 hrly )
Combination of above two

13. Acute severe Asthma Treatment (Contd.) Obtain IV access
Start steroids (4 mg/kg hydrocortisone loading dose, then 100 mg 6 hrly)
Antibiotics ( not routinely )
Adequate hydration
Still deteriorating - Start Aminophylline infusion ( mg/kg/hr)

14. Acute severe Asthma Treatment (Contd.) Adrenaline (0.1 mg sc)
Cautious CPAP (ideally BiPAP)
Mechanical ventilation RR
Low TV ( ml / kg)
I:E ratio 1:3 or longer
Maintain PaO2 > 60 mmHg
Allow PaCO2 to rise, provided pH > 7.2
Adequate sedation and paralysis

15. Management of acute severe Asthma in children > 2 years
High O2 concentrations
β2 agonist –nebulised or MDI + spacer
Systemic steroids ( Oral / IV )
IV Bronchodilators ( Salbutamol 15μg/kg bolus or continuous infusion of 1-2μg/kg/min upto 5μg/kg/min in PICU)

16. Treatment (general practice)
Oxygen (Check Room air O2 saturation if available)
Nebulised salbutamol 5 mg
Prednisolone (30-60 mg) or IV Hydrocortisone 200 mg
Nebulised Ipratropium Bromide (500 mcg)
SC Terbutaline / IV Aminophylline (5mg/kg bolus over 20 mins.)
Arrange for ambulance

17. Acute Asthma Emergency Department Management
Initial Assessment History, Physical Examination, PEF or FEV1
Initial Therapy Bronchodilators , O2 if needed
Good Response
Incomplete/Poor Response
Respiratory Failure
Add Systemic Glucocorticosteroids
Observe for at least 1 hour
Good Response
Poor Response
If Stable, Discharge to Home
Discharge
Admit to Hospital
Admit to ICU

18. Instructions / points on discharge
Been on discharge medication for 24 hours
Inhaler technique checked
PEFR diurnal variability < 25%
Oral + inhaled steroids / bronchodilators
? PEFR meter
Follow-up appointment < 48 hrs with GP

19. ‘Treat acute severe asthma at least 4 days before it occurs’
Thomas Petty

20. PREVENT ACUTE ATTACKS OF ASTHMA BY TAKING REGULAR INHALED CORTICOSTEROID TREATMENT