1. The Saudi Initiative for Asthma Guidelines for the Diagnosis and Management of Asthma in Adults and Children 2013 update
Management of Acute Asthma in Adults
On behalf of the SINA panel
Mohamed S. Al-Moamary, FRCP (Edin) FCCP
Dep. of Medicine, King Abdulaziz Medical City-Riyadh
King Saud bin Abdulaziz University for Health Sciences

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Management of Acute Asthma in Adults
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3. 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.

4. 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

5. The SINA guidelines booklet is available at: www.sinagroup.org
Where do you find SINA?
The SINA guideline was published in the Annals of Thoracic Medicine (
Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012;7:
The SINA guidelines booklet is available at:

6. 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

7. What is new in SINA-2012
Comprehensive revision with the addition of new 125 references
Addition of charts and algorithms for asthma diagnosis and management
Updating asthma management
Rewritten “asthma in children” section
New section on “difficult to treat asthma”

8. SINA Panel
Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for Health Sciences, Riyadh
Sami Alhaider, King Faisal Specialist Hospital and Research Center, Riyadh
Mohamed S. Al-Hajjaj, King Saud University, Riyadh
Mohammed O. AlGhobain, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Majdy M. Idrees, Military Hospital, Riyadh
Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh
Adel S. Alharbi, Military Hospital, Riyadh
 Hussain Al-Matar, Imam Abdulrahman Al Faisal, Dammam
Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah
 Hassan S Alorainy, King Faisal Specialist Hospital and Research Center, Riyadh

9. Acknowledgment
The SINA panel would like to thank the following reviewers :
Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada
Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and the Montreal Chest Research Institute
Prof. Sheldon Spier, the University of British Columbia, Vancouver, Canada
Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa (SINA 2009)
Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. (SINA 2009)

10. SINA Documents
Published manuscript
Booklet
Electronic version
Slides kit
Flyers
Website:

11. Sections of SINA – update cover
Epidemiology
Pathophysiology
Diagnosis
Medications
Approach to Management
Treatment Steps
Special Situations
Acute Asthma

12. Prevalence of asthma has increased between 1986 – 1995
Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296

13. 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)

14. 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)

15. The prevalence of wheeze and associated symptoms in the study group
Al-Ghobain et al, NBC Pulm Med 2012;12:39

16. Pattern of asthma treatment
Al-Shimemeri, Ann Thorac Med 2006;1:20-5

17. Airway Hyper-responsiveness
Pathology of Asthma
Inflammation
Airway Hyper-responsiveness
Airway Obstruction
Symptoms of Asthma

18. Pathophysiology

19. Inflammation  Remodeling
Airway Hypersecretion
Subepithelial fibrosis
Angiogenesis

20. Diagnosis - History Episodic attacks:
Cough
Breathlessness
Wheezing
Nocturnal symptoms
Patient could be asymptomatic between attacks
co-existent conditions: GERD, rhinosinusitis.

21. Relevant Questions
Does the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis?
Does the patient have recurrent attacks of wheezing?
Does the patient have a troublesome cough at night?
Does the patient wheeze or cough after exercise?
Does the patient experience wheezing, chest tightness, or cough after exposure to pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke?

22. Relevant Questions
Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal inflammatory medication or use of B-blockers?
Does the patient's cold “go to the chest” or take more than 10 days to clear up?
Are symptoms improved by appropriate asthma treatment?
Are there any features suggestive of occupational asthma

23. 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

24. Measurements of lung function:
Investigations
Measurements of lung function:
Spirometry
Peak expiratory flow (PEF)
Normal Spirometry does not role out asthma
Spirometry is superior to PEF

25. Bronchodilator response
Proper instructions on how to perform the forced expiratory maneuver must be given to patients, and the highest value of three readings taken.
The degree of significant reversibility is defined as an improvement in FEV1 ≥12% and ≥200 ml from the pre-bronchodilator value.

26. 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

27. Assessment of Asthma Control

28. Asthma Control Test Level of Control: Total: 25 Control: 20-24
Partial control:
Uncontrolled: < 16

29. 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

30. Management of Acute Asthma

31. Acute Asthma in Adults
Most patients who present with an acute asthma exacerbation have chronic uncontrolled asthma
The following should be carefully checked:
previous history of near fatal asthma
patient taking three or more medications
heavy use of SABA and frequent ER visits
Patient should be assessed to determine the severity of acute attacks
PEF and pulse oximetry measurements are complementary to history taking and physical examination

32. Levels of severity of acute asthma exacerbations in adults

33. Initial Assessment of Acute Asthma

34. Medications used in acute asthma
Oxygen
High concentration of inspired oxygen to correct hypoxemia (do not miss COPD)
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 need for specialist consultation

35. Bronchodilators
Inhaled salbutamol is the preferred choice
Repeated doses is recommended 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.

36. Bronchodilators
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

37. Steroid therapy
Systemic steroids: reduce relapses and subsequent hospital admission
Oral steroid = injected steroids
Oral prednisolone: 40–60 mg daily
Systemic steroids should be given for seven days for adults and three to five days for

38. 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

39. Intravenous aminophylline
In acute asthma, the use of intravenous aminophylline did not result in any additional bronchodilation compared to standard care with B2-agonists

40. 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

41. Initial Management of Acute Asthma

42. If there is an adequate response

43. If there is a partial response

44. If there is a poor response

45. 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

46. 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

47. 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.

48. 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