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Acute asthma- adults

increasing symptoms peak flow is > 50-75 % of the best predicted no features of acute or severe asthma Undertake an assessment noting the following points note the patient’s degree of agitation and consciousness signs of exhaustion ( inability to complete sentences ) cyanosis use of accessory muscles of respiration auscultate the chest and note down RR , pulse , BP , oxygen saturation use the best of 3 recordings to measure PEFR value

first-line treatment is high dose inhaled beta2 agonist like salbutamol ○ for e.g 4 puffs initially followed by 2 puffs / 2 mins according to response upto 10 puffs a pressurized metered dose inhaler and spacer can be used prescribe an adequate dose of oral corticosteroid in all cases of acute asthma- continue ( @ 40-50 mg/ day ) until recovery with a minimum of 5 days therapy ) prescribe antibiotic only if symptoms and signs suggest bacterial infection nebulised ipratropium bromide may be combined with a nebulised beta 2 agonist ( for those with severe or life-threatening acute asthma or in those with poor initial response to beta2 agonist therapy ) to provide greater bronchodilatation

the episode may have happened due to a failure of using preventative therapy – a review is essential to prevent future episodes obtain a careful history ( to find the reason for the attack ) check inhaler technique , peak flow , discuss compliance , trigger factors review regular treatment , consider stepping up treatment advice on lifestyle , vaccination , diet , exercise and smoking check understanding -can they recognise poor asthma control ( worsening symptoms or peak flows ) a written asthma action plan should be agreed / given to prevent relapse , optimise treatment and prevent delay in seeking assistance in future consider issuing a rescue steroids pack to keep at home advice to start during early signs of exacerbation and seek help if they are not certain to start treatment or not if the person had 2 asthma attacks within 12 months – refer to an asthma specialist clinic 

FAST ( fourfold Asthma STudy ) concludes that this can reduce clinically important asthma exacerbations ○ the plan is cost effective ○ it also reduced reported emergency GP / hospital visits ○ number of steroid tablets prescribed per participant was also reduced CKS mentions to consider advising quadrupling at the onset of an asthma attack and for up to 14 days but cautions that ○ ceiling effect -highly adherent people may not gain any additional benefit from this ○ people already on high doses of ICS – weigh the benefit / risk if they are suffering with frequent attacks and or / still needing oral steroids ○ people who are on fixed dose combination inhalers -the increase in ICS can only be achieved by adding a single ICS inhaler

Give supplemental oxygen to all hypoxaemic patients with acute severe asthma titrated to maintain an SpO2 level of 94 % to 98 % Do not delay oxygen administration if pulse oximetry is not available Nebulizer for giving beta 2 agonists should preferably be driven by Oxygen

In a patient with severe asthma and any one of the following PEF < 33 % best or predicted SpO2 < 92 % PaO2 < 8 kPa ” normal ” PaCo2 ( 4.6 to 6 kPa ) altered level consciousness exhaustion arrhythmia hypotension cyanosis silent chest poor respiratory effort

when patients are discharged from hospital , it is advised that the ○ GP practice is informed within 24 hrs of discharge ○ patient be reviewed within 2 working days all patients admitted with a severe asthma attack should be under a respiratory specialist supervision for up to 12 months after the attack patients who had a near fatal asthma attack – would be under specialist supervision indefinitely

REFERENCES

  1. Scenario: Acute exacerbation of asthma | Management | Asthma | CKS | NICE
  2. Asthma, acute | Treatment summary | BNF content published by NICE
  3. McKeever T, Mortimer K, Bradshaw L, Haydock R, Pavord I, Higgins B, et al. Temporarily quadrupling the dose of inhaled steroid to prevent asthma exacerbations: FASTHealth Technol Assess 2018;22(70)
  4.  SIGN 58 British guideline on the management of asthma qrg158.pdf (sign.ac.uk)
  5. Oxygen cylinder attribution<a href=”https://www.vecteezy.com/free-vector/oxygen”>Oxygen Vectors by Vecteezy</a>

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