Treatment of Acute Exacerbation of Asthma
See also Management of acute expiratory airflow obstruction and exacerbation of asthma in children Management of Acute Expiratory Airflow Obstruction and Exacerbation of Asthma in Children.
Essentials
- The patient, family members, and the physician often underestimate the severity of an acute exacerbation of asthma.
- The aim of the treatment is
- to restore the condition and the pulmonary functions of the patient to a satisfactory level as soon as possible
- to maintain an optimal functional status and to prevent exacerbations.
Recognition of an acute exacerbation of asthma
- Occurrence of even one of the following signs means that the attack is severe:
- wheezing and dyspnoea have increased so that the patient cannot finish one sentence without stopping for breath, or cannot stand up from a chair
- respiratory frequency constantly 30/min or more
- heart rate constantly 100-120/min or more (> 30 minutes after salbutamol inhalation)
- PEF less than 60% of the best previous value
- oxygen saturation below 90-95%
- the condition of the patient deteriorates despite treatment.
Signs indicating a life-threatening attack
- Silent respiration sounds in auscultation
- Cyanosis
- Bradycardia or hypotension
- Exhaustion, confusion or unconsciousness
- Arterial blood pO2<8 kPa even after breathing extra oxygen, arterial pCO2>6 kPa or decreased pH.
Tests and investigations
- PEF in the beginning of the treatment and in the follow-up
- Pulse oximetry (reveals hypoxia, but not hypercapnia)
- Heart rate and blood pressure
- Arterial blood gas analysis in severe conditions; repeated as needed
- Plasma potassium and blood glucose
- ECG in elderly patients
- Chest x-ray in severe and poorly responding cases to exclude pneumothorax, pulmonary infiltrates, infections and pulmonary oedema
- Exclusion of sinusitis Acute Maxillary Sinusitis
Indications for intensive care
- Persistent severe dyspnoea despite short-acting inhaled bronchodilator given with an inhalation spacer repeatedly 3-4 times at 20-30 min intervals or short-acting bronchodilator given with a nebulizer twice at a 30-60 min interval.
- Alternative dosages
- Salbutamol 100 µg 2-4 puffs with an inhalation spacer 3-4 times, each at least 20 min apart; then at least 4 hours between subsequent doses
- Salbutamol 100 µg 2-4 puffs and ipratropium bromide 20 µg 2 puffs with an inhalation spacer 3-4 times, each at least 20 min apart; then at least 4 hours between subsequent doses
- Salbutamol (2.5 mg) and ipratropium bromide (0.5 mg) 1 dose container; the dose can be repeated, as necessary, after 30-60 min, followed by 1 dose container with an interval of at least 4 hours
- Arterial blood pO2 is below 8 kPa despite breathing of extra oxygen
- Arterial blood pCO2 is over 6 kPa
- Exhaustion
- Confusion, drowsiness
- Unconsciousness
- Respiratory arrest
Further treatment
- The patient should not be left alone until the condition has clearly improved.
- Continue oxygen therapy as needed.
- Continue oral glucocorticoid therapy (e.g. 30-40 mg prednisolone/day)Corticosteroids for Preventing Relapse Following Acute Exacerbations of Asthma.
- If the condition is improving, continue nebulisation treatment at 4-hour intervals.
- If the condition has not improved, repeat nebulisation treatment in 20-30 minutes.
- Sedative drugs must not be used in exacerbation of asthma, except in intensive care units.
- Antimicrobial drugs are not indicated if there are no signs of a bacterial infection.
Hospital discharge after acute exacerbation of asthma
- Pulmonary functions must be normalised before the patient is discharged
- PEF value must be over 70% of reference value or of previous maximal value.
- Upon discharge, make sure that the patient has