ASTHMA - A Clinical Approach

ASSESSMENT

MANAGEMENT

  • Place in monitored area (if Moderate/Severe episode)
  • Oxygen (maintain SaO2 > 93)
  • If severely unwell, CPAP (but BIBAP is better) or Intubation and ventilation may be eventually required (see Ventilation Strategy for Acute Asthma) - Remember ventilatory support is generally a last resort
  • Commence treatment
  • Monitor treatment (see Assessing severity)
  • Address complications of treatment (e.g. anaphylaxis, hypokalemia, arrhythmias)
  • Treat complications (e.g. pneumothorax)
  • Treat/Avoid precipitants
  • Antibiotics (only if pneumonia, acute sinusitis)

INVESTIGATONS

CXR

Indications

  • first presentation of asthma
  • T > 37.8o C
  • focal chest findings
  • pleuritic chest pain
  • on long term maintenance steroids
  • failure to respond to therapy
  • deterioration after initial response

ABG

Indications

  • severe asthma
  • altered mental state
  • SpO2 < 90%

Do not delay treatment to take ABGs

DISPOSAL

Consider this:

Admit the following:

  • pre-treatment PEFR < 25% previous best or predicted
  • post-inital nebuliser PEFR < 40% previous best or predicted

(Have lower threshold for patients with High risk factors)

Admit HDU/ICU if:

  • Respiratory failure
  • Persistent Moderate/Severe asthma following aggressive treatment

Discharge

If after 2 hours after last nebulisation:

DISCHARGE PLAN

  • Prednisolone 50mg daily (3-5 days) [no need to taper unless course duration > 2 weeks)
  • Start or increase steroid inhaler to 4 puffs bd
  • Give asthma discharge advice handout
  • GP review within 48 hours.