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GUIDELINESONMANAGEMENTOFADULTASTHMA
ACONSENSUSSTATEMENTOFTHEMALAYSIANTHORACICSOCIETY
Outline
Foreword
Acknowledgements
Preface
ListOfParticipants
Introduction
Conceptofasthma
ManagementOfChronicAsthma
Aimofmanagement
Approachtomanagement
Educationofpatientandfamily
Avoidanceofprecipitatingfactors
Drugtreatment
Bronchodilators
AntiInflammatoryDrug
Othertreatments
DrugDelivery
ApproachToDrugTherapy"StepwiseApproach"
Step1
Step2
Step3
Step4
Stepdown
ManagementOfChronicAsthmaInAdults
RescueCourseOfSteroidTablets
AssessmentOfSeverityAndResponseToTreatment
PEFMeasurements
SpecialistReferral
PregnancyAndAsthma
GuidelinesForTheManagementOfAcuteAsthmaInAdults
AimsOfManagement
Assessment
Featuresofmoderatelysevereasthma
Featuresofacutesevereasthma
Lifethreateningfeatures
ManagementOfAcuteAsthmaInAccidentAndEmergencyDepartment
InitialPEF>75%
InitialPEF<75%
ImmediateTreatment
SubsequentManagementInTheWardOrICU
MonitoringTheEffectsOfTreatment
OtherInvestigations
TransferPatientToTheIntensiveCareUnitOrPrepareToIntubate
BeforeDischarge,thepatient
ManagementOfAcuteAsthmaInGeneralPractice
SummaryOfEmergencyRoomManagementOfAcuteAsthma
ChartAndTable
Chart1:ManagementOfChronicAsthmaInAdults
Chart2:SummaryOfEmergencyRoomManagementOfAcuteAsthma
Table1:DiseaseSeverity
Table2:EmergencyRoomManagement30MinutesAfterInitial
TreatmentOfAcuteAsthmaWithAPEF<75%PredictedOrBest
OnArrival
References
Appendix1
Foreword
Asthmamorbidityandmortalityisontheincreaseinanumberofdevelopedcountries.Ourcountry,whichisrapidlybecomingindustrialized,is
alsoprobablysimilarlysaddled,especiallywithincreasedmorbidity.Itisthereforetimelythataguidelineonthemanagementofasthmabe
producedforuseofMalaysiandoctors.Theseguidelineswillhopefullyprovidewellacceptedandwellrecognizedmethodsforthemanagementof
asthmatodoctorswhoseeandtreatpatientswithasthmaintheirpractice.Thecommitteewhichsetuptodrawtheseguidelinesconsistedofchest
physicianswithmanyyearsofexperienceinmanagingtheasthmaticpatients.Theyhavealsoextensivelystudiedguidelinespreviouslyestablished
byothergroupsonasthmamanagementandmodifiedseveralaspectstosuitthelocalsituation.
ItisthesinceresthopeoftheMalaysianThoracicSocietythattheseguidelineswillbenefitbothMalaysiandoctorsandtheirpatientswhosuffer
fromasthma.
Thankyou.
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Dr.I.Kuppusamy
President,
MalaysianThoracicSociety

Acknowledgements
Wewouldliketoexpressourgratitudetothefollowingcompanieswhohavecontributedtothesuccessfulproductionoftheseguidelines:
AstraPharmaceutical(M)SdnBhd
BoehringerIngelheimDivision,DiethelmMalaysiaSdnBhd
GlaxoWellcome(Malaysia)SdnBhd
3MPharmaceuticals,3MMalaysiaSdnBhd
WewouldalsoliketoexpressourgratitudetoPuanNorhayatiBakriforherhelpinthepreparationoftheseguidelines.

Preface
Asthmaisacommondiseasewhichaffectsbothadultsandchildren.Itcontinuestocausesignificantmortalityandpotentiallypreventablewith
propermanagement.Cliniciansmanagingasthmaneedtokeepabreastwiththecurrentconceptofthediseaseanditsmanagementsothatoptimal
carecanbeprovided.Whilethismaybepossibleforsome,manymaynotbeabletodosobecauseoftheconstrainoftimeduetothenatureof
theirworkorpracticeandthedifficultytogetaccesstoreadingmaterials.Thereareguidelinespublishedbyanumberofsocieties/countrieswhich
areavailablebutsomerecommendationsconcerningcertainaspectsofthemanagementmaynotbesuitableforlocalpatients.Realisingthese
variousfactorstheMalaysianThoracicSocietyhasinitiatedtheeffortstoproducetheguidelinesonthemanagementofasthmainadults.Iam
greatlyhonoredtobegiventhetasktogatheragroupofdedicatedandhighlyknowledgeablepeoplewhohavespenttheirinvaluabletimeand
experiencetoproducetheseguidelines.Iwouldliketoexpressmygratitudeandthankstothesememberswhohavepatientlyworkedtogetheruntil
thecompletionoftheguidelines.TheyincludeDr.AziahAhmadMahayuddin,Dr.HooiLaiNgor,Dr.IKuppusamy,AssociateProfessorC.K.
Liam,Dr.GeorgeSimon,AssociateProfessorDr.A.WahabSufarlan,Dr.WongWingKinandAssociateProfessorDr.IsmailYaacob.Without
theirhelpIdonttthinkwecouldhavesuccessfullyproducedthesesguidelines.IamalsothankfultomembersoftheMalaysianThoracicSociety
whohavegiventheirconstructiveviewsorcommentsontheguidelines.
WearealsoindebtedtoAstraPharmaceutical(Malaysia)SdnBhd,BoehringerIngelheimDiv.DiethelmMalaysiaSdnBhd,GlaxoWellcome
(Malaysia)SdnBhdand3MMalaysiaSdnBhdfortheirgenerosityinfinanciallysupportingthisproject.MyspecialthanksalsogoestoMs
NorhayatiBakrifortypingthemanuscript.
Thecompletionoftheseguidelinesdoesnotmeantheendofoureffortstodisseminateinformationonproperasthmacarebutratherthebeginning
ofmoreeffortstowardsachievinganoverallbetterinformedandcompetentclinicianswhoaretomanageasthmaeffectively.Obviouslymore
seminars,workshopandroundtablediscussionsareneededtoachievethisgoalandMTSwilldefinitelyhaveabigroleplayinthisrespect.
WithyoursupportIamsurewecandoit.

BMZZainudin,MD,MRCP,FCCP,AM
ChairmanoftheCommitteeonAsthmaManagementGuidelines
MalaysianThoracicSociety
March1996

ListOfParticipantsParticipants:ChairmanAProffesorDrBMZZainudinDepartmentofMedicineUniversitiKebangsaan
MalaysiaKualaLumpur
DrAMAziahInstituteofRespiratoryMedicineHospitalKualaLumpur
DrLNHooiChestUnitPenangHospital
AProfessorDrAWSufarlanDepartmentofMedicineUniversiti
KebangsaanMalaysiaKualaLumpur
AProfessorDrIsmailYaacobDepartmentofMedicineUniversitiSains
MalaysiaKubangKerian

DrIKuppusamyInstituteofRespiratoryMedicineHospital
KualaLumpur
DrGeorgeSimonChestUnitHospitalAlorSetar
AProfessorDrCKLiamDepartmentofMedicineHospital
UniversityKualaLumpur
DrWKWongPantaiMedicalCentreKualaLumpur

Introduction
Asthmaisacommondiseasewithunacceptablyhighmorbidityandmortality.Manydeathsandmorbidityhavebeenassociatedwithinadequate
treatment,underuseofobjectivemeasurementofseverityandinadequatesupervision.Realisingtheneedtoimprovethemanagementofasthma
amongdoctorsinMalaysia,theMalaysianThoracicSocietyinitiatedeffortstoproduceandpublishthisconsensusstatementonthemanagementof
asthma.SinceconsensusonmanagementofasthmainchildrenwasinitiatedataboutthesametimebytheAcademyofmedicineofMalaysia,this
statementbytheMalaysianThoracicSocietyonlycoversmanagementofasthmainadults.
WerealisethatseveralasthmamanagementguidelinesforexamplethosebytheBritishThoracicSociety,thosefromAustraliaandNewZealand
andtheInternationalconsensusarealreadyavailable.However,localfactorssuchasourhealthcaredeliverysystem,diversesociocultural
backgroundandlevelofeducationwhichareuniquetoourcountryneedtobeaddressed.Thispromptedustoproducetheselocalguidelines.
Weregardthepublicationofguidelinesonasthmamanagementasoneofthestrategiestoimprovetheoverallmanagementofasthmainthe
country.Itshouldcomplementotherprogrammessuchaslectures,workshops,meetingsandperiodicpublications.Wehopetheseguidelineswill
serveasausefulreferencefordoctorsalthoughwealsoappreciatethatviewsmaydifferincertainaspectsofmanagement.Incertain
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circumstances,modificationinmanagementmayhavetobecarriedout.
Althoughthereisnoevidencetodatethatasthmamanagementguidelinesreduceasthmamortality,itisnotunreasonabletoexpectthatproper
managementwillresultmorbidityandconsequentlymortalitytoo.
Toensureaspreadofopinionstheworkingpartywasselectedamongdoctorsworkingingovernmenthospitals,academicinstitutionsandprivate
hospital.

ConceptOfAsthma
Asthmaisachronicinflammatoryconditionoftheairwaysthecauseofwhichisnotcompletelyunderstood.Theinflammationischaracterisedby
oedema,infiltrationwithinflammatorycellsespeciallyeosinophils,hypertrophyofglandsandsmoothmuscleanddamagedepithelium.The
inflammationresultsinthestateofhyperresponsivenesswhereairwaysnarroweasilyinresponsetoawiderangeofstimuli.7Thismayresultin
coughing,wheezing,chesttightnessandshortnessofbreath,whichareoftenworseatnight.Thesearethesymptomsofanattack.Theairway
narrowingisusuallyreversiblebutinsomepatientswithchronicasthmatheinflammationmayleadtoirreversibleairwaysobstruction.8Ingeneral
themoreseveretheasthmathemorefrequentandseverearetheattacks.Sometimesanacuteattackcanbefatal.

ManagementOfChronicAsthma
Aimsofmanagement
Theaimsofmanagementare:
i.torecogniseasthma
ii.toabolishsymptoms
iii.torestorenormalorbestpossiblelongtermairwayfunction
iv.toreducemorbidityandpreventmortality

Approachtomanagement
Inordertoachievethoseaimstheapproachtomanagementshouldinclude:
i.Educationofpatientandfamily
ii.Avoidanceofprecipitatingfactors
iii.Useofthelowesteffectivedoseofconvenientmedicationsminimisingshortandlong
termsideeffects.
iv.Assessmentofseverityandresponsetotreatment.

Educationofpatientandfamily
Thisisanimportantbutoftenneglectedaspectinthemanagementofasthma.Itisessentialinensuringthepatientscooperationandcompliance
withtherapy.Asfaraspossiblepatientsandtheirfamiliesshouldbeencouragedandtrainedtoactivelyparticipateinthemanagementoftheirown
asthma.Patienteducationshouldincludethefollowinginformation:
i.Natureofasthma
ii.Preventivemeasures/avoidanceoftriggers
iii.Drugsusedandtheirsideeffects
iv.Properuseofinhaleddrugs
v.Properuseofpeakflowmeter
vi.Knowledgeofthedifferencebetweenrelievingandpreventivemedications
vii.Recognitionoffeaturesofworseningasthma(increaseinbronchodilator
requirement,developmentofnocturnalsymptoms,reducingpeakflowrates).
viii.Selfmanagementplanforselected,motivatedpatientsorparents.(Appendix1)
ix.Thedangerofnonprescribedselfmedicationincludingcertaintraditional
medicines.

Avoidanceofprecipitatingfactors
Thefollowingfactorsmayprecipitateasthmaticattacks:
i.Betablockerscontraindicatedinallasthmatics
ii.Aspirinandnonsteroidalantiinflammatorydrugsifknowntoprecipitateasthma,these
drugsshouldbeavoided.
iii.Allergens,e.g.housedustmites,domesticpets,pollenshouldbeavoidedwhenever
possible.
iv.Occupationshouldbeconsideredasapossibleprecipitatingfactor.
v.Smokingactiveorpassive.
vi.Daytodaytriggerssuchasexerciseandcoldair.Itispreferabletoadjusttreatment
ifavoidanceimposesinappropriaterestrictionsonlifestyle.
vii.Atmosphericpollution.
viii.Foodifknowntotriggerasthma,shouldbeavoided.

Drugtreatment
Thereare2majorgroupsofdrugstotreatasthma:
1.Bronchodilatordrugstorelievebronchospasmandimprovesymptoms.
2.Antiinflammatorydrugstotreattheairwayinflammationandbronchial
hyperresponsiveness,theunderlyingcauseofasthma,i.e.topreventattacks.
1.Bronchodilators
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Thesedrugstreatsymptomsofasthma.Theyshouldbeusedasrequiredratherthanregularly.Whenasthmaissevereanddifficulttocontrol,
bronchodilatorsmaybetakenonregularbasis.Thereare3maingroupsofbronchodilators:
a.Beta2agonists
b.Anticholinergics
c.Methylxanthines
a.Beta2agonists
Thesedrugsarethemosteffectivebronchodilatorsavailable.Theyaresafedrugswith
fewsideeffectswhentakenbyinhalation.Thetherapeuticeffectisfeltwithinafew
minutesofinhalation.Themainsideeffectsaretremorsandtachycardia.Oralslow
releasepreparationsandinhaledlongactingbeta2agonistssuchasSalmeterol/
bambuterolareusefulfornocturnalasthma.
Examples:Inhaledbeta2agonist:
salbutamol(Ventolin,Respolin)
terbutaline(Bricanyl)
fenoterol(Berotec)
salmeterol(Serevent)longacting
Orallongactingbeta2agonist:
salbutamol(Volmax)
terbutaline(Bricanyldurules)
bambuterol(Bambec)
Oralshortactingbeta2agonist:
salbutamol
terbutalineetc.
b.Anticholinergicdrugs
Inhaledanticholinergicshaveloweronsetbutlongerdurationofaction.Theyhavevery
fewsideeffects.
Examples:Ipratropiumbromide(Atrovent)
c.Methylxanthines
Thesedrugsareavailableinoralandparenteralforms.Theirusefulnessislimitedbyveryvariablemetabolismandanarrowtherapeutic
window.Sustainedreleasepreparationsmaybeusefulinnocturnalasthma.9
Examples:NuelinSR,Theodur,Euphylline
Note:Inhaledbeta2agonistsarethebronchodilatorofchoice.Asfaraspossible,avoid
usingoralbeta2agonistsorxanthinesasfirstlinebronchodilatordrugs.
2.AntiInflammatoryDrug
Asasthmaisachronicinflammatorycondition,antiinflammatorydrugsshouldbealogicaltreatmentformostpatientsexceptforthosewith
mildestasthma.Reducingtheinflammatorywilldecreasebronchialhyperresponsiveness.Thetypesofantiinflammatorydrugsinclude:
i.Corticosteroids
Steroidsarethemainprophylacticdrugsinadultasthmatics.Theyshouldbetakenbyinhalationandthedosageshouldbekepttoa
minimumtoreducesideeffects(usuallylocalsideeffects).10Oralsteroidsmayberequiredforseverechronicasthma.
Examples:Beclomethasonedipropionate(Becotide,Becloforte,Beclomet,Aldecin,
Respocort)Budesonide(Pulmicort)
ii.Sodiumcromoglycate(Intal)
Thisdrugisverysafewithnosignificantsideeffects.Itisgivenbyinhalation(powerSpinhalerormetereddoseinhaler).Itisof
greatestbenefitinyoung,atopicpatients.11

Othertreatments
Antihistaminesincludingketotifenhavebeenproventobeoflimitedefficacyinmanyclinicaltrialsinasthma.1214Hyposensitisationisoflimited
valueinthemanagementofasthma.15

DrugDelivery
Theinhaledrouteispreferredforbeta2agonistsandsteroidsasitproducesthesamebenefitwithfewersideeffectsascomparedtotheoralroute.
Thepressurisedmetereddoseinhaler(MDI)issuitableformostpatientsaslongastheinhalationtechniqueiscorrect.
Forpatientswithpoorcoordination,alternativemethodsfordurginhalationinclude:
spacerdevices,drypowderdevicesandbreathactuatedpressurisedMDI.1621
Althoughoraltreatmentisconvenientformostpatients,thedoserequiredishigherandthereforesideeffectsaremorecommon.2223

ApproachToDrugTherapy"StepwiseApproach"
Treatmentshouldbecarriedoutinastepwisemanner.Patientsshouldbestartedontreatmentatthestepmostappropriatefortheinitialseverityof
theircondition.Treatmentwouldthenbechanged(steppeduporsteppeddown)accordingtotheirprogress.

Step1
ThistreatmentisforpatientswithMILDEPISODICASTHMA,characterisedbynormalornearnormallungfunction,infrequentsymptomsand
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nonocturnalsymptoms(Table1).
Abeta2agonistbyinhalationshouldbeusedonanasneededbasis.Ifnotwellcontrolled,i.e.requiringusageofbeta2agonistmorethanoncea
day,advancetoStep2.

Step2
ThistreatmentisforMODERATEASTHMAcharacterisedbyabnormallungfunction(PEF6080%predicted),frequentsymptomsrequiring
beta2agonistmorethanoncedailyorwithnightsymptoms.
Additionofaninhaledantiinflammatoryagentisrequired.Lowdoseinhaledcorticosteroidsarethedrugsofchoice(e.g.beclomethasoneor
budesonide200800mcgdaily).Twicedailydosingispreferredtoimprovecompliance.Sodiumcromoglycatemayalsobeeffectiveinsome
patients.

Step3
ThisstepisforSEVERECHRONICASTHMA,i.e.patientswithpersistentsymptoms(especiallynocturnalsymptoms),acontinuingneedfor
inhaledbronchodilatorsandpeakflowoflessthan60%predictedorbest.
Highdoseofinhaledsteroidshouldbeused(beclomethasoneorbudesonide8002000mcgdaily)whilstinhaledbeta2agonistshouldbetakenon
anasrequiredbasis.Itmaybenecessarytoaddoneormoreofthefollowing:
i.Regularbeta2agonistsoralbeta2agonists(preferablylongacting)orinhaledlong
actingbeta2agonistornebulisedbeta2agonists.
ii.Inhaledipratropiumbromide(Atrovent)40mcg34timesaday.
iii.Sustainedreleasetheophylline.Wheneverpossiblebloodlevelsshouldbe
monitored.
Alternatively,wheneverthereareproblemswithhighdosesofinhaledsteroids,thesedrugsmaybeaddedtoStep2medications.

Step4
ThisstepisforVERYSEVEREASTHMAcharacterisedbypersistentsymptomsnotcontrolledbytheabovemeasures.
Oralsteroidsshouldbeaddedandthedosekepttothelowestpossiblethatachievescontrol.

Stepdown
Patientsshouldbereviewedregularly.Whenthepatientsconditionhasbeenstablefor36months,drugtherapymaybesteppeddowngradually.
Themonitoringofsymptomsandpeakflowrateshouldbecontinuedduringdrugreduction.

ManagementOfChronicAsthmaInAdults
SeeChart1

RescueCourseOfSteroidTablets
"Rescue"coursesoforalsteroidsmaybeneededtocontrolexacerbationsofasthmaatanystep.Indicationsmayinclude:
a.symptomsandpeakexpiratoryflow(PEF)getprogressivelyworsedaybyday.
b.PEFfallsbelow60%ofpatientsbest.
c.sleepisdisturbedbyasthma.
d.morningsymptomspersistuntilmidday.
e.thereisadiminishingresponsetoinhaledbronchodilators.
f.emergencytreatmentwithnebulisedorinjectedbronchodilatorsisrequired.
Method:
Give3060mgofprednisoloneimmediately.Thedoseshouldbetapereddownandstoppedwithin714days.

AssessmentOfSeverityAndResponseToTreatment
Assessmentshouldbedoneasfollows:
1.Clinicalassessment.Thisshouldincludepatientssymptoms,sleepdisturbances,effort
tolerance,disturbanceofdailyactivitiesandthefrequencyofbronchodilatordrug
and/orrescuecoursesofsteroidused.
2.Measuringpeakexpiratoryflow(PEF).ThiscaneitherbemeasuredbyWrightpeak
flowmeterorminiWrightpeakflowmeter.MiniWrightpeakflowmetersare
affordableformanypatients.

PEFMeasurements
i.Duringperiodsofwellbeing
ThisallowsmeasurementofpatientsbestPEFvaluewhichwillprovidethetargetforthedoctorandthepatienttoaimfor.Twicedaily
measurements(morningandevening)beforeanyinhaledbronchodilatortreatmentwilldeterminethediurnalvariabilityofairwaycalibre.
Thisiscalculatedastherangedividedbythehighestvalueandexpressedasapercentage.
PEF(max)PEF(min)x100=_____________%
PEF(max)
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PEFvariabilityoflessthan20%isregardedasmild,between2030%ismoderateandmorethan30%issevere.Agoodcontrolofasthma
meansPEFvariabilityismaintainedatlessthan10%.
ii.Duringsymptomaticepisodes
DuringanattackofasthmaPEFfairlyaccuratelymeasuresthedegreeofbronchospasm.APEFoflessthan50%ofnormalorbestsuggestsa
severeattachandaPEFoflessthan33%suggestsaverysevereandlifethreateningattack.WhenthebestPEFvalueisnotknown,asingle
readingoflessof200l/minusuallyindicatesasevereattack.
Hence,inadditionaltohistoryandphysicalfindingsthePEFhelpsthedoctortodecideontheappropriatetherapy(besideshistoryand
physicalfindings).AsfaraspossiblepatientswithmoderateandsevereasthmashouldregularlymeasuretheirPEFtwiceadayespecially
whentheirasthmaisworseningorwhentreatmentisaltered.Comparisontolocalnormalvaluesshouldbemade24.

SpecialistReferral
Referraltoarespiratoryphysicianisappropriatewhen:
a.thereisdoubtaboutthediagnosis
b.occupationalasthmaissuspected
c.managementisdifficult,e.g.brittleasthmaorverysevereasthmanotsuccessfully
controlled
d.longtermtreatmentwithnebulisedbronchodilatorisneeded
e.asthmaisworseninginapregnantwoman
f.asthmaisinterferingwithpatientslifestyledespitechangesintreatment

PregnancyAndAsthma
Duringpregnancyasthmainaboutonethirdofwomenbecomesworse,inonethirdbetterandinonethirdremainsunchanged.Howeverthis
cannotbepredicted.Achievinggoodcontrolofasthmaismoreimportantinordertopreventadverseeffectsonbothfetusandmotherthanthe
theoreticalrisksofanyofthepresentlyusedantiasthmamedications.Mostdrugsusedtotreatasthmaaresafewiththeexceptionofalpha
adrenergiccompoundsandepinephrine(botharenotusuallyusedtotreatasthmainMalaysia).Asthmainpregnancythereforeshouldbemanaged
asinotherpatients.Acuteexacerbationsshouldbetreatedaggressivelyinordertoavoidfatalhypoxiaandmaintainmaternalwellbeing.
Treatmentshouldincludenebulisedbeta2agonistsandoxygen,systemiccorticosteroidsshouldbeinstitutedwhennecessary.Patientsshouldalso
haveadequateopportunitytodiscussthesafetyoftheirmedication.

GuidelinesForTheManagementOfAcuteAsthmaInAdults
Thepresentationofapatientwithacuteasthmarequiresrapidassessmentofitsseveritysothattheappropriatetreatmentcanbeinstituted.
Althoughanacutesevereattackofasthmamayoccasionallydevelopwithinafewminutesorhours,itusuallyoccursagainstabackgroundoflong
termpoorlycontrolledasthmaorasthmathathasbeenworseningforsomedaysorweeks.Theseverityofacuteasthmaattacksisusually
underestimatedbypatients,theirrelativesandtheirdoctors,mainlybecauseofthefailuretomakeobjectivemeasurements.25Inadequate
assessmentofsuchattacksorinappropriatetreatmentwithoverrelianceonbronchodilatorsandunderuseofsteroidscontributetomorbidityand
deaths.2629

AimsOfManagement
Theaimsofmanagementare:
i.Topreventdeath
ii.Torelieverespiratorydistress
iii.Torestorethepatientslungfunctiontothebestpossiblelevelassoonaspossible.
iv.Topreventearlyrelapse

Assessment4,3032
Theseverityoftheattackshouldbeassessedby:
i.Historytaking
ii.Physicalexamination
iii.PEFmeasurement

Featuresofmoderatelysevereasthma
normalspeech
pulserate<110/min
respiratoryrate<25breaths/min
PEF>50%predictedorbestvalue

Featuresofacutesevereasthma
Thepresenceofanyofthefollowingindicatesasevereattackofasthma:
toobreathlesstocompletesentencesinonebreath
respiratoryrate25breaths/min
pulserate110/min
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PEF50%predictedorbestvalue

Lifethreateningfeatures
Thepresenceofanyofthefollowingindicatesaverysevereattackofasthma:
centralcyanosis
feeblerespiratoryeffort
silentchestonauscultation
bradycardiaorhypotension
exhaustion
confusionorunconsciousness
PEF<33%predictedorbestvalue(orasinglereadingof<150l/minofpatientswhoarenotabletoblow)
Arterialbloodgas(ABG)tensionsshouldbemeasuredifapatienthasanyofthesevereorlifethreateningfeatures.
ABGmarkersofaverysevere,lifethreateningattachinclude:
anormal(56kPa,or3645mmHg)orhighPaCO2
severehypoxaemia:PaO2<8kPa(60mmHg)irrespectiveoftreatmentwithoxygen
alowpH

ManagementOfAcuteAsthmaInAccidentAndEmergencyDepartment
InitialPEF>75%(Mildacuteasthma)
Sometimes,patientswithmildacuteasthmamaypresentattheA&E.ThisischaracterisedbyaninitialPEFof>75%ofpredictedorbestvalue.In
thissituation,justgiventhepatientsusualinhaledbronchodilator(e.g.salbutamol,terbutalineorfenoterol)fromametereddoseinhaler.
Observefor60minutes.IfthepatientisstableandPEFisstill>75%,discharge.
Beforedischarge:
reviewadequacyofusualtreatmentandstepupifnecessaryaccordingtoguidelinesfortreatmentofchronicpersistentasthma
ensurepatienthasenoughsupplyofmedications
checkinhalertechniqueandcorrectiffaulty
advisepatienttoreturnimmediatelyifasthmaworsens.
makesurepatienthasaclinicfollowupappointment
P/S:Patientsshouldbeconsideredforadmissionifsocialsituationssuchasstayingalone,
lackoftransportforemergencyvisittohospital,etc.

InitialPEF<75%
PatientswhopresenttotheA&EwithmoreseveredegreesofacuteasthmacharacterisedbyaninitialPEF<75%predictedorbestvalue,should
bemanagedasfollows:
1.ImmediateTreatmentWith:
a.Highconcentrationoxygen(>40%)incaseswithinitialPEF<50%atpresentation.
b.Highdosesofinhaledbeta2agonist(salbutamol5mgorterbutaline5mgorfenoterol
5mg)vianebuliserdrivenbyoxygen.Ifcompressedairnebuliserisused,
administrationofsupplementaloxygenwhenindicatedshouldbecontinued.
Alternatively,beta2agonistmaybegivenbymultipleactuationsofapressurised
aerosolinhalerintoalargespacerdevice(25mg,i.e.2050puffs,fivepuffsata
time).
Consideraddinganticholinergic(e.g.ipratropiumbromide0.5mg)tonebulised
beta2agonistforpatientswithacutesevereasthma.
c.Prednisolonetablets3060mg.Veryillpatientsshouldbegivenintravenous
hydrocortisone200mgstat.
NB.Sedativesshouldnotbeprescribed.
Antibioticsareindicatedonlyifthereisevidenceofabacterialinfection.
Doachestxrayifpneumothoraxorpneumoniaissuspectedorfeaturesofacute
severeorlifethreateningasthmaarepresent.
Iflifethreateningfeaturesarepresent:
d.Intravenousaminophylline250mgslowlyover20minutesorintravenousterbutaline
orsalbutamol250mcgover10minutes.(Bolusaminophyllineshouldnotbegivento
patientsalreadytakingoraltheophylline).
*Patientswithfeaturesoflifethreateningasthmarequireadmissionpreferablytothe
intensivecareunit(ICU)andshouldbeaccompaniedbyadoctor.

EffectsOfTreatment
Theeffectsoftreatmentaremonitoredby:
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thepatientsassessmentofsymptoms
physicalexamination
repeatmeasurementofPEF1530minutesafterstartingtreatment
Goodresponsetoinitialtreatment
Suchpatientshould
befreeofwheezinganddyspnoea
haveaclearchestonauscultation
haveapostbronchodilatorPEFwhichis>75%ofpredictedorbestvalue.
Incompleteresponsetoinitialtreatment
Suchapatienthas
persistentwheezingordyspnoea
rhonchionchestauscultation
apostbronchodilatorPEFwhichis5075%ofpredictedorbestvalue.
Poorresponsetoinitialtreatment
Suchapatienthas
persistent,markedwheezingorbreathlessness
diffuserhonchionchestauscultationandothersignsofacutesevereasthma
apostbronchodilatorPEF<50%ofpredictedorbestvalue.
Thesubsequentmanagementofpatientswithaninitial<75%predictedorbestvalueis
summarisedinTable2.

2.SubsequentManagementInTheWardOrICU
Continueoxygenat40%
intravenoushydrocortisone200mg6hourlyorprednisolone3060mgdaily
nebulisedbeta2agonist4hourlythiscansubsequentlybechangedtometereddoseinhaler(Itmaybenecessarytogive
nebulisedbeta2agonistmorefrequently,uptoevery1530minutesandtoaddipratropiumbromide0.5mgtonebulisedbeta2
agonistandrepeat6hourlyifpatientisnotimproving.)
Ifpatientisstillnotimproving,alsogive
aminophyllineinfusion(0.50.9mg/kg/hour)monitorbloodlevels(wherefacilityisavailable)ifaminophyllineinfusionis
continuedformorethan24hours.
terbutalineorsalbutamolinfusionasanalternativetoaminophylline,at320mcg/minafteraninitialintravenousbolusdoseof
250mcgover10minutes.
3.MonitoringTheEffectsOfTreatment
RepeatmeasurementofPEF1530minutesafterstartingtreatment.
Maintainarterialoxygensaturationabove92%(iffacilityforpulseoximetryisavailable)
Repeatarterialbloodgasmeasurementsifinitialresultsareabnormalorifpatientdeteriorates.
ChartPEFbeforeand15minutesaftergivingnebulisedorinhaledbeta2agonistatleast4timesdailythroughoutthehospital
stay.
4.OtherInvestigations
serumelectrolytes(hypokalaemiaisarecognisedcomplicationoftreatmentwithbeta2agonistandcorticosteroids)
electrocardiogramifindicated.
5.TransferPatientToTheIntensiveCareUnitOrPrepareToIntubateIfThereIs:
deterioratingPEF
worseninghypoxaemia,orhypercapnia
exhaustionorfeeblerespirations
confusionordrowsiness
comaorrespiratoryarrest
InICU,
Continuewithoxygensupplementation
Continuewithintravenoushydrocortisone
Ifthepatientismechanicallyventilated,administernebulisedbeta2agonist(withorwithoutipratropium)viatheendotracheal
tube.Thiscanbegivenuptoevery1530minutes.
Intravenousaminophyllineinfusionorterbutalineorsalbutamolinfusionmayalsobegiven.
6.BeforeDischarge,thepatientshouldbe:
startedoninhaledsteroidsforatleast48hoursinadditiontoashortcourseoforalprednisoloneandbronchodilators.
stableonthemedicationheisgoingtotakeoutsidethehospitalforatleast24hours.
havingPEFof>75%ofpredictedorbestvalueandPEFdiurnalvariabilityof<25%.
taughtandcheckedonthecorrectinhalertechniqueandifnecessary,alternativeinhalerdevicesshouldbeprescribed.
educatedonthedischargemedication,homepeakflowmonitoringandselfmanagementplan(forselected,motivatedpatients),
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andtheimportanceofregularfollowup.
givenanearlyfollowupappointmentwithin4weeksforreassessmentoftheconditionandforadjustmentofthemedications.

ManagementOfAcuteAsthmaInGeneralPractice
Managementissimilartothatintheaccidentandemergencydepartment.Theclinicshouldhavefacilityforoxygenadministrationanditis
essentialthatequipmentforresuscitationshouldbeavailable.

Theseareindicationsforimmediatereferraltohospital
Anylifethreateningfeatures
Anyfeaturesofasevereattackthatpersistafterinitialtreatment
PEF1530minutesafternebulisationwhichis<50%ofpredictedorbestvalue.

Thresholdforreferraltohospitalshouldbeloweredforpatients:4
seenintheafternoonoreveningratherthanearlierintheday.
withprevioussevereattacks,especiallyiftheonsetofthecurrentattackwasrapid
inwhomthereisconcernoverthesocialcircumstancesorrelativesabilitytorespondappropriately.

SummaryOfEmergencyRoomManagementOfAcuteAsthma
SeeChart2

ChartAndTable
CHART1:ManagementOfChronicAsthmaInAdults
STEP1

STEP2

MILDEPISODICASTHMA
Infrequentsymptoms
Nonocturnalsymptoms
PET80100%predicted
Treatment:
inhaledbeta2agonist"as
needed"forsymptomrelief.
Ifneededmorethanoncea
day,advancetoStep2

STEP3

MODERATEASTHMA

SEVERECHRONIC
ASTHMA

Frequentsymptoms
Nocturnalsymptoms
present
PEF6080%predicted
Treatment

Persistentsymptoms
Frequentnocturnal
symptoms
PEF60%predictedorless
Treatment:

inhaledsteroids,e.g.
beclomethasoneor
budesonide200800
mcg/day
inhaledsodium
cromoglycateplus
inhaledbeta2agonist"as
needed"

inhaledbeclomethasoneor
budesonide8002000
mcg/dayplus
inhaledbeta2agonistas
neededplus,ifnecessary
oralbeta2agonist
preferablylongacting,or
inhaledlongactingbeta2
agonist,or
inhaledipratropium
bromide40mcg34times
aday,or
oraltheophylline(sustained
release),or
nebulisedbeta2agonist,24
timesaday

STEP4
VERYSEVEREASTHMA
Persistentsymptomsnot
controlledbystep3
medications
Treatment:
asinstep3,plusoral
steroids(thelowestdose
possible)

NOTE:
Educationisimportantforpatientsandrelatives
Triggersavoidancewheneverpossible
Initialtreatmentdependsonseverityofasthmaatfirstassessment
Reviewtreatmentevery36months.Whensymptomsarecontrolled,considergradualstepdownoftreatment,Ifuncontrolled,considerstep
up.
Monitorpeakflowwheneverpossibleformoderate,severeandverysevereasthma.
Usewrittenasthmaplanwheneverfeasibleformoderate,severeandverysevereasthma.

CHART2:SummaryOfEmergencyRoomManagementOfAcuteAsthmaTABLE1DiseaseSeverity
Grade

History

Bronchodilator
requirement

Variability
inPEF

BestPEF
(percentageof
predicted)

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Severe

Wakesatnightfrequently
withwheeze,coughchest
tightnessonwakingin
morninghospital
admissioninthelastyear
previouslifethreatening
attacks

Neededmore
thanfourtimesa
day

>30%

Moderate

Symptomsonmostdays
Nocturnalsymptoms
>twiceamonth

Neededonmost
days

20%30%

Mild

Mildoccasionalsymptoms
e.g.onlywithexerciseor
infections

Needed
occasionally

10%20%

<60%

60%80%

80%100%

Note:Oneormorefeaturesmaybepresentforanygradeofseverity.Anindividualshouldbeassignedtothemostseveregradeinwhichany
featureoccurs.

TABLE2:EmergencyRoomManagement30MinutesAfterInitialTreatmentOf
AcuteAsthmaWithAPEF<75%PredictedOrBestOnArrival
GoodresponseandPEF
>75%predictedorbest
value

Observeforanother60minutes
IfpatientisstableorimprovingandPEFisstill>75%,DISCHARGE.

Incompleteresponseand
PEF5075%predictedor
bestvalue

Repeatnebulisedbeta2agonist
Observefor60minutes.
(1)IfPEFisstill75%,
ADMIT
(2)Ifpatientimprovesand
PEF>75%,
DISCHARGE.
*Patientsrequiring
admissionshouldbe
accompaniedbyanurse
ordoctor.

PoorresponseandPEF
<50%predictedorbest
value

ADMIT
*Patientsrequiring
admissionshouldbe
accompaniedbyanurse
ordoctor.

Beforedischarge:
giveprednisolone3040mgdailytaperingover714days,plusregularinhaledsteroidsandinhaledbeta2agonisttobetakenas
needed
reviewadequacyofusualtreatmentandstepupifnecessaryaccordingtoguidelinesfortreatmentofchronicpersistentasthma
ensurepatienthasenoughsupplyofmedications
checkinhalertechniqueandcorrectiffaulty
arrangeforfollowup
advisepatienttoreturnimmediatelyifasthmaworsens
P/S:Patientsshouldbeconsideredforadmissionifsocialsituationssuchasstayingalone,
lackoftransportforemergencyvisittohospitaletc.

References
1.BritishThoracicAssociation.DeathfromasthmaintworegionsofEngland.
BrMedJ1982285:12515
2.BucknallCE,RobertsonC,MoranF,StevensonRD.Differencesinhospital
management.Lancet1988I:74850
3.EasonJ.MarkoweHLJ.Controlledinvestigationofdeathsfromasthmainhospitals
intheNorthEastThamesregion.BrMedJ1987294:12558
4.BritishThoracicSociety,BritishPaediatricAssociation,RoyalCollegeofPhysicians
ofLondon,KingsFundCentre,NationalAsthmaCampaign,RoyalCollegeof
GeneralPractitioners,GeneralpractitionersAsthmaGroup,BritishAssociationof
AccidentandEmergencyMedicine,BritishPaediatricRespiratoryGroup:
Guidelinesinthemanagementofasthma.Thorax199348(suppl):S1S24
5.WoolcockA,RubinfeldAR,SealeP,LandauLL,AnticR,Mitchellc,ReaHH,
ZimimermanP.ThoracicSocietyofAustralianandNewZealand:Asthma
ManagementPlan,1989.MedJAustralia1989151:6502
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6.Internationalconcensusreportonthediagnosisandmanagementofasthma.Clin
ExpAllergy199222(suppl):172
7.HolgateST,FinnertyJP.Recentadvancesinunderstandingthepathogenesisof
asthmaanditsclinicalimplications.QJMed1988249:519
8.RocheWR,BeasleyR,WilliamsJH,HolgateST.Subepithelialfibrosisinthe
bronchiofasthmatics.Lancet1989I:5204
9.WeinbergerM,HendelesL.Slowreleasetheophylline:rationaleandbasisfor
productselection.NEnglJMed.1983308:7604
10.ToogoodJA.Complicationsoftopicalsteroidtherapyofasthma.AmRevRespir
Dis1990141:589596
11.EigenH,ReidJJ,DahlR,DelBufaloC,FasanoL,GuinellaGetal.Evaluation
oftheadditionofcromolynsodiumtobronchodilatormaintenancetherapyinthe
longtermmanagementofasthma.JAllergyClinImmunol198780:61221
12.PattersonJW,YellinRH,TarolaRA:Evaluationofketotifen(HC20511)in
bronchialasthma.EurJClinPharmacol198325:187193
13.TinkelmanDG,WebbCS,VanderpplGE,Carrols,SpranglerDL,LotnerGZ:The
useofketotifenintheprophylaxisofseasonalallergicasthma.
AnnAllergy198656:2137
14.GrafflonnevigV,HadlinG.Theeffectofketotifenonbronchialhyperreactivityin
childhoodasthma.JAllergyClinImmunol198576:5963
15.BritishThoracicSociety,RoyalCollegeofPhysiciansofLondon,KingsFund
Centre,NationalAsthmaCampaign:Guidelinesformanagementofasthmainadults:
1chronicpersistentasthma.BrMedJ19903016513
16.SvedmyrN,LofdhlC,SvedmyrK.Theeffectofpowderaerosolcomparedto
pressurisedaeosol.EurJRespirDis198263
17.HetzelMR,ClarkTJH.ComparisonofsalbutamolRotahalerwithconventional
pressurisedaerosol.ClinAllergy19777:5638
18.HultquistC,AhlstromH,KjellmanNM,MalmqvistLA,SvenoniusE,MelinS.
Adoubleblindcomparisonbetweenanewmultidosepowderinhaler(Turbuhaler)
andmetereddoseinhalerinchildrenwithasthma.Allergy198944:46770
19.PedersonS.Aerosoltreatmentofbronchoconstrictioninchildrenwithor
withoutatubespacer.NEnglJMed1983308:132830
20.LindgrenSB,LarssonS.Inhalationofterbutalinesulphatethroughaconventional
actuatororapearshapedtube:Effectsandsideeffects.
EurJRespirDis198263:5049
21.ZainudinBMZ,BiddiscombeM,TolfreeSEJ,ShortM,SpiroSG.Comparisonof
bronchodilatorresponsesanddepositionpatternsofsalbutamolinhaledfroma
pressurisedmetereddoseinhaler,asadrypowderandasanebulisedsolution.
Thorax199045:46973
22.ShimC,WilliamsMHJr.Bronchialresponsestooralversusaerosol
metaproterenolinasthma.AnnInternMed198093:42831
23.LarssonS,SvedmyrN.Bronchodilatingeffectanddifferentmodesofadministration
(tablets,meteredaerosol,andcombinationthereof):Astudywithsalbutamolin
asthmatics.AmRevRespirDis1977116:8619
24.DaCostaJL,GohBK.PeakexpiratoryflowrateinnormaladultChinesein
Singapore.SingaporeMedJ197314:5114
25.StatementbytheBritishThoracicSociety,ResearchUnitoftheRoyalCollege
ofPhysiciansofLondon,KingsFundCentre,NationalAsthmaCampaign.
Guidelinesforthemanagementofasthmainadults:IIacutesevereasthma.
BrMedJ1990301:797800
26.SearsMR.Increasingasthmamortality:Factorartifact?
AllergyClinImmunol198882:95760
27.GlazebrookKN,SutherlandDC.Managementofacuteasthmaattacksin
AucklandA&EDepartments.NZMedJ198598:5903
28.JohnsonAJ,NunnAJ,SommerAR,StableforthDE,StewartCJ.
Circumstancesofdeathfromasthma.BrMedJ1984288:11702
29.BarnesPJ.Managingasthmainhospital:Causeforconcern.
PostgradMedJ199167:13
30.AdamsSL,MartinHG.Theemergentapproachtoasthma.
Chest1992101:S422S425
31.FitzGeraldJM,HargreaveFE.Theassessmentandmanagementofacute
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32.Reportofthesecondmeeting.Theinternationalclinicalrespiratorygroup.
Chest1992101:14204

Appendix1
Exampleofawrittenasthmamanagementplan.
Name:.
Address:

Tel.Numbers
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GeneralPractitioner:.
Specialist:.
Ambulance:..
Hospital:..
UsualMedication:
1..
2...
3...
4...
BestPeakFlowReading:.L/min.
YOURASTHMAISMODERATELYSEVEREIF:
Youwakeuponceortwiceanightwithasthma.
Youneedyourbronchodilatormorethan4timesaday.
Younoticewheezeanddifficultyinbreathingmorethanusualduringtheday.
Yourpeakflowislessthan(80%ofbest)
Youshoulddoublethedoseof.for2weeks
YOURASTHMAISSEVEREIF:
Youwakeupwithasthmamorethantwiceanight.
Youneedyourbronchodilatormorethan6timesaday.
Younoticewheezeanddifficultyinbreathingmostoftheday.
Yourpeakflowislessthan(60%ofbest)
Youshoulddoublethedoseof.for2weeksandtaketabletsofprednisolone(..mg)onthefirstday
andreducethatby1tableteachday.
YOURASTHMAISVERYSEVEREIF:
Youareawakemostofthenight.
Youareshortofbreathatrest.
Youcanonlyspeakinshortsentencesofafewwords.
Yourpeakflowislessthan(50%ofbest)evenafterextradosesofmedication.
Youshouldtake5puffsof.andimmediatelytaketabletsofprednisolone(..mg)andsee
yourdoctor.

FAZZA'99

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