Management of Acute Asthma in Adults MOHW August 2020

A. Assessment of severe asthma

(<60mmHg)
(35-45mmHg)

B. Investigations
 Pulse oximetry
 Arterial blood gases
Patients with SpO₂<92% or other features of life-threatening asthma require
ABGmeasurement
 Chest X ray
Chest X-ray is not routinely recommended in patients in the absence of:
- suspected pneumomediastinum or pneumothorax
- suspected consolidation
- life-threatening asthma
- failure to respond to treatment satisfactorily
- requirement for ventilation

C. Treatment of Acute Asthma

 Most patients will require admission

 Oxygen therapy
 Give controlled supplementary oxygen to all hypoxaemic patients with acute severe
asthma titrated to maintain anSpO₂ level of 94–98%.
 Do not delay oxygen administration in the absence of pulse oximetry but commence
monitoring of SpO₂ as soon as it becomes available.
 Nebulisers for giving β₂ agonist bronchodilators should preferably be driven by oxygen

 Steroid Therapy
 Give steroids in adequate doses to all patientswith an acute asthma attack
i. prednisolone 40-50mg/day if patient can tolerate orally
ii. Hydrocortisone 200mg IV stat followed by 100mg IV TDS if patient cannot
tolerate orally
  Continue prednisolone (40–50 mg daily) untilrecovery (minimum 5 days)
 β₂ agonist bronchodilators
 Use high-dose inhaled β₂ agonists as firstline agents in patients with acute asthma and
administer as early as possible – salbutamol 5mg
 Reserve intravenous β₂ agonists for those patients inwhom inhaled therapy cannot be
used reliably
 Ipratropium bromide
 Add nebulised ipratropium bromide (0.5 mg 4–6 hourly) to β₂ agonist treatment for
patients with acute severe or life-threatening asthma or those with a poor initial response
to β₂ agonist therapy
 Other therapies
 Consider giving a single dose of IV magnesiumsulphate(1.2–2 g IV infusion over
 20 minutes)to patients with acute severe asthmawho havenot had a good initial response
to inhaledbronchodilator therapy.
 Routine prescription of antibiotics is notindicated for patients with acute asthma.
 Referral to intensive care
Refer any patient:
• requiring ventilatory support
• with acute severe or life-threatening asthma,who is failing to respond to therapy,
as evidenced by:
- persisting or worsening hypoxia
- hypercapnia (PaCO2>45mmHg)
- ABG analysis showing ↓pH (<7.36) or  H+ (>45nmol/L)
- exhaustion, feeble respiration
- drowsiness, confusion, altered conscious state
- respiratory arrest

References:
British Thoracic Society. British guideline on themanagement of asthma. Quick reference guide. 2019.
www.sign.ac.uk.

Summary of recommendations
A. Assessment of severe asthma
 (<60mmHg)
(35-45mmHg)

B. Investigations
 Pulse oximetry
 Arterial blood gases
 Chest X ray if
- suspected pneumomediastinum or pneumothorax
- suspected consolidation
- life-threatening asthma
- failure to respond to treatment satisfactorily
- requirement for ventilation
C. Treatment
 Admission
 Oxygen therapy
 To maintain SpO₂ level of 94–98%.
 Steroid Therapy
 prednisolone 40-50mg/day if patient can tolerate orally
 Hydrocortisone 200mg IV stat followed by 100mg IV TDS if patient cannot
tolerate orally
 Bronchodilators
 Nebulise with Salbutamol 5mg with or without ipratropium bromide 0.5 mg 4–6
hourly
 Consider giving a single dose of IV magnesium sulphate (1.2–2 g IV infusion over 20
minutes)
 Routine prescription of antibiotics is not indicated for patients with acute asthma.
 Referral to intensive care in case deteriorating or life threatening features.

Differentiating Asthma from COPD

Clinical Features COPD ASTHMA

 Age Onset > 40 years < 40 years/ Childhood

Family History No Common

Smoker Very Often Rare

Allergy No Common
( Eczema / Rhinitis)

Chronic Sputum Production Yes NO

Dyspnoea Persistent Variable

Nocturnal Wheeze Rare Common

Disease Course Progressively worse Stable between exacerbations

Acute Dyspnoea ? Respiratory ? Cardiac

Clinical Features favouring Respiratory Cardiac Origin

Age Young Middle Aged / Elderly *

Fever + 0

Cough + Rare

Orthopnoea 0 +

Sputum Production Often No

Past History Asthma / COPD Often DM / HBP / CAD

Wheeze +++ +/-

Bilateral Fine Crepitations 0 +++

*Concomitant respiratory and cardiac causes can occur in middle aged /elderly

Investigations:
ECG / CXR / Arterial Blood gases / FBC