Status asthmaticus

ACUTE EXACERBATION OF ASTHMA

Defined as progressive or sudden onset of worsening symptoms such as shortness of
breath, chest tightness, wheezing and coughing.
• Early recognition is required to prevent morbidity and mortality as symptoms can
progress rapidly to respiratory failure and death. Exacerbation rate in Malaysia was
68.1% in a year

Status asthmaticus is a life-threatening and medical emergency situation

Asthma : Airflow limitation which is usually reversible

ii) Airway hyperresponsiveness to a wide range of stimuli
iii) Inflammation of the bronchi
Symptoms of Physical
asthma Examination
Assessment of Severity
1. Focused history
• [time of onset, severity of symptoms, current treatment and risk
factors of asthma-related death]
• Further history taking and detailed physical examination can be done
after initiation of emergency treatment
2. Physical examination should be performed along with the initiation
of acute treatment
Signs of severe exacerbation of
asthma are
o sit forward o speak in words or short phrases
o use of accessory muscles
o agitation/altered consciousness
o tachypnoea
o tachycardia
o hypoxia
o silent chest

The severity of these symptoms and signs, in addition to objective measurement of lung function
(PEF/FEV1) are used to catogerise asthma exacerbations as mild, moderate, severe or life-
threatening
Level of severity of acute asthma
attack
Monitoring and Evaluation of
asthma severity
1. PEF or FEV1
• Measurement of airway calibre
• Expressed as a percentage of the patient’s previous best value or percentage of predicted
• Measurement will determine severity and treatment
2. Oxygen saturation (SpO2)
• Measured with pulse oximeter to determine the adequacy of oxygen therapy
• Aim of oxygen therapy is to maintain SpO2 at 94 - 98%
3. Arterial blood gases
• Assessment of pH, level of oxygen and carbon dioxide from blood via direct arterial puncture
• To be performed in life-threatening asthma or SpO2
4. Chest radiograph
• Is recommended in patients with:
- suspected pneumothorax or pneumomediastinum
- suspected consolidation
- failure responding to treatment
- life-threatening asthma
Risk factors for asthma related
death patients
• H/o near fatal-asthma requiring intubation and mechanical ventilation
• H/o hospitalization or emergency visit for asthma within the past year
• Currently using/recent stopped of oral glucocorticosteroids
• Not using oral glucocorticosteroids
• Over dependent [ use >1 canister of salbutamol monthly]
• H/o PSY or usage of sedative
• H/o non-compliance to asthma medication plan
EMERGENCY MANAGEMENT
INITIAL ASSESSMENT
• History
• PE [auscultation, use of accessory muscles, HR, RR, PEFR or FEV1, oxygen saturation, arterial blood gas if patient in
extremis]

The aims of treatment in acute asthma are to achieve rapid improvement of symptoms and prevent mortality

INITIAL TREATMENT
• Oxygen to achieve O2 saturation of >/= to 90%
• Inhaled rapid acting beta 2 agonist continuously for one hour
• Systemic glucocorticosteroids if no immediate response
• Sedation is contraindicated in treatment of exacerbations

REASSESS PATIENT AFTER 1 HOUR

PE, PEFR, 02 saturation
MILD ATTACK OF ASTHMA
*PEFR >80%, no features of severe/life threatening symptoms

1. Give inhaled bronchodilator or Neb w B2 agonist

2. Observe 60 mins
3. If stable, PEFR >80%, discharge home with
- Oral prednisolone
- Adequate supply of med at least 1000 ug/day of inhaled beclomethasone / budesonide /
fluticasone
- Already on inhaled steroids : Advise quadruple the dose for 2 weeks or add LABA
- Asthma management plan
- F/u
MODERATE ATTACK OF ASTHMA
*PEFR 60-80%, moderate symptoms w accessory muscle use

1. Oxygen
2. Immediately give Neb Salbutamol 5 mg or Terbutaline 10 mg every 60 min
3. Oral Prednisolone 1mg/kg
4. Continue treatment for 1-2 hours, repeated doses of inhaled/neb steroids.
Budesonide
Via spacer 800ug
Via neb 500-1000ug every 30 min for 120 min

REASSESS AFTER 1 hour

Improvement -> continue observing for 1-3 hours ->stable ->discharge

Unchanged -> repeat neb beta agonist
Worsen -> admit or PEFR<30%, ICU
SEVERE or LIFE THREATENING ATTACK OF ASTHMA
*PEFR <60% , risk factors for near fatal asthma, PE : severe symptoms at rest, chest retraction, no improvement
after initial treatment

1. Oxygen 40-60%
2. Immediately give Neb Salbutamol 5mg or terbutaline 10mg, given every 15-30 min or continuous per hour
[Repeat neb w salbutamol or terbutaline every 15-30mins or continuous at 10-15mg/hr]
3. Add Ipratropium 0.5mg
4. IV hydrocortisone 200 mg or Oral Prednisolone 30-60mg
5. IV magnesium 2g [4ml of 50% magnesium sulphate], given over 20 mins
6. Anxiolytic and hypnotic drugs shouldn’t be given due to respiratory depressant effects
7. CXR to exclude pneumothorax or lung collapse

REASSESS AFTER 30-60 mins

Incomplete response ->admit to acute ward for close monitoring
Poor response -> PEFR<30%, admit ICU and give:
8. IV aminophylline 250mg over 20 mins or salbutamol 250ug over 10 mins or terbutaline 250ug over 10 min
9. Consider intubation and ventilation
AFTER RE-ASSESSMENT
GOOD RESPONSE
1. Response sustained 60 mins
after last treatment
2. PE : NO distress
3. O2 saturation >90%
INCOMPLETE RESPONSE
RF near fatal asthma
PEFR <60%
O2 saturation no improvement
PE : mild to moderate signs
Admit to acute care setting
1. Oxygen
2. Inhaled beta2 agonist +/-
anticholinergic
3. Systemic glucocorticosteroid
4. IV magnesium
5. Monitor PEFR, O2 saturation
and pulse
No improvement in 6-12hrs,
consider admit to ICU
POOR RESPONSE
RF near fatal asthma, pt drowsy or
in confusion state
PEFR <30%
PCO2 >45mmHg
PO2 <60mmHg
Admit to ICU
1. Oxygen
2. Inhaled beta2 agonist +
anticholinergic
3. IV glucocorticosteroids
4. Consider IV beta2 agonist
5. Consider IV theophylline
6. Possible intubation and
mechanical ventilation
Intubation and mechanical
ventilation
Required in patients with :
• Severe respiratory distress
• Worsening hypoxaemia
• Mental status changes
• Obvious exhaustion
• CO2 retention

Consider midazolam infusion or propofol if sedation needed with available

expertise . Morphine will precipitate further bronchospasms
Monitor effects of treatment
1. Repeat PEFR 15-30 mins after start treatment
2. Maintain Arterial oxygen saturation >92%
3. Repeat ABG measurement
4. Chart PEFR before and 15 min after giving neb or inhaled B2 agonist
[at least 4 times daily]
5. Monitor serum electrolytes
*hypokalaemia complication of B2 agonist and corticosteroids
Criteria for admission
• deteriorating PEF
• persisting or worsening hypoxia
• hypercapnia
• arterial blood gas analysis with worsening acidosis
• exhaustion
• drowsiness, confusion or altered conscious state
• respiratory arrest
DISCHARGING PATIENTS
• Stable on discharge medication for at least 24 hours
• Criteria : PEFR >75%

• BEFORE DISCHARGE..
• Started/continue inhaled beta2agonist [higher dose & at least bd] for
at least 48 hours
• Oral prednisolone 0.5-1mg/kg/day
• Adding combination inhaler as option
• Educate : discharge medication, inhaler technique, home peak flow
monitoring, importance of regular follow up
• Give Asthma management plan to maintain asthma control
THANK YOU