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Department of Emergency medicine

Seminar on approach to Acute asthma

Moderator: Dr. Shimelis K (MD, Emergency medicine and
critical care specialist)

Presenter: Habib Geribe

June 06/2022

Adama, Ethiopia
 Outlines

 Introduction

 Classification

 Approach to acute asthma pt

 Differentials

 Management principles

 References
 Objectives

At the end of this seminar students will be able to:

 Define bronchial asthma and acute asthma

 Understand epidemiology of asthma

 Understand how to approach to acute asthma

 Know of management principles of acute severe

asthma
 Introduction

 Asthma is a chronic inflammatory disorder

characterized by increased responsiveness of the
airways to multiple stimuli and associated with
reversible airflow obstruction.
 EPIDEMIOLOGY

 Asthma affects approximately 8% of the U.S. population

 the most common chronic disease of childhood (9%
prevalence) and affects 7% of the elderly
 Approximately one half of cases of asthma develop
before the age of 10 year
 one third develop before the age of 40 years old.
PATHOPHYSIOLOGY
 Triggaring factor

 infections Drug like aspirin, β-

 allerge blockers, and NSAID

Exposure to cold air
 Exercise
 Endocrine factors
 Environmental
Emotional stress
 Occupational exposures
 Acute asthma

 Episodes of acute bronchospasm that results life

threatening condition require emergency medical care

 Near fatal asthma

 Increase pCO2 and/or requiring mechanical
ventilation
 Acute severe asthma

 Any 1 of:
• Inability to complete sentences in 1 breath.
• Respiratory rate ≥25/min.
• Heart rate ≥110/min.
• Peak flow 33–50% best or predicted
 Risk factors for severe Asthma

 Factors increasing the risk of severe life-threatening

asthma
 previous ventilation
 hospital admission for asthma in the last year
 heavy rescue medication use
 >3 classes of asthma medication
 repeated attendances at emergency room for asthma
care
 Patiant approach
Initial assessment
1. Assess for signs of imminent respiratory arrest. If present start treatment
immediately
 Characteristics of imminent arrest iv. No wheezing
v. Bradycardia
i. Unable to walk
vi. (Unable to perform PEF
ii. Drowsy or confused measurement)
iii. Has paradoxical chest movements

2. If no signs of imminent arrest, assess for signs of clinical distress

3. If the patient is not in imminent arrest, proceed with assessment and treatment
.
classification
DDX
 DIAGNOSIS AND PATIENT MONITORING

 Pulmonary Function Tests

 Chest x-ray

 Pulse oxometry
 ABG

 CBC
 ECG
 Management of acute asthma

 The goal
 Symptom contora
 Risk reduction
 Management of acute asthma

Principles of management

 Use the ABC approach

 Put patients on oxygen

 Treat the respiratory distress

 Identify and treat precipitating factors

 Adequate hydration –essential

 Ventilatory considerations
 Drug of choice

 Controller
 Add-on controll
 Reliver medication
 The GINA 2021 treatment for adults and
adolescents

 GINA treatment has two ‘tracks

 Track 1, with low dose ICS-formoterol as the reliever
 the preferred approach
 it reduces the risk of exacerbations
 Track 2, with SABA as the reliever,
 is an alternative approach
.
 Acute severe asthma

 Immediate therapy
 Priorities of treatment
 Treat hypoxia
 Treat bronchospasm and inflammation
 Assess need for intensive care
 Treat any underlying cause if present
 Severe or life threatening attack

 Initial treatment
 give Oxygen and Maintain O2 saturation > 92%
 Bronchodilators ( SABA) and ICS-
 Technique of salbutamol puff

Puff: 4-8 puffs Q 20 min for up to 4 hrs, then Q 1-4 hrs

as needed
 Severe or life threatening attack

 Start steroids
o Hydrocortisone: 200mg IV stat followed by
100mg IV QID or
o Prednisolone: 40-60mg po per day or
o Dexamethasone: 0.6mg/Kg/day (18mg maxi dose)

Side effects
 Severe or life threatening attack

 Add Ipratropium bromide 0.5 mg 4-6 hourly if initial

response to B agonist is poor
 If no improvement
 Add magnesium sulfate 2 gm administered over
20 minutes or
 Aminophilline
 Loading dose- 5mg/kg or 250 mg over 20
minutes
 Severe or life threatening attack

 Maintenance dose- 0.5mg/kg/hr Q 12 hr (increase

dose in smokers & decrease in elderly, corpulmonale,
CHF& liver failure)
 Adrenaline -0.3-0.5 mg (1:1000 solution) Q 20 min
for 3 doses subcutaneously
 Severe or life threatening attack


Ketamine : 0.2mg/kg iv bolus followed by 0.5mg/kg/hr

side effects: confusion, delirium, hallucinations ,

prolonged anesthesiaS

Antibiotics

Adequate hydration
 Ventilatory considerations
 Non-invasive ventilation
 Invasive ventilation
If deteriorating mental status or coma
Respiratory or cardiac arrest
Cyanosis and hypoxemia on O2
PaCO2 greater than 50 mmHG
Pneumothorax.
 Assessment of response

 Clinical improvement
 Patient is less distressed
 Decreased respiratory rate and heart rate
 Able to talk in sentences
 Louder breath sounds on auscultation ( may be more
wheeze )
 Pulse oximeter- aim O2 saturation of 94-98%
 Admission criteria

 Failure of outpatient treatment

 persistent or worsening dyspnea

 PEFR or FEV1 <40% of predicted

 Hypoxia, hypercarbia

 Altered mental status

 Presence of comorbidities increases likelihood of
need for admission
 Prior To Discharge
 Patient should be stable
 nebulizer therapy should be discontinued for at least
24hrs
 PEF should reach 75% of predicted or personal best
 Asthma educatio
 Plan follow up
Follow up
 Follow up

 Patients should preferably be seen 1–3 months after

starting treatment and every 3–12 months after that,
but in pregnancy, asthma should be reviewed every
4–6 weeks.
 After an exacerbation, a review visit within 1 week
should be scheduled
 Stepping up asthma treatment
 Sustained step-up (for at least 2–3 months):
 if symptoms and/or exacerbations persist despite 2–3 months
of controller treatment
 before step-up assess;
 incorrect inhaler technique
 poor adherence
 modifiable risk factors, e.g. smoking
 are symptoms due to comorbid conditions, e.g. allergic
rhinitis
 Stepping up asthma treatment

 Short-term step-up (for 1–2 weeks) when

 viral infection or
 allergen exposure

 This is particularly effective in reducing severe

exacerbations.
 Stepping down treatment

 once good asthma control has been achieved and

maintained for 3 months

 Step down through available formulations to reduce

the ICS dose by 25–50% at 2–3 month intervals
 summer

 Asthma is a chronic inflammatory disorder

characterized by increased responsiveness of the
airways to multiple stimuli
 the main aim of ashma Management is to controlloa
symptome and risk reduction
 Patient follow up is help for pt asses,adjust treatemnt
and risk identify
 References

1.Global Initiative for Asthma (GINA) 2021

2.Joshua G. Kornegay, Tintinalli’s emergency medicine

10th edition

3.up to date 21.2 edition

 .

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