DIAGNOSIS AND MANAGEMENT OF

ACUTE SEVERE ASTHMA

Moderator-Dr.Biniam (MD, Internist)

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Presented By Tadele.Y
 PRESENTATION OUT LINE

 Introduction(definition, prevalence, triggering factors, clinical

manifestation)
 Diagnostic approach to asthmatic patients
 Management of Asthma
Goals and components of management
Basics of asthmatic pharmacotherapy
MX of acute exacerbation of Asthma

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 INTRODUCTION

 Asthma is a syndrome characterized by air flow obstruction

that varies markedly both spontaneously and with treatment.
 Limitation of airflow is due to bronchoconstriction, airway
edema and luminal occlusion with exudate.
 Results in reduction in FEV in 1sec(FEV1),FEV1/FVC and
PEF as well as an increase in air way resistance.

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 PREVALENCE

Asthma is one of the most common chronic diseases globally

Currently affects ~300 million people worldwide, with
~250,000 deaths annually.

Asthma can present at any age, with a peak age of 3 years

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 RISK FACTORS AND TRIGGERS

• Asthma is a heterogeneous disease with interplay between

genetic and environmental factors

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 Clinical feature and diagnosis

 Characteristic symptoms of asthma are wheezing,dyspnea and

coughing which are variable both spontaneously and with therapy.
 Cough-worse at night and patients typically awoke in the early morning
hrs.
 Increased mucus production with typically tenacious mucus that is
difficult to expectorate.

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 Cont…..

 Respiratory distress with use of accessory muscle of

ventilation.
 Prodromal symptoms may precede acute exacerbation
itching under the chin, discomfort between
scapulae.
 Inexplicable fear (impending doom)

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 ACUTE SEVERE ASTHMA

 Patients are aware of increasing chest tightness, wheezing, and dyspnea

that are often not or poorly relieve by their usual reliever inhaler.
 Patients maybe so breathless that they are unable to complete sentence
 Examination usually shows increased ventilation,
 Hyperinflation, and tachycardia and may become cyanotic
 Pulsus paradoxus may be present

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 Diagnosis :-

 The diagnostic tools used to determine if a patient has asthma

include:-
history, respiratory symptoms consistent with asthma
physical examination,
pulmonary function testing, and
 other laboratory evaluations.

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 cont…

 Clinically diagnosed.
 Pulmonary function tests with reduced
• forced expiratory volume in one second (FEV1)
• FEV 1/FVC ratio and
• peak expiratory flow rate, (PEFR)

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 cont…
 variability of the measurement(Bronchodilator response)
Reversibility is demonstrated by a >12% and 200-mL increase in
FEV1 15 minutes after an inhaled short acting beta agonist (SABA)
therapy or by a 2-4 weeks trial of OCS(prednisolone 30–40 mg daily)
– Total serum IgE and specific IgE to inhaled allergens.

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 cont…
 Chest radiograph is generally unhelpful; obtain if complications
suspected (e.g., pneumonia, pneumothorax), diagnosis is in doubt, or
patient is high-risk (e.g., IV drug abuser, immunosuppressed, chronic
pulmonary disease, heart failure)
-normal
-hyper inflated lungs in more severe cases.
-acute exacerbations there may be evidence of pneumothorax

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 MANAGMENT OF ASTHMA

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 Asthma pharmacotherapy
 The mainstay of management in most patients with
asthma generally has two groups of medications.
1.Relievers(bronchodilators): these are rescuer
drugs used during exacerbation
2.controllers

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 Cont….
• Initial assessment (ABC of life)
• Are any of the following present Drowsiness, confusion, silent
chest.
• If yes consult ICU, start SABA and oxygen, and prepare patient
for intubation
• If no, further triage by clinical status as mild-moderate ,severe

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 Classification of asthma exacerbation
 Mild to moderate exacerbation
 Talks in phrases
 Prefers sitting to lying
 Not agitated
 No use of accessory muscle
 Increased respiratory rate
 Tachycardia 100-120 BPM
 Oxygen saturation (on air) 90-95%,
 PEF1 >50 predicted or best
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 Cont…
 Severe exacerbation
Talks in words, sits hunched forward, agitated, use of
accessory muscle, respiratory rate> 30/min , pulse rate>120/min ,
oxygen saturation on air<90, PEF1<50
 Life threatening …Drowsy, confused or silent chest

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 cont…
 Life-threatening airway obstruction can still occur when these
signs are NOT present
 Inability to maintain respiratory effort, cyanosis, and
depressed mental status portend imminent respiratory
arrest

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 Standard treatments

 Inhaled beta agonist: give albuterol 2.5 to 5 mg every 20

minutes for three doses by nebulization, or 4 to 8 puffs every 20
minutes for up to four hours, properly administered, by metered
dose inhaler (MDI) with spacer.
 Alternatively, for severe exacerbations, 10 to 15 mg can be
administered by continuous nebulization over one hour.

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 Cont’d…
 Oxygen: give sufficient oxygen to maintain SpO 2 ≥92 percent (>95
percent in pregnancy)
 IV: establish intravenous access; may give bolus of normal saline for
prolonged episode to replace insensible losses

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 Cont…
 Ipratropium bromide: give 500 mcg by nebulization every 20
minutes for 3 doses, or 8 puffs by MDI with spacer every 20
minutes as needed for up to 3 hours

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 Cont…
 Systemic glucocorticoids: for patients with impending respiratory
failure, give methylprednisolone 60 to 125 mg IV. For the majority of
less severe asthma exacerbations, give prednisone 40 to 60 mg orally;
 alternatives include: dexamethasone 6 to 10 mg IV or hydrocortisone
150 to 200 mg IV; glucocorticoids may be given IM or orally if IV
access is unavailable.

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 Cont…
 Magnesium sulfate: give 2 g (8 mmol) IV over 20 minutes for life-
threatening exacerbations and exacerbations that remain severe after one
hour of intensive bronchodilator therapy

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 Cont’d…
 Asses clinical progress frequently and measure lung
function in all patients one hour after initial treatment
 FEV1,or PEF 60-80% of predicted or
 Personal best and symptoms improved(moderate), consider
for discharge planning

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 Cont…
 FEV1, or PEF< 60 % of predicted or personal best, or lack of clinical
response(severe),
 continue treatment as above and reassess frequently

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 Additional treatments

 Epinephrine: for patients suspected of having an anaphylactic

reaction or unable to use inhaled bronchodilators for severe
asthma exacerbation, give epinephrine 0.3 to 0.5 mg IM (e.g., 0.3
to 0.5 mL of 1 mg/mL [also labeled 1:1000] solution

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 Cont’d…
 If severe asthma but no evidence of anaphylaxis, can give epinephrine
0.3 to 0.5 mg SC (e.g., 0.3 to 0.5 mL of 1 mg/mL [also labeled 1:1000]
solution); give epinephrine OR terbutaline but not both.

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 Cont…
 Terbutaline: may give 0.25 mg by SC injection every 20
minutes times 3 doses for severe asthma unresponsive to
standard therapies;
 Give terbutaline OR epinephrine but not both

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 Endotracheal intubation and ventilation

 The decision to intubate during the first few minutes of a severe

asthma attack is clinical.
Slowing of the respiratory rate,
depressed mental status,
inability to maintain respiratory effort, or
 severe hypoxemia during an asthma exacerbation suggests the
patient requires intubation.

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 Cont…
 The goal of mechanical ventilation is to maintain adequate oxygenation
and ventilation while minimizing elevated airway pressures.
 This is accomplished by using high inspiratory flow rates (80 to 100
L/min), low tidal volumes (6 to 8 mL/kg), and low respiratory rates (10
to 14/minute).

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 Cont…

 Arrange at discharge
Reliever: as needed rather than routinely
Controller: start or step up , check inhale technique or adherence
Prednisolone: continue usually for 5-7 days
Follow up: with in 2-7 days

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 Reference
 Harrison 20th edition
 GINA asthma treatment guideline 2019
 Up-to-date 21.6

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 YO U
AN K
TH

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