The goals of treatment are rapid reversal of airway obstruction and correction of

hypoxemia.
The management of acute asthma can be considered in three settings: at home, at
physician's office or at emergency department, and at hospital in cases of status
asthmaticus

The importance of early intervention should have been emphasized to the parents or older
child. They should realize that in acute asthmatic attack "the longer it lasts, the worse it
gets" and "the worse it gets, the longer it lasts". Initial therapy should be directed at
assessing the reversibility of bronchial obstruction using objective measurements of
pulmonary function if possible. Beta-2 agonists administered by nebulizations or metered-
dose inhaler (MDI) with spacer should be given first. Prompt administration of systemic
corticosteroids should be considered in severe cases.

Home/Office Management
Management of acute asthma exacerbation at home/office is greatly facilitated by
providing an asthma action plan. This is a written management plan that is jointly
prepared by the patient and the physician. The front page of this action plan contains a
general information regarding the present status of the patient's asthma. The back page is
the action plan itself which is divided into 3 columns corresponding to the state of control
of the patient's asthma.

The GREEN ZONE implies that the asthma is well controlled - asymptomatic with normal
(>80%) of personal best/predicted PEFR. If indicated, maintenance medications are written
in this section.
The YELLOW ZONE indicates that the patient has mild to moderate attacks of asthma with
the presence of at least one sign/symptom (cough, wheeze, chest tightness. shortness of
breath) and/or PEFR within 60-79% of personal or predicted. Patients are instructed at this
zone to take inhaled short-acting beta-2 agonist every 20 min for three doses. Poor
response to this medication would mean that the patient should be rushed to the
emergency room (ER) and call their physician. A good response to this therapy would
mean that he can stay home and just continue to take the inhaled beta-2 agonist for 5
days and call their physician for further instructions.
The RED ZONE signifies that the patient has the clinical features of severe or impending
respiratory arrest with PEFR greater than 60% personal/ predicted. These patients should
be rushed to the ER, and inhaled beta-2 agonist and oral corticosteroids are given during
the transit.

Hospital management
At this point, the severity of the asthma must be at least moderate, and can easily
progress to severe, or
in status asthmaticus. The management can be seen in Figure 5.

Pharmacologic management

In summary, the pharmacologic management of acute asthma includes the following:

1. Inhaled short-acting beta-2 agonist by nebulization or MDI with spacer - salbutamol,
terbutaline
2. Oral corticosteroids prednisone/prednisolone at least 2 mg/kg/day.
3. Intravenous corticosteroids - methylprednisolone and hydrocortisone.

Intravenous corticosteroids require at least 4 hours to provide clinical improvement.

Suggested dose of corticosteroids is 60-80 mg methylprednisolone or 300-400 mg
hydrocortisone per day. These doses are adequate for hospitalized patients. Duration of
treatment could be 3-5 days in children. Current evidence suggests that there is no benefit
of tapering the dose of oral prednisone if given in short term.

Follow-up care
Patient Discharge
From the ER: The decision to discharge the patient from the ER depends on his or her
response to treatment. Discharge may be appropriate when:
a) symptoms are absent or minimal
b) PEFR > 80% predicted
c) response sustained tor at least 4 h

From the hospital: The decision to discharge from the hospital is subjective. However, the
following guidelines may be used:
a) physical examination is normal or near normal
b) no nocturnal awakenings
c) PEFR >80% predicted
d) sustained response to inhaled short-acting beta-2 agonist at least 4h

The following instructions should be given before sending the patient home, whether from
the ER or (from
the hospital:
1. Educate patient especially to identify and avoid triggers that precipitated the
attack.
2. Prescribe sufficient medication to continue the treatment for this acute
exacerbation after discharge.
3. Review inhaler technique.
4. Consider using a peak flow meter, if feasible to monitor the status of the asthma,
give written action
plan, review and modify if the patient has already one
5. Depending on the severity of the disease - intermittent, mild persistent, severe
persistent asthma emphasize the importance of long-term therapy with inhaled
anti-inflammatory agent (inhaled corticosteroid) as controller. Treatment plan
depends on the severity of the disease.
6. Emphasize the importance of regular, continuous follow-up with the physician.

Patient education
It is important that patients and their caregivers be educated prior to discharge not only to
prevent future recurrences, but also to teach them how to manage future attacks. The
objectives of an asthma education program are as follows:
a) Demonstrate increase level of knowledge regarding asthma, its prevention and
management.
b) Recognize signs and symptoms of asthma.
c) Identify his or her asthma triggers and measures to avoid them.
d) Demonstrate correct technique of using inhaler and peak flow meter.
e) Follow personalized action plan.

Preventive measures
Every physician who manages an asthmatic patient should adapt the following goals
recommended by the "Philippine Consensus for the Management of Childhood Asthma"
which are as follows:
a) Maintain normal activity levels including exercise.
b) Maintain (near) normal pulmonary function test.
c) Prevent chronic and troublesome symptoms.
d) Prevent recurrent exacerbations.
e) Avoid adverse effects from asthma medications.

To achieve these, the following management guidelines should be considered

a) Drug therapy for acute exacerbations.
b) Drug therapy for long-term management (see references).
c) Environmental control.
d) Treatment of associated medical conditions known to trigger exacerbations.
e) Asthma education to establish patient-parent-physician partnership in asthma care.
f) Indices that monitors status of disease.
Symptomatology and physical examination.
 Measurements of pulmonary function.
Ability to enjoy normal activities including exercise.
Need for medications and medical attention.
Adverse reactions to drugs being administered.
Status Asthmaticus (Acute Severe Asthma)
1. Definition
Severe asthma unresponsive to emergency therapy with
beta-2 adrcnergic agonists. It is a medical emergency for which immediate recognition and
treatment are necessary
to avoid fatal outcome. For practical purposes status asthmalicus is present in the absence
of meaiiingtul response to
(wo aerosol treatments with beta-2 adrencrgic agonists or with two or three subcutaneous
injections of epinephrine
given in 15 min interval intramuscular cpinephrine (two or
three injections).
It is important that the physician who treats infants and children with asthma should
realixe important anatomic and physiologic peculiarities of the airway in early life that
prcdi.sposc them to airway narrowing and susceptibility to
fluid and electrolyte disturbances. Some of these peculiaritics include a decreased amount
of smooth muscle in the
peripheral airways that may result in less support; mucous
gland hypcrplasia in the major bronchi that favors increased
intraluminal mucus production; disproportionately narrow
peripheral airways up to 5 years of age rendering them vulnerable to obstructive disease;
decreased clastic recoil of the
young lung predisposes to early airway closure; highly compliant chest; etc. In childhood
status asthinaticus, respirdlory acidusis is frequently complicated by the development of
metabolic acidosis. Hence, the administration of sodium
bicarbonate to correct the metabolic acidcmia seems rational
provided the alveolar ventilation is sut'ricient to eliminate
(he carlxw dioxide produced.

2. Causes
2.1. Respiratory tract infections.
2.2. Underlrcatmcnt and undcrassc.ssmcnl of ati acultf asthma exacerbations.
2.3. Exposure to allergens - animal danders. Uustmitcs.
2.4. Exposure to intrinsic factors - smoke, strong (xJors, etc.
2.5. Withdrawal or loo sudden reduction of systemic corticosteroids.
2.6. Overuse of antiaslhinatic medications - sympathomimclics, thcophylline.
3. Clinical manifestations
An asthmatic, with known risk factors, who developed
increasingly severe asthma that is not responsive to drugs
that are effective should be diagnosed to have status aslhmaticus. The risk factors (Table
3) include:
3.1. Infants in moderatc/sevcre exacerbations.
3.2. Current use or recent withdrawal (<1 week) from systemic coriicostcroids.

3.3. Hospilalization tor moderate or severe asthma in the

past year.
3.4. Prior intubation or history of impending respiratory
failure from asthma.
3,5. Psychiatric disease or psycho.social probleni.s - crisis,
family dysfunction.
3.6. DitTiculty perceiving airflow obstruction or its severity.
3.7. Recurrent visits to the emergency room in past 48 h.
3.8. Non-compliance with asthma medication plan.
Physical examination findings include: pulsus paradoxus greater than 20 mmHg,
hypotension; tachycardia; tachypnca; cyanosis; one- to two-word dy.spnea;
lethargy; agitation; stemocleidomastoid; intcrcostals; suprastomal; retractions; poor air
exchange (quiet chest with severe distress).
4. Laboratory procedures
4.1. Blood gas analysis - hypcrcarbia, hypoxemia with supplemental oxygen.
4.2. Pulmonary function test - less than 30% expected, no
improvement 1 h after aerosol therapy.
4.3. Clic.st X-ray niay show pncumothorax, pneumomediastinum.
4.4. Baseline complete blood count and serum electrolyte.
5. Mnnagement (Figure 5)
A patient in whom the diagnosis is made should be admitted to a hospital, preferably to an
intensive care unit, wherever the condition can be carefully monitored rcgularty. Baseline
complete blood count, scrum electrolytes,
blood gas analysis (p0;, pCO; and pH) and cardiac status
be done.