MANAGEMENT OF ACUTE

SEVERE ASTHMA
 DEFINITIONS
Asthma is a heterogeneous disease, characterized by
chronic airway inflammation. It is defined by the history
of respiratory symptoms such as wheeze, shortness of
breath, chest tightness and cough that vary over time
and in intensity, together with variable expiratory airflow
limitation.

Exacerbations of asthma are episodes characterized

by a progressive increase in symptoms of shortness
of breath, cough, wheezing or chest tightness and
progressive decrease in lung function, i.e. they
represent a change from the patient’s usual status
that is sufficient to require a change in treatment.
CLINICAL ASSESSMENT OF SEVERITY OF ASTHMA
 ACUTE SEVERE ASTHMA
(status asthmaticus)

• A life-threatening exacerbation of asthma

symptoms.
• Findings:
PEF (peak expiratory flow) 33-50% predicted (< 200 l/min)
Respiratory rate ≥ 25/min
Heart rate ≥ 110/min
Arterial blood gas analysis PaO2 (N: 75-105 mm Hg)and
. PaCO2 (N: 35-45 mm Hg)
Inability to complete sentences in 1 breath
 MANAGEMENT

• Initial assessment

• Treatment

• Mechanical ventilation

• Monitoring
 TREATMENT GOALS
Management goals for status asthmaticus are-
(1) to reverse airway obstruction rapidly through
the aggressive use of beta2-agonist agents and
early use of corticosteroids,
(2) to correct hypoxemia by monitoring and
administering supplemental oxygen, and
(3) to prevent or treat complications such as
pneumothorax and respiratory arrest.
 INITIAL ASSESSMENT
• Immediate assessment of

A. ability to speak

B. Vital signs

• Measurement of PEF is mandatory unless the

patient is too ill to cooperate

• Arterial blood gas analysis

 TREATMENT
• Oxygen

• High doses of inhaled bronchodilators

• Systemic corticosteroids

• Intravenous fluids

• Subsequent management
 Treatment contd…
• Oxygen
– High concentrations of oxygen (humidified if
possible)

– Goal: SaO2 > 92%

– Failure to achieve appropriate oxygenation

 assisted ventilation.
 Treatment contd…
• High doses of inhaled bronchodilators
– Short-acting β2-agonists (Salbutamol 5mg/hr)
• via nebuliser driven by oxygen or via a metered dose
inhaler through a spacer device.

– An inhaled anticholinergics (Ipratropium bromide

500µg) may be added.
 Treatment contd…
• Systemic corticosteroids

– intravenous hydrocortisone 200 mg : in patients

who are unable to swallow or are vomiting.

– Oral prednisolone 40 mg/day.

 Treatment contd…
• Intravenous fluids
– To correct dehydration and acidosis.

– Normal saline + sodium bicarbonate infusion.

– Potassium supplements to treat hypokalemia

induced by Salbutamol.
 Treatment contd…
• Subsequent management
– If patients fail to improve
• Intravenous magnesium sulphate(1.2–2 g over 20 min)
• Intravenous β2 agonists(e.g. Salbutamol)
• Intravenous aminophylline (5mg/kg loading dose over
20 minutes followed by continuous infusion at
1mg/kg/hr )
• Intravenous leukotriene receptor antagonists
• Anaesthetics (e.g. halothane)
 Mechanical Ventilation
• Initial goals
– To correct hypoxaemia
– To achieve adequate alveolar ventillation
– To minimize circulatory collapse
– To buy time for medical management to work
• Indications
– Coma
– Respiratory arrest
– Deterioration of arterial blood gas tensions despite
optimal therapy
– Exhaustion, confusion, drowsiness
 Monitoring of treatment
• PEF should be recorded every 15-30 minutes
• Pulse oximetry should ensure that SaO2 remains >
92%
• If aminophylline is given, then monitor the serum
concentration (therapeutic range 10–20 µg /ml)
• Repeat arterial blood gases if
– initial PaCO2 measurement was raised
– PaO2 was < 8 kPa (60 mmHg) or
– the patient deteriorates.
 COMPLICATIONS
Complications of acute severe asthma can
include the following:
• Cardiac arrest
• Respiratory failure or arrest
• Hypoxemia with hypoxic ischemic central
nervous system (CNS) injury
• Pneumothorax or pneumomediastinum
• Toxicity from medications