Asthma Emergency Treatment

ER management

The survival of patients suffering severe asthma attacks often depends on the asthma emergency treatment they receive. All physicians, especially those working in emergency rooms, must know how to deal with patients near or at respiratory arrest.

I. ASSESSMENT ON ARRIVAL

  • Brief history and physical examination (auscultation of heart and lungs noting heart rate and respiratory rate as well as use of accessory muscles of respiration
  • PEFR or Forced Expiratory Volume in One Second (FEV 1) (maximum amount of air one can blow out forcefully in one second after a maximum inspiration)
  • Arterial oxygen saturation (SaO2)
  • Other indicated tests

  • If impending or actual respiratory arrest:
    1. Intubate and mechanically ventilate with 100% oxygen
    2. Use nebulized SABA or Ipratropium
    3. Use intravenous corticosteroids
    4. Consider other therapies that may be needed
    5. Admit to hospital ICU

  • IF FEV 1 or PEFR greater than or equal to 40% of predicted or personal best (if known) (Mild to Moderate Exacerbation)
    1. Give oxygen to get an SaO2 of 90% or more
    2. Give SABA by nebulizer, up to 3 doses in first hour
    3. Give oral corticosteroids

  • If FEV 1 or PEFR are less than 40% of predicted or personal best (Severe Exacerbation)
    1. Give oxygen to get an SAO2 of 90% or more
    2. Give high-dose inhaled SABA and Ipratropium by nebulizer
    3. Give oral corticosteroids

II. REPEAT ASSESSMENT OF ASTHMA EMERGENCY TREATMENT

  • Check symptoms and physical examination
  • Check PEFR
  • Check SaO2
  • Check other tests as needed

    1. If after repeat assessment there is moderate exacerbation (FEV 1 or PEFR is 40 to 69% of predicted or personal best - Moderate Exacerbation)
      1. Physical examination shows moderate symptoms
        1. Give inhaled SABA every 60 minutes
        2. Give oral corticosteroids
        3. Give treatment for 1 to 3 hours, provided there is improvement and make decision as to admitting the patient from ER to hospital in 4 or more hours

    2. If after repeat exacerbation there is severe exacerbation (FEV 1 or PEFR is less than 40% of predicted or personal best - Severe Exacerbation)
      1. Physical examination shows severe symptoms at rest, accessory muscle use and chest retractions, the patient is a high risk patient (see above high risk factors for fatal asthma), and there is no improvement after initial treatment
        1. Give oxygen
        2. Give nebulized SABA and Ipratropium, hourly or continuously
        3. Give oral corticosteroids
        4. Consider other asthma emergency treatment therapies as needed

III. RESPONSE AFTER ASTHMA EMERGENCY TREATMENT - For patients who had a repeat assessment (moderate or severe exacerbation, the response can be good, incomplete or poor.)

  • Good response:
    • FEV 1 or PEFR 70%of predicted or personal best
    • Response sustained for 60 minutes after last treatment
    • No distress present
    • Physical examination is normal
  • Incomplete response
    • FEV 1 or PEFR 40 to 69% 0r predicted or personal best
    • Mild to moderate symptoms
  • Poor response
    • FEV 1 or PEFR are less than 40% of predicted or personal best
    • Pa CO2 is equal to or more than 42 mmHg
    • Physical examination shows a patient with severe symptoms including drowsiness and confusion

    Treatment

    1. Patients who have a good response or an incomplete response (individualized description by physician), but the physician in charge feels that the patient can go home, are managed in the following manner:
      1. Discharge home:
        1. Continue treatment with inhaled SABA
        2. Continue course with oral corticosteroids
        3. Consider initiation of ICS
        4. Patient is educated as to medications to be taken (especially inhaler technique), is given a written action plan, and is recommended for close follow-up

    2. Patients who have an incomplete response, and the physician in charge feels they should be admitted to the hospital, are managed in the following manner:
      1. Admit to hospital ward:
        1. Give oxygen
        2. Give inhaled SABA
        3. Give oral or intravenous corticosteroids
        4. Consider other needed therapies
        5. Monitor vital signs, FEV 1, PEFR, and SaO2
      2. With improvement the patient may be discharged home:
        1. Continue inhaled SABA
        2. Continue a course of oral corticosteroids
        3. Continue inhaled ICS
        4. Patient is educated as to medications to be taken, is given a written action plan, and is recommended for close follow-up
        5. Before discharge, schedule follow-up appointment with primary care provider or asthma specialist in 1-4 weeks

    3. Patients who have a poor response are admitted to the hospital ICU and managed in the following manner:
      1. Admit to ICU:
        1. Give oxygen
        2. Give inhaled SABA hourly or continuously
        3. Intravenous corticosteroid therapy
        4. Consider other needed therapies
        5. Possible intubation and mechanical ventilation
      2. With improvement the patient can leave the ICU and be admitted to the hospital ward (see admit to hospital ward above)
      3. With improvement the patient can go home (see discharge home above)


References:

This asthma emergency treatment presentation is modeled in part after the following:

National Asthma Education and Prevention Program
Expert panel Report 3:
Guidelines for the Diagnosis and Management of Asthma
Full Report 2007

U. S. Department of Health and Human Services
National Institutes of Health
National Heart, Lung and Blood Institute

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