Day 2- Asthma Exacerbation

1. Assess for Stability

   ABC’s

   • If severe or near death symptoms, CALL FOR HELP including critical care team and an advanced intubator!

   • Decision to intubate is clinical. Patients can decompensated quickly. Hypoxia is not commonly present in asthma exacerbations.

   • Severe: laboured breathing, agitated, diaphoretic, difficulty speaking, tachycardia, no relief with Beta agonists

   • Near death: exhausted, confused, dec LOC, cyanotic, silent chest, dec resp effort, dec HR

2. Oxygenation

   • O2 via NP or venturi to keep SaO2>94 %

3. Inhalers (Be generous)

   • Salbutamol (with nebulizer if available or ) q15min 1-2hrs then every 1-4 hrs PRN

   • Salbutamol (MDI with aero chamber) 100mcg 8puffs (repeat 15-20 min for 4 hrs then every 1-4hrs PRN)

     • If patient not responding, consider continuous nebulization at 5-10mg/hr if institution allows

   +

   • Atrovent 0.5mg via nebulizer q20min then PRN

   • Atrovent 20mcg 8 puffs every 20 min for 3 hrs then PRN)

4. Steroids (Give ASAP, benefit can be seen in first hour)

• Prednisone 40-50mg PO or IV methylprednisolone 125mg IV

• Other

  • Avoid sedatives and narcotics

  • IV magnesium 2g in 250ml NS IV over 20 min (additional bronchodilator effect)

  • Routine use of Epinephrine not recommended in current guidelines

  • Use of NIV is contreversial (EBM link)

After exacerbation:

• investigate triggers

• PEF daily

• salbutamol and ipatropium q4hrs while awake with salbutamol q1-2hr break-through dosing

• Continue prednisone 1mg/kg for 5-7 days (some patients may require longer duration)

• Continue inhaled corticosteroids in addition to oral (if patient is not on inhaled corticosteroids prescribe before discharge)

• Arrange in-patient or out-patient Respirology follow-up

• Can be discharged when PEF>70% or if symptoms minimal or absent