Asthma Management

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Basics of asthma management:

ACUTE MANAGEMENT:

  • Categories of Acute Asthma

1) Moderate Acute Asthma:

  • Increasing symptoms
  • PEF>50-75% best or predicted
  • No features of acute severe asthma

2) Acute Severe Asthma

  • PEF 33-50% best or predicted
  • Respiratory rate >25/min
  • Heart rate >110/min
  • Inability to complete sentences in one breath

3) Life Threatening Asthma

  • PEF <33% best or predicted
  • SpO2 <92% (will require an ABG if SpO2 <92%)
  • PaO2 <8 kPa
  • Normal PaCO2 (4.6 – 6.0 kPa)
  • Silent chest
  • Cyanosis
  • Poor respiratory effort
  • Arrhythmia
  • Exhaustion
  • Altered conscious level
  • Hypotension

4) Near Fatal Asthma (raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures)

MANAGEMENT

  • Admit patients with any feature of life-threatening/near fatal asthma attack or any feature of severe asthma attack persisting after initial treatment
  • OXYGEN: Give controlled supplementary oxygen to all hypoxaemic patients with acute severe asthma to maintain an SpO2 level of 94-98%. Do not delay oxygen administration in the absence of pulse oximetry but commence monitoring of SpO2 as soon as it becomes available. In hospital, ambulance and primary care, nebulisers for giving nebulised beta agonist bronchodilators should preferably be driven by oxygen
  • BRONCHODILATOR: Use high-dose inhaled beta agonist as a first line agents in patients with acute asthma and administer as early as possible. Reserve intravenous beta agonist for those patients in whom inhaled therapy cannot be used reliable. In patients with acute asthma with life threatening features the nebulisers should be oxygen driven. In severe asthma that is poorly responding to bolus nebulised beta agonist, consider continuous nebulisation with appropriate nebuliser
  • STEROID: give steroids in adequate doses to all patients with an acute asthma attack. Continue prednisolone (40-50mg daily) for at least 5 days or until recovery
  • IPRATROPIUM BROMIDE: Add nebulised ipratropium bromide (0.5mg 4-6 hourly) to beta agonist treatment for acute severe or life threatening asthma or poor initial response to beta agonist therapy
  • MAGNESIUM SULPHATE: consider single dose of IV magnesium sulphate (1.2-2g IV infusion over 20 minutes) to patients with acute severe asthma (PEF <50%) who have not have not had a good initial response to inhaled bronchodilator therapy. Note this should only be used following consultation with senior medical staff
      • NB: routine prescription of antibiotics is not indicated for patients with acute asthma***
  • REFERRAL TO ITU: Refer any patient who is requiring ventilator support or with acute severe/life threatening asthma who is failing to respond to therapy (as evidenced by deteriorating PEF, persisting or worsening hypoxia, hypercapnia, ABG analysis showing acidosis, exhaustion/feeble respiration, drowsiness, confusion/altered conscious state, respiratory arrest)


For UCLH Acute Asthma Exacerbations: http://insight/departments/other/NursingandMidwifery/nursingdocumentation/Management%20plans/003.%20Asthma%20-%20Acute%20Exacerbation.pdf


CHRONIC/WARD MANAGEMENT

  • Monitor Obs as per normal patient, ensure peak flows are being recorded (pre and post neb), check peak flow technique to help aid interpretation
  • Contact respiratory CNS (Bleep 2086 or 07961 221848 or 07887 787959) for spirometry, peak flow technique, inhaler technique, setting up home nebulisers etc
  • Common Inhalers
  • Stepwise management of inhalers

1) Short acting beta agonist PRN (if using more than 3 doses per week consider stepping up) 2) Additional low dose inhaled corticosteroid (ICS) 3) Add inhaled long acting beta agonist (LABA) (normally as a combination inhaler with ICS) 4) If no response to LABA stop and increase dose of ICS. If benefit from LABA but not ideal control, can continue LABA and increase ICS to medium dose. Consider trial of other therapy (e.g. LTRA, SR theophylline, LAMA) 5) Consider trial of high dose ICS and addition of a fourth drug (e.g. LTRA, SR theophylline, beta agonist tablet, LAMA) 6) Use daily steroid tablet in the lowest dose providing adequate control while maintaining high-dose ICS and consider other treatments to minimize use of steroid tablets

  • Aminophylline dosing and levels: discuss with pharmacists, generally check aminophylline/theophylline level 4-8 hours post dose or immediately pre-dose.
  • Severe Asthma Service:
- Therese Bidder and Prof Douglas Robinson are the people to contact about patients with severe asthma
- Any patient who is admitted with asthma, especially if they were in ITU or had treatment resistant asthma they should be seen by Prof Robinson within two weeks of discharge

On Discharge

  • Discuss with the respiratory nurses prior to discharge (Bleep 2086 or 07961 221848 or 07887 787959) – they will complete the BTS asthma discharge bundle including checking inhaler technique, medication review, personalised asthma management plan, triggers and exacerbating factors and follow up arrangements)
  • Discuss with Therese Bidder and/or Prof Robinson for follow up if acute severe asthma service required
  • Patient should be at least 24 hours without needing nebulisers prior to discharge (unless they have home nebulisers)
  • The rule of thumb is PEFR should be ~75% predicted prior to discharge
  • Predicted PEFR can be calculated based on height, age and sex (http://reference.medscape.com/calculator/peak-expiratory-flow)

References • http://reference.medscape.com/calculator/peak-expiratory-flowhttps://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/