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National Asthma Education and Prevention Program, Second Expert Panel on the Management of Asthma. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 1997 Jul.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma.

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Pharmacologic Therapy: Managing Exacerbations of Asthma

Key Points

  • Early treatment of asthma exacerbations is the best strategy for management. Important elements of early treatment include:
    • A written action plan to guide patient self-management of exacerbations at home, especially for patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations
    • Recognition of early signs of worsening asthma
    • Appropriate intensification of therapy
    • Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to inhaled beta2-agonists, or decreased duration of effect
  • Management of asthma exacerbations includes:
    • Inhaled beta2-agonist to provide prompt relief of airflow obstruction
    • Systemic corticosteroids, for moderate-to-severe exacerbations or for patients who fail to respond promptly and completely to an inhaled beta2-agonist, to suppress and reverse airway inflammation
    • Oxygen to relieve hypoxemia for moderate-to-severe exacerbations
    • Monitoring response to therapy with serial measurements of lung function

Asthma exacerbations are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness or some combination of these symptoms. Exacerbations are characterized by decreases in expiratory airflow that can be documented and quantified by simple measurement of lung function (spirometry or peak expiratory flow [PEF]). These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms.

General Considerations

The Expert Panel recommends that clinicians consider the following general principles and goals for managing asthma exacerbations, based on the scientific literature and the opinion of the Panel.

  • Early treatment is the best strategy for management of asthma exacerbations. Important elements of early treatment include:
    • A written action plan (see figure 9-4) to guide patient self-management, especially for patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations
    • Recognition of early indicators of an exacerbation, including worsening FEV1 or PEF
    • Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to inhaled beta2-agonist, or decreased duration of effect
    • Appropriate intensification of therapy, often including a short course of systemic corticosteroids
    • Removal of or withdrawal from allergic or irritant precipitants in the environment that may be contributing to the exacerbation
  • Patients at high risk of asthma-related death require special attention—particularly intensive education, monitoring, and care. They should be counseled to seek medical care early during an exacerbation and instructed about the availability of ambulance services. Such patients include those with identifiable risk factors (see box 8-1).
  • Infants require special attention, especially due to their greater risk for respiratory failure (see box 8-2).
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Box 8-1

Risk Factors for Death from Asthma. Past history of sudden severe exacerbations Prior intubation for asthma

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Box 8-2

Special Considerations for Infants. Assessment depends on physical examination rather than objective measurements. Use of accessory muscles, paradoxical breathing, cyanosis, and a respiratory rate >60 are key signs of serious distress. Objective (more...)

Treatment Goals

The principal goals for treating asthma exacerbations are:

Achieving these goals requires close monitoring by serial measurements of lung function to quantify the severity of airflow obstruction and its response to treatment. The improvement in FEV1 after 30 minutes of treatment correlates significantly with a broad range of indices of the severity of asthma exacerbations (Rodrigo and Rodrigo 1993), and repeated measurement of airflow in the emergency department can help reduce unnecessary admissions (Taylor 1994). Use PEF or FEV1 values to guide treatment decisions, along with the patient's history, current symptoms, and physical findings. In using PEF expressed as a percentage of personal best, it is important to consider the impact of irreversible airflow obstruction. For a patient whose best PEF is 160 L/min, for example, a fall of 40 percent represents severe, potentially life-threatening obstruction.

Home Management of Asthma Exacerbations

Beginning treatment at home avoids treatment delays, prevents exacerbations from becoming severe, and also adds to patients' sense of control over their asthma. The degree of care provided in the home depends on the patients' (or parents') abilities and experience and on the availability of emergency care. General guidelines for managing exacerbations at home are presented in figure 8-1.

Figure 8-1. Management of Asthma Exacerbations: Home Treatment.

Figure 8-1

Management of Asthma Exacerbations: Home Treatment.

The Expert Panel recommends the following actions to prepare patients for home management of asthma exacerbations, based on scientific literature (see component 1-Periodic Assessment and Monitoring and component 4) and the opinion of the Panel.

  • Teach all patients how to monitor symptoms to recognize early signs of deterioration (see component 1-Periodic Assessment and Monitoring and component 4) and how to adjust their medications accordingly.
  • Teach patients with moderate-to-severe persistent asthma and those with a history of severe exacerbations how to monitor their peak flow to assess the severity of an exacerbation and the response to therapy (see component 1-Periodic Assessment and Monitoring). In the absence of PEF measurement, severity can be judged only from the presence and intensity of signs and symptoms (see table 8-1), which correlate imperfectly with the severity of airflow obstruction. This is especially true in a subgroup of patients (“poor perceivers”) who do not sense airway narrowing until it is far advanced (Kikuchi et al. 1994).
  • Give a written asthma action plan to be followed in the event of an exacerbation (see figure 9-4), especially to patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations. Children should also receive a plan appropriate to the school setting (see figure 9-5). The plan should direct the patient to adjust medications in response to particular signs, symptoms, and peak flow measurements and should state when to seek medical help. Review the plan with the patient and family. The clinician should tailor the plan to the needs of individual patients. Patients at risk for asthma death (see box 8-1) require especially close monitoring.
  • Teach patients to seek medical help early if (1) an asthma exacerbation is severe, (2) therapy does not give rapid, sustained improvement, or (3) there is further deterioration.
  • Advise patients with moderate-to-severe persistent asthma or a history of severe exacerbations to have the medication (e.g., corticosteroid tablets or liquid) and equipment (e.g., peak flow meter, compressor-driven nebulizer for young children) for treating exacerbations at home.
Table 8-1. Classifying Severity of Asthma Exacerbations.

Table 8-1

Classifying Severity of Asthma Exacerbations.

The Expert Panel recommends the following pharmacologic therapy, based on the scientific literature, for home management of exacerbations:

  • Increase the frequency of inhaled beta2-agonist.
  • Initiate or increase corticosteroid treatment under certain circumstances. For mild exacerbations in patients already taking an inhaled corticosteroid, many experts prescribe doubling the dose until peak flow returns to predicted or personal best. Although this practice has not been proved in a clinical trial, a few studies suggest its benefit (Lahdensuo et al. 1996; Wilson and Silverman 1990). For moderate-to-severe exacerbations (see table 8-1), and for mild exacerbations that persist despite an increased dose of inhaled corticosteroids, a course of oral corticosteroids is necessary (Chapman et al. 1991; Fiel et al. 1983; Harris et al. 1987; Deshpande and McKenzie 1986; Loren et al. 1980; Rowe et al. 1992).
  • Continue more intensive treatment for several days. Recovery from an exacerbation is often gradual. Greater use of medication should be continued until symptoms and PEF are stable, but patients should seek medical care rather than rely on bronchodilator therapy in excessive doses or for prolonged periods.

The Expert Panel does not recommend the following home management techniques because there are no studies demonstrating effectiveness and it is the opinion of the Panel that these techniques may delay patients from obtaining necessary care.

  • Drinking large volumes of liquids or breathing warm, moist air (e.g., the mist from a hot shower).
  • Using over-the-counter products such as antihistamines, cold remedies, and bronchodilators. Over-the-counter metered-dose inhalers may provide transient bronchodilation, but their use should not be permitted to delay seeking medical care.

The Expert Panel also notes that although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory distress, they do not bring about improvement in lung function.

Prehospital Emergency Medicine/Ambulance Management of Asthma Exacerbations

The Expert Panel recommends that prehospital providers administer supplemental oxygen and inhaled short-acting bronchodilators to patients who have signs or symptoms of asthma. Prehospital administration of inhaled bronchodilators reduces airflow obstruction and relieves symptoms (Fergusson et al. 1995). Thus, advanced life support units should have available an inhaler plus spacer/holding chamber and/or nebulizer for beta2-agonist administration (see table 8-2 for dosages). If these are not available, subcutaneous epinephrine or terbutaline should be given for severe exacerbations (see table 8-2) (Sly et al. 1977; Smith et al. 1977).

Table 8-2. Dosages of Drugs for Asthma Exacerbations in Emergency Medical Care or Hospital.

Table 8-2

Dosages of Drugs for Asthma Exacerbations in Emergency Medical Care or Hospital.

Ambulance services should develop prehospital protocols for the treatment of acute asthma in children and adults. Prehospital providers should receive training in how to respond to the clinical signs and symptoms of severe airway obstruction and imminent respiratory failure.

Emergency Department and Hospital Management of Asthma Exacerbations

Severe exacerbations of asthma are potentially life threatening. Care must be prompt. Effective initial therapies (i.e., a short-acting beta2-agonist and the means of giving it by aerosol and a source of supplemental oxygen) should be available in a physician's office. However, serious exacerbations require close observation for deterioration, frequent treatment, and repetitive measurement of lung function. Therefore, most severe exacerbations of asthma require prompt transfer to an emergency department for a complete course of therapy (Brenner 1983a). An overview of the treatment strategies in emergency departments and hospitals is presented in figure 8-2 and detailed below.

Figure 8-2. Management of Asthma Exacerbations: Emergency Department and Hospital-based Care.

Figure 8-2

Management of Asthma Exacerbations: Emergency Department and Hospital-based Care.

Assessment

The Expert Panel recommends that all clinicians treating asthma exacerbations be familiar with the characteristics of patients at risk for life-threatening deterioration (see boxes 8-1 and 8-2). In the emergency department, treatment should be started as soon as an asthma exacerbation is recognized and an assessment of lung function is made.

While treatment is given, obtain a brief, focused history and physical examination pertinent to the exacerbation (see table 8-1). Take a more detailed history and complete physical examination and perform laboratory studies only after initial therapy has been completed.

  • The objectives of functional assessment are to:
    • Obtain objective information on the severity of airflow obstruction (FEV1 or PEF) and the patient's response to treatment. In the emergency department, obtain FEV1 or PEF on presentation, after initial treatment, and at frequent intervals thereafter, depending on the patient's response to therapy. Rarely, a patient's airflow obstruction may be so severe as to prevent performance of a maximal expiratory maneuver. In the hospital, measure FEV1 or PEF before and 15 to 20 minutes after bronchodilator therapy during the acute phase of the exacerbation. Thereafter, measure FEV1 or PEF at least daily until discharge. Values <30 percent of predicted that improve by <10 percent after bronchodilator therapy or that fluctuate widely over 24 hours indicate a heightened risk of life-threatening deterioration.
    • In patients with severe distress or with FEV1 or PEF <50 percent of predicted, assess the adequacy of arterial oxygen saturation by pulse oximetry (Connett and Lenney 1993; Geelhoed et al. 1994).
  • Objectives of the brief history are to determine:
    • Time of onset and cause of current exacerbation
    • Severity of symptoms, especially compared with previous exacerbations
    • All current medications and time of last dose
    • Prior hospitalizations and emergency department visits for asthma, particularly within the past year
    • Prior episodes of respiratory insufficiency due to asthma (loss of consciousness or intubation and mechanical ventilation)
    • Other potentially complicating illness, especially other pulmonary or cardiac disease or diseases that may be aggravated by systemic corticosteroid therapy such as diabetes, peptic ulcer, hypertension, and psychosis
  • Objectives of the physical examination are to:
    • Assess the severity of the exacerbation as indicated by the findings listed in table 8-1.
    • Assess overall patient status, including level of alertness, fluid status, and presence of cyanosis, respiratory distress, and wheezing. Wheezing can be an unreliable indicator of obstruction; in rare cases, extremely severe obstruction may be accompanied by a “silent chest” (Shim and Williams 1980).
    • Identify complications (e.g., pneumonia, pneumothorax, or pneumomediastinum).
    • Identify other diseases that may affect asthma (e.g., allergic rhinitis, rhinitis, sinusitis).
    • Rule out upper airway obstruction. Both intrathoracic and extrathoracic central airway obstruction can cause severe dyspnea and may be diagnosed as asthma. Causes include epiglottitis, organic diseases of the larynx, vocal cord dysfunction, and extrinsic and intrinsic tracheal narrowing (see component 1-Initial Assessment and Diagnosis). Clues as to their presence include dysphonia, inspiratory stridor, monophonic wheezing loudest over the central airway, normal values for PO2, and unexpectedly complete resolution of airflow obstruction with intubation. When upper airway obstruction is suspected, obtain further evaluation by flow-volume curves and by referral for laryngoscopy (see component 1-Initial Assessment and Diagnosis).
  • The most important objective of laboratory studies is detection of actual or impending respiratory failure; other objectives include detection of theophylline toxicity and of conditions that complicate the treatment of asthma exacerbations. Do not permit these studies to delay initiation of treatment. For example,
    • Consider arterial blood gas (ABG) measurement for evaluating arterial carbon dioxide tension (PCO2) in patients with suspected hypoventilation, with severe distress, or with FEV1 or PEF 30 percent of predicted after initial treatment.

      (Respiratory drive is typically increased in asthma exacerbations, so a “normal” PCO2 of 40 mm indicates severe airflow obstruction and a heightened risk of respiratory failure.)

    • Complete blood count (CBC) may be appropriate in patients with fever or purulent sputum; keep in mind that modest leukocytosis is common in asthma exacerbations and that corticosteroid treatment causes a further outpouring of polymorphonuclear leukocytes within 1 to 2 hours of administration.
    • Measure serum theophylline concentration in patients taking theophylline prior to presentation.
    • It may be prudent to measure serum electrolytes in patients who have been taking diuretics regularly and in patients with coexistent cardiovascular disease, because frequent beta2-agonist administration can cause transient decreases in serum potassium, magnesium, and phosphate.
    • Chest radiography is not recommended for routine assessment but should be obtained in patients suspected of a complicating cardiopulmonary process, such as pneumothorax, pneumomediastinum, pneumonia, lobar atelectasis, or congestive heart failure.
    • Electrocardiograms need not be routinely obtained, but a baseline electrocardiogram and continual monitoring of cardiac rhythm are appropriate in patients older than 50 years of age and in those with coexistent heart disease or chronic obstructive pulmonary disease. The electrocardiogram may show a pattern of right ventricular strain that reverses promptly with treatment of airflow obstruction.
  • Assessment considerations unique to children and infants are as follows:
    • It is often difficult for physicians and parents to determine the severity of the airway obstruction in infants and small children with asthma. However, using a combination of the subjective and objective parameters in table 8-1 permits a fairly accurate assessment to guide initial therapy. Many of these parameters have not been systematically studied, so they serve only as general guides.
    • The differences in the anatomy and physiology of the lungs of infants place them at greater risk for respiratory failure. These differences include greater peripheral airway resistance, fewer collateral channels of ventilation, further extension of airway smooth muscle into the peripheral airways, less elastic recoil, and mechanical disadvantage of the diaphragm. Viral infections, particularly respiratory syncytial virus, are the most common cause of acute wheezing illness in infants. The edematous inflammatory response in the airways leads to air trapping and hyperinflation, atelectasis, increased respiratory rate, and wheezing. This sequence of changes can rapidly progress to respiratory failure. Close monitoring is critical.
    • It is particularly important to monitor O2 saturation by pulse oximetry in infants because their ventilation/perfusion characteristics lead them to become hypoxemic more readily than adults. SaO2 should be normal for altitude (>95 percent at sea level). Decreased oxygen saturation is often an early sign of severe airway obstruction, and an SaO2 <91 percent on room air is a good predictor of the need for hospitalization in small infants (Connett and Lenney 1993; Geelhoed et al. 1994).
    • Capillary or ABG measurements should be performed in infants suspected of respiratory failure. PCO2 is the best measurement of ventilation in infants, as it is in adults. Children with a normal PCO2 but in obvious respiratory distress are at high risk for respiratory failure.

Treatment

In the emergency department and hospital, tailor the intensity of treatment and surveillance to the severity of the exacerbation. The primary therapies—the administration of oxygen, inhaled beta2-agonist, and systemic corticosteroids—are constant, but the dose and frequency with which they are given and the frequency with which the patient's response is assessed may vary. Thus, for patients presenting with a severe exacerbation, give inhaled beta2-agonist therapy at the higher dose (table 8-2) either repeatedly (three treatments in the first hour) or continuously (by nebulization), give systemic corticosteroids immediately, and watch closely for signs of worsening airflow obstruction or fatigue. For patients with mild exacerbations, give inhaled beta2-agonist therapy and assess the patient's response before deciding whether additional therapy is necessary. Give supplemental oxygen to patients with significant hypoxemia and to patients with FEV1 or PEF <50 percent of predicted when arterial oxygen monitoring is not available.

The following recommendations are based on scientific evidence (key studies are cited) and the opinion of the Expert Panel:

  • Oxygen is recommended for most patients. Administer supplemental oxygen (by nasal cannulae or mask, whichever is best tolerated) to maintain an SaO2 >90 percent (>95 percent in pregnant women and in patients with coexistent heart disease). Monitor oxygen saturation until a clear response to bronchodilator therapy has occurred.
  • Inhaled short-acting beta2-agonists are recommended for all patients (for recommended doses, see table 8-2).
    • The repetitive or continuous administration of inhaled short-acting beta2-agonists is the most effective means of reversing airflow obstruction (Lipworth et al. 1988; Lin et al. 1993; Rudnitsky et al. 1993).
    • In the emergency department, three treatments of beta2-agonists spaced every 20 to 30 minutes can be given safely as initial therapy. Thereafter, the frequency of administration varies according to the improvement in airflow obstruction and associated symptoms and the occurrence of side effects. Continuous administration of beta2-agonists may be more effective in children and severely obstructed adults (Lin et al. 1993; Rudnitsky et al. 1993; Papo et al. 1993; Kelly and Murphy 1992).
    • Because of the risk of cardiotoxicity, use only selective beta2-agonists (albuterol, terbutaline, pirbuterol, bitolterol) in high doses.
    • Studies show that equivalent bronchodilation can be achieved by either high doses (6 to 12 puffs) of a beta2-agonist by MDI with a spacer/holding chamber under the supervision of trained personnel or by nebulizer therapy (Idris et al. 1993; Colacone et al. 1993; Kerem et al. 1993). However, nebulized therapy is more effective in patients who are unable to coordinate inhalation of medication from an MDI because of their age, agitation, or severity of the exacerbation.
    • The onset of action for inhaled beta2-agonist is less than 5 minutes; repetitive administration produces incremental bronchodilation (Lipworth et al. 1988).
    • Duration of action of bronchodilation from beta2-agonists in severe asthma exacerbations is not precisely known.
  • Anticholinergics may be considered. Adding high doses of ipratropium bromide (0.5 mg in adults, 0.25 mg in children) to an aerosolized solution of a selective beta2-agonist has been shown to cause additional bronchodilation, particularly in those with severe airflow obstruction (Schuh et al. 1995; Reisman et al. 1988; O'Driscoll et al. 1989; Kelly and Murphy 1991), although some studies did not demonstrate this effect (Karpel et al. 1996).
  • Systemic corticosteroids are recommended for most patients (for recommended doses, see table 8-2).
    • In the emergency department: Give systemic corticosteroids to patients who have moderate-to-severe exacerbations and patients who do not respond completely to initial beta2-agonist therapy. These medications appear to speed the resolution of airflow obstruction and reduce the rate of relapse (Fanta et al. 1983; Rowe et al. 1992; Scarfone et al. 1993; Connett et al. 1994; Chapman et al. 1991).
      • Oral administration of prednisone has been shown to have effects equivalent to those of intravenous methylprednisolone (Harrison et al. 1986; Ratto et al. 1988) and, in the opinion of the Expert Panel, is usually preferred because it is less invasive.
      • Give supplemental doses of oral corticosteroids to patients who take them regularly, even if the exacerbation is mild.
      • In infants and children, it is especially important to give corticosteroids early in the course of an asthma exacerbation (Harris et al. 1987).
    • In the hospital: Give systemic corticosteroids to patients admitted to the hospital, because they speed the resolution of asthma exacerbations (Connett et al. 1994; Rowe et al. 1992; Singh and Kumar 1993).
  • Methylxanthines are not generally recommended.
  • Antibiotics are not recommended for asthma treatment but may be necessary for comorbid conditions. Bacterial, chlamydia, and mycoplasma respiratory tract infections are thought to contribute only infrequently to exacerbations of asthma. The use of antibiotics is generally reserved for those patients with fever and purulent sputum (discolored because of polymorphonuclear leukocytes, not eosinophils) and for patients with evidence of pneumonia. When the presence of bacterial sinusitis is suspected, treat with antibiotics.
  • Aggressive hydration is not recommended for older children and adults but may be indicated for infants and young children. Intravenous or oral administration of large volumes of fluids does not play a role in the management of severe asthma exacerbations. However, infants and young children may become dehydrated as a result of increased respiratory rate and decreased oral intake. In these patients, make an assessment of fluid status (urine output, urine specific gravity, mucus membrane moisture, electrolytes) and provide appropriate corrections.
  • Chest physical therapy is not generally recommended. In general, chest physiotherapy is not beneficial and is unnecessarily stressful for the breathless asthma patient.
  • Mucolytics are not recommended. Avoid mucolytic agents (e.g., acetylcysteine, potassium iodide) because they may worsen cough or airflow obstruction.
  • Sedation is not recommended. Anxiolytic and hypnotic drugs are contraindicated in severely ill asthma patients because of their respiratory depressant effect.

Repeat Assessment

The Expert Panel recommends that repeat assessment of patients with severe exacerbations be made after the initial dose of inhaled bronchodilator and that repeat assessment of all patients be made after three doses of inhaled bronchodilator (60 to 90 minutes after initiating treatment). The response to initial treatment in the emergency department is a better predictor of the need for hospitalization than is the severity of an exacerbation on presentation (Rodrigo and Rodrigo 1993). The elements to be evaluated include the patient's subjective response, physical findings, measurement of airflow, and measurement of ABG if the patient now meets the criteria described in the discussion of laboratory studies in the Assessment section, page 110.

Hospitalization

The decision to hospitalize a patient should be based on duration and severity of symptoms, severity of airflow obstruction, course and severity of prior exacerbations, medication use at the time of the exacerbation, access to medical care and medications, adequacy of support and home conditions, and presence of psychiatric illness. In general, the principles of care in the hospital resemble those for care in the emergency department and involve both treatment with oxygen, aerosolized bronchodilators, and systemic corticosteroids and frequent assessment, including clinical assessment of respiratory distress and fatigue and objective measurement of airflow (PEF or FEV1) and oxygen saturation.

Impending Respiratory Failure

Most patients respond well to therapy. However, a small minority will show signs of worsening ventilation, whether from worsening airflow obstruction, worsening respiratory muscle fatigue, or a combination of the two. Signs of impending respiratory failure include a declining mental clarity, worsening fatigue, and a PCO2 of ≥42 mm Hg. Exactly when to intubate is based on clinical judgment; however, the Expert Panel recommends that intubation not be delayed once it is deemed necessary. Because respiratory failure can progress rapidly and can be difficult to reverse, early recognition and treatment are critically important.

Because intubation of a severely ill asthma patient is difficult, additional treatments are sometimes attempted, such as intravenous administration of magnesium sulfate (Kuitert and Kletchko 1991; Skorodin et al. 1995; Tiffany et al. 1993; Green and Rothrock 1992) and substituting a mixture of helium and oxygen (“heliox”) for oxygen-enriched air (Manthous et al. 1995; Gluck et al. 1990). Although limited observations suggest that these therapies may be effective, possibly among certain subgroups (Bloch et al. 1995), they have not yet been proven consistently effective. Intravenous administration of a beta2-agonist also falls into this category of unproven treatment. Recent studies suggest that albuterol is more effective and has fewer side effects when it is given by aerosol than when given intravenously (Salmeron et al. 1994), but the efficacy of adding an intravenous beta2-agonist to high-dose nebulized therapy has not been studied. Do not use intravenous isoproterenol in the treatment of asthma because of the danger of myocardial toxicity (Maguire et al. 1991).

The Expert Panel recommends the following actions regarding intubation:

  • Patients presenting with apnea or coma should be intubated immediately. There are no other absolute indications for endotracheal intubation, but persistent or increasing hypercapnia, exhaustion, and depression of mental status strongly suggest the need for ventilatory support.
  • Consultation with or comanagement by physicians expert in ventilator management is appropriate because mechanical ventilation of patients with severe refractory asthma is complicated and fraught with risk.
  • Because intubation is difficult in asthma patients, it is best done semi-electively, before the crisis of respiratory arrest.
  • Intubation should be performed in a controlled setting by a physician with extensive experience in intubation and airway management.
    • It is preferable that patients with severe exacerbations who are slowly responsive to therapy be admitted to an intensive care unit where they can be monitored closely and intubated if it is indicated.
    • Because intubation should not be delayed once it is deemed necessary, it may be performed in the emergency department or inpatient ward and the patient transferred to an intensive care unit appropriate to the patient's age.
    • Children intubated for asthma should be admitted to a pediatric intensive care unit or transferred to a facility that has such a unit.
  • Issues to consider at the time of intubation include the following:
    • Close attention should be given to maintaining or replacing intravascular volume, because hypotension commonly accompanies the initiation of positive pressure ventilation.
    • Once mechanical ventilation has been started, it is important to avoid high ventilator pressures and the associated risks of barotrauma.
  • “Permissive hypercapnia” or “controlled hypoventilation” is the recommended ventilator strategy to provide adequate oxygenation and ventilation while minimizing high airway pressures and barotrauma (Tuxen 1994; Darioli and Perret 1984; Menitove and Goldring 1983). It involves administration of as high an FiO2 as is necessary to maintain adequate arterial oxygenation, acceptance of hypercapnia, and treatment of respiratory acidosis with intravenous sodium bicarbonate. Adjustments are made to the tidal volume, ventilator rate, and I:E ratio to minimize airway pressures. Bronchodilators are continued, and even in ventilated patients, aerosol delivery is the route of choice (Dhand and Tobin 1996).

This ventilator strategy is not uniformly successful in critically ill asthma patients, and additional therapies are being evaluated. Their review is beyond the scope of this report.

Patient Discharge

Before discharge, provide patients with necessary medications and education in how to use them, instruction in self-assessment (e.g., by monitoring symptoms and peak flow), a followup appointment, and instruction in an action plan for managing recurrence of airflow obstruction. To ensure that these steps are taken, a discharge checklist may be useful (see example in table 8-3).

Table 8-3. Hospital Discharge Checklist for Patients with Asthma Exacerbations.

Table 8-3

Hospital Discharge Checklist for Patients with Asthma Exacerbations.

From the Emergency Department

  • Release of the patient from the emergency department depends on the patient's response to treatment.
    • In general, discharge is appropriate if FEV1 or PEF has returned to ≥70 percent of predicted or personal best and symptoms are minimal or absent. Patients with an incomplete response to therapy (FEV1 or PEF ≥50 but <70 percent predicted or personal best) and with mild symptoms should be assessed individually for their suitability for discharge home, with consideration of factors listed in box 8-1.
    • The Panel's opinion is that patients with a rapid response should be observed for 30 to 60 minutes after the most recent dose of bronchodilator to ensure stability of response before discharge to home.
    • Extended treatment and observation in a holding area, clinical decision unit, or overnight unit to determine the need for hospitalization may be appropriate provided there is sufficient monitoring and nursing care.
  • Prescribe sufficient medications for the patient to continue treatment after discharge. Patients given systemic corticosteroids should continue oral systemic corticosteroids for 3 to 10 days. The need for further corticosteroid therapy should be assessed at a followup visit. If the patient is receiving inhaled corticosteroids, it is not necessary to taper the dose gradually when the course is completed (O'Driscoll et al. 1993).
  • Emphasize the need for continual, regular care in an outpatient setting. Refer the patient to a followup medical appointment. A visit to the emergency department is often an indication of inadequate long-term management of asthma or inadequate plans for handling exacerbations. Notify the patient's health care professional (or provide a referral to one if the patient does not name a source of asthma care), and instruct the patient to seek a followup medical appointment within 3 to 5 days. When possible, schedule such an appointment prior to the patient's discharge. The followup visit should include a detailed review of the patients' medications, inhaler and peak flow meter technique, and development of comprehensive daily management and action plans that will help prevent exacerbations and urgent care visits (see figures 9-2, 9-3 and 9-4). Referral to an asthma specialist for consultation should be considered because this has been reported to reduce the rate of subsequent emergency department visits (Zeiger et al. 1991).
  • Review written discharge medications and, whenever possible, provide patient education on avoidance of asthma triggers and correct use of an inhaler (see figure 9-1).
  • Instruct the patient in a simple action plan for increasing medications or returning for care should asthma worsen.
  • Consider issuing a peak flow meter and providing patient education on how to measure and record daily PEF rates.

From the Hospital

  • Prior to discharge, adjust the patient's medication to an oral and/or inhaled regimen. The optimal timing of this transition is not precisely established, but the general approach is to wait until the patient is minimally symptomatic from asthma and has little wheezing on chest examination. Usually this clinical status corresponds to a PEF or FEV1 of ≥70 percent of predicted or personal best. During the first 24 hours after this medication adjustment, observe the patient for possible deterioration.
  • Discharge medications should include a short-acting inhaled beta2-agonist and sufficient oral corticosteroid to complete the course of therapy or to continue therapy until the followup appointment. If the decision is made to start the patient on inhaled corticosteroids, they should be started before the course of oral corticosteroids is completed, because their onset of action is gradual (Kraan et al. 1988). Starting the inhaled corticosteroid therapy before discharge gives the patient additional time to learn and demonstrate appropriate technique.
  • Provide patient education:
    • An exacerbation severe enough to require hospitalization may reflect a failure of the patient's self-management plan. Hospitalized patients may be particularly receptive to information and advice about their illness; take the opportunity to review patient understanding of the causes of asthma exacerbations, the purposes and correct uses of treatment, and the actions to be taken for worsening symptoms or peak flow values.
    • Educate patients about their discharge medications and the importance of a followup medical visit. Referral to an asthma specialist should be considered for patients with a history of life-threatening exacerbations or multiple hospitalizations (see component 1, page 23) (Mayo et al. 1990).
    • Educate patients older than 5 years of age in the use of peak flow meters to monitor their lung function at home.
    • Review or develop an action plan for management of recurrent symptoms or exacerbations. The plan should describe the signs, symptoms, and/or peak flow values that should prompt increases in self-medication, contact with a health care provider, or return for emergency care. The plan given at discharge from the emergency department may be quite simple (e.g., instructions for discharge medications and returning for care should asthma worsen). The plan developed for discharge from the hospital should be more complete (see table 8-3). A detailed plan for comprehensive long-term management and handling exacerbations should be developed by the regular provider at a followup visit (see figure 9-4).

References

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