Asthma

Asthma Exacerbations Figure 1. Management of Asthma Exacerbations: Emergency Department and Hospital-Based Care Initial Assessment > History and physical exam (auscultation, accessory muscle use, heart and respiratory rate) > FEV1 > O2 or PEFR (vs. personal best or predicted if personal best unknown) > Other tests as indicated saturation FEV1 or PEFR ≥ 40% (Mild-to-Moderate) > Oxygen to achieve SaO2 > Inhaled SABA by nebulizer or MDI with valved holding chamber, up to 3 doses in first hour ≥ 90% > Oral systemic corticosteroids if no immediate response or if patient recently took oral systemic corticosteroids FEV1 or PEFR < 40% (Severe) > Oxygen to achieve SaO2 > High-dose inhaled SABA plus ipratropium by nebulizer or MDI plus valved holding chamber, every 20 minutes or continuously for 1 hour Repeat Assessment (symptoms, physical exam, PEFR, O2 Moderate Exacerbation > FEV1 or PEFR 40-69% > Physical exam; moderate symptoms > Inhaled SABA q60min > Oral systemic corticosteroid > Continue treatment 1-3 hr provided there is improvement, make admit decision in ≤ 4 h predicted/personal best Good Response > FEV1 ≥ 90% Impending/Actual Respiratory Arrest > Intubation and mechanical ventilation with 100% O2 > Nebulized SABA and ipratropium > Oral systemic corticosteroids saturation, other tests as needed) Severe Exacerbation > FEV1 > Physical exam: severe symptoms at rest, accessory muscle use, chest retractions or PEFR < 40% predicted/personal best > History: high risk > No improvement after initial treatment: ▶ Oxygen ▶ Nebulized SABA + ipratropium, hourly or continuously ▶ Oral systemic corticosteroid ▶ Consider adjunct therapies > Response sustained 60 min after last treatment or PEFR ≥ 70% > No distress > Physical exam normal Discharge Home > Continue with SABA > Continue oral systemic corticosteroid Incomplete Response > FEV1 > Mild to moderate symptoms or PEFR 40-69% Individualize decision regarding hospitalization > Patient education: ▶ Review medication use and inhaler technique ▶ Review/initiate action plan ▶ Recommend close medical follow-up Admit to Hospital Ward > Inhaled SABA > Systemic corticosteroid (oral or IV) Admit to Hospital ICU (Table 9) > O2 > Monitor vital signs, FEV1 or PEFR, SaO2 Improved Poor Response > FEV1 > PCO2 > Intravenous corticosteroid > Consider adjunct therapies > Symptoms severe, drowsiness, confusion or PEFR < 40% ≥ 42 mm Hg > O2 > Inhaled SABA hourly or continuously > IV corticosteroid > Possible intubation and mechanical ventilation Improved

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