Managing asthma attacks

Question 1

What are the criteria for mild asthma exacerbation?

Answer 1

• PEFR >75%

- Very slight worsening of asthma symptoms

Question 2

What are the criteria for moderate asthma exacerbation?

Answer 2

• PEFR <75%
• Increasing asthma symptoms
• No features of severe asthma

Question 3

What are the criteria for severe asthma exacerbation?

Answer 3

Any ONE of:

• PEFR 33-50%
• RR ≥25/min
• HR ≥110/min
• Inability to complete sentences in one breath

Question 4

What are the clinical signs of life-threatening asthma exacerbation?

Answer 4

Any ONE of the following:

• Exhaustion
• Arrhythmia
• Hypotension
• Cyanosis
• Silent chest
• Poor respiratory effort

Question 5

What measurements indicate life-threatening asthma exacerbation?

Answer 5

Any ONE of the following:

• PEF <33% predicted
• SpO2 <92%
• PaO2 <8 kPa
• ‘Normal PaCO2 (4.6-6.0 kPa)

Question 6

What are the criteria for near-fatal asthma exacerbation?

Answer 6

• Raised PaCO2

- and/or requiring mechanical ventilation with raised inflation pressures

Question 7

What must be prescribed immediately once asthma exacerbation is recognised (adults)?

Answer 7

All of these are given together (would be prescribed and given during B part of A-E assessment):

1. Oxygen (maintain between 94-98%, usually non-rebreathe mask 15L)
2. Salbutamol 5mg via an oxygen-driven nebuliser
   - repeat at 15-30 minute intervals
3. Hydrocortisone (IV) 100mg, or Prednisolone tablets 40-50mg
4. Ipratropium bromide 0.5mg via oxygen-driven nebuliser 4-6 hrly

Question 8

What additional pharmacological agents should be prescribed if asthma exacerbation is life-threatening (adult)?

Answer 8

• Give with senior input
  1. Magnesium sulphate 2g IV over 20 mins
• one-off dose
  2. Theophylline: aminophylline infusion
  3. Escalate care (intubation and ventilation)

Question 9

At what points during assessing an asthma exacerbation should senior involvement be requested?

Answer 9

1. Any signs of airway obstruction
2. Reduced air entry suggesting airway compromise
3. If magnesium sulphate or IV aminophylline needs to be administered
4. If a patient has a negative response or isn’t responding adequately to boluses of IV fluids
5. If intracranial pathology is suspected and CT head is indicated
6. Concerns regarding consciousness/GCS of a patient ESPECIALLY if GCS is 8 or less
7. Deterioration or no improvement when re-assessing ABCDE

Question 10

What should be done once a patient is stabilised following asthma exacerbation?

Answer 10

1. Take a history
2. Review notes, charts, recent investigations, current medications
3. Clearly document your ABCDE assessment (inc history, examination, observations, investigations, interventions, patient’s response)
4. Discuss patient’s current clinical condition with a senior clinician using SBARR format
   - Are any further assessments or interventions required?
   - Does the patient need a referral to HDU/ICU?
   - Does the patient need reviewing by a specialist?
   - Should any changes be made to the current management of their underlying condition(s)?
5. Handover