Acute Respiratory distress 2/2 to Asthma Exacerbation
H&P performed.
Differential diagnosis.
Causes of asthma exacerbation.
Peak expiratory flow (PEF): ___
Oxygen saturation: ___
Asthma Severity Classification.
Consider CXR, ABG, and CBC and CMP as indicated. These are not necessary for most patients.
Treatment
–Oxygen to keep SpO2 > 92% (or 95% if pregnant).
–Inhaled SABA Nebs or MDI. Albuterol 2.5 mg per 3mL by neb q 20 minutes x 3 doses, then 2.5 mg q1-4hrs prn OR Albuterol MDI with a spacer, 4 to 8 puffs q 20 minutes x 3 doses, then 4 to 8 puffs q1-4hrs prn. For critically ill patients, may do continuous nebs giving 10 to 15 mg of albuterol over one hour. May use Levalbuterol (Xopenex) to mitigate tachycardia.
–Ipratropium Nebs or MDI. Duonebs or Xopenex-Ipratropium for patients w/ severe exacerbation. Ipratropium 0.5 mg per 2.5 mL by neb (or 4-8 puffs from MDI) q 20 minutes x 3 doses, then prn for up to 3 hours.
-Breathing tx above q1h as needed.
–Systemic corticosteroids. Prednisone 40 to 60 mg (methylprednisolone 32 to 48 mg IV) once daily for 5 to 7 days for pts discharged home.
–Magnesium sulfate 2g IV infused over 20 minutes if pt has a severe asthma exacerbation that is not responding to initial therapy.
-Reassess pt frequently.
-Admit pts if they don’t respond well to tx in the ED, if s/sx of cough, wheezing, and SOB preclude self-care at home, and/or if PEF ≤60% of predicted or their personal best value. In other pts, the decision to admit should be individualized.
-At discharge, will provide pt education about meds, inhaler technique, Asthma Action Plan, and instructions for f/u w/ PCP.
-Send home with inhaled corticosteroids to start after completing systemic steroids.
Asthma Pearls and Important links
- Rapid administration of steroids (within the first hr) increases outcomes and can decrease the frequency of hospitalization in patients with severe exacerbation.
- Good response to tx is symptoms resolved; PEF > 80% of predicted or personal best.
- Incomplete response to tex is symptoms persisting and PEF between 60 to 80% of predicted or personal best.
- Ipratropium provides benefit during ER/urgent care administration but no benefit during hospitalization.
- PO and IV steroids have the same bioavailability.
- Don’t use IV beta-agonists, methylxanthines, or leukotriene receptor antagonists for asthma exacerbation except in rare situations (and let a specialist do that).
- Inhaled steroids are NOT recommended for exacerbation. Systemic steroids are.
- How to Order Inhaled Albuterol and a Nebulizer Machine.
- Asthma severity and initiating treatment for ages 12 years and older.
- Asthma Action Plan.
- How to use a peak flow meter.
- Obstructive and Restrictive Lung Diseases.
Additional reading:
https://www.uptodate.com/contents/acute-exacerbations-of-asthma-in-adults-emergency-department-and-inpatient-management (this article has a nice algorithm for ER tx and making admission and d/c decisions).