Acute severe asthma

Acute severe asthma

Assessment:

Assess heart rate (HR

respiratory rate (RR

O2 saturation

peak expiratory flow rate

use of accessory muscles

pulsus paradoxus (>20 mmHg difference in systolic BP for inspiratory versus expiratory phase

dyspnea, alertness, color.

Initial management

Oxygen to keep saturation >95%.

Inhaled β-agonists: Nebulized salbutamol 0.05 to 0.15 mg/kg/dose every 20 minutes to effect.

Additional nebulized bronchodilators

ipratropium bromide 0.25 to 0.5 mg nebulized with salbutamol  (as above).

Benefit has only been demonstrated for moderate to severe exacerbations.

If there is very poor air movement, or the patient is unable to cooperate with a nebulizer, give epinephrine 0.01 mL/kg SC (1:1000; maximum dose 0.3 mL) every 15 min up to three doses, or terbutaline 0.01 mg/kg SC (maximum dose 0.4 mg) every 15 minutes up to three doses.

Start corticosteroids if there is no response after one nebulized treatment or if patient is steroid dependent.

Prednisone or prednisolone 2 mg/kg PO every 24 hr; or (if severe) methylprednisolone 2 mg/kg IV/IM then 2 mg/kg/day divided every 6 hr.

Parenteral steroids have not been proven to routinely provide more rapid onset of action or greater clinical effect than oral steroids in children with mild to moderate asthma.

Further management if incomplete or poor response

Continue nebulization therapy every 20 to 30 minutes and space interval as tolerated.

Administer magnesium 25 to 75 mg/kg/dose IV/IM (2 g max.) infused over 20 minutes every 4 to 6 hr up to three to four doses.

Administer terbutaline 2 to 10 mcg/kg IV load followed by continuous infusion at 0.1 to 0.4 mcg/kg/min titrated to effect

A helium (>70%)-oxygen mixture may be of some benefit in the critically ill patient, but is more useful in upper-airway edema. Avoid use in the severely hypoxic patient.

Although aminophylline may be considered, it is no longer considered a preferred mode of therapy for status asthmaticus

Intubation: Intubation of those with acute asthma is dangerous and should be reserved for impending respiratory arrest. Premedicate with lidocaine and ketamine