Management Of Acute Severe Asthma Research Articles

Emergency presentation and management of acute severe asthma in children.

Acute severe asthma is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition. In this article we present a summary of the pathophysiology as well as guidelines for the treatment of acute severe asthma in children. The cornerstones of the management of acute asthma in children are rapid administration of oxygen, inhalations with bronchodilators and systemic corticosteroids. Inhaled bronchodilators may include selective b2-agonists, adrenaline and anticholinergics. Additional treatment in selected cases may involve intravenous administration of theophylline, b2-agonists and magnesium sulphate. Both non-invasive and invasive ventilation may be options when medical treatment fails to prevent respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.

External chest compression in acute asthma—A potentially life-saving intervention?

Purpose of the study: To search for scientific evidence of the benefit for external chest compression in acute asthma. To report a case in which external chest compression was used in the management of acute severe asthma in the prehospital setting. Materials and methods: A literature survey was made. One pilot study, four case reports and three reviews were found. A case from the Göteborg EMS is reported. Results: Literature survey: Most patients with asthma and acute exacerbation respond to conventional therapy.

The management of acute severe asthma in adults

Asthma is a common condition, which can develop into a severe, life-threatening form in any sufferer. Generally, those at risk of an acute attack are women from minority ethnic groups, who have a poor compliance history. Most patients that die of asthma do so in the community. Those who attend the emergency room generally respond to conventional treatments and hospital admission. However, a small proportion of patients will require ITU admission and mechanical ventilation, and, if the admission is not secondary to cardiorespiratory arrest, generally survive. Ventilation techniques that prevent dynamic hyperinflation and the consequent complications of hypotension and barotrauma, are now generally adopted. This includes a pressure-limited mode of ventilation associated with low tidal volumes, high flows and low respiratory rate. Follow up of these patients is essential as they form a very poor prognostic group. Detailed self-management planning, PEFR monitoring and physician review should be therefore encouraged.

The management of acute severe asthma 1,2

Asthma is a common cause of morbidity and mortality in the United States, with over two million Emergency Department (ED) visits each year. Airway inflammation is recognized as a major component in the pathophysiology of asthma. The classic presentation of asthma is that of wheezing, cough, and dyspnea, however, the severity of airflow limitation correlates poorly with clinical signs. Forced exhaled volume in 1 s (FEV 1) and the peak expiratory flow rate (PEFR) are direct reflections of the severity of airflow obstruction and are the standard measures used in the ED to assess the severity of airflow obstruction and the response to therapy. β2-adrenergic bronchodilators, ipratropium bromide, and corticosteroids form the cornerstone of therapy. Inhaled corticosteroids, leukotriene modifying drugs, and noninvasive positive pressure ventilation should be considered in patients with severe disease and in those who have responded poorly to standard therapy. Mechanical ventilation is usually well tolerated and may be lifesaving in patients with refractory asthma. Precautions are required to prevent dynamic hyperinflation during assisted ventilation.

The Management of Acute Severe Asthma

Acute severe asthma exacerbations resulting in emergency department visits and hospitalization usually constitute a failure of long-term control therapy. However, even patients with relatively mild asthma can have severe life-threatening episodes. In both children and adults, viral respiratory infections are the major triggering event, although outbreaks of severe asthma have been associated with high concentrations of aeroallergens. Patients should be provided with written action plans on what to do for acute deterioration, and more severe patients may keep prednisone at home to begin after consultation with their physician. The primary therapy of acute asthma exacerbations remains frequent administration of aerosol β2-agonists and systemic corticosteroids for those patients not fully responding to the β2-agonists. Mild exacerbations may be treated with an increased dosage of inhaled corticosteroids. Patients at risk for acute exacerbations may benefit from peak flow measurement, particularly those who have difficulty perceiving airway obstruction. It is recommended that patients remain on full dose of prednisone until they achieve 70-80 percent of predicted normal or personal best peak flow. In the emergency department, the use of β2-agonists by metered-dose inhaler and holding chamber is as effective as nebulizer if given in a sufficient dose 6-10 puffs equivalent to 5 mg via nebulizer. In those patients not responding completely, the addition of ipratropium bromide has shown to produce additive bronchodilation and reduce hospitalizations. Other therapies such as magnesium sulfate, intravenous β2-agonists, heliox and ketamine have been used, but data demonstrating efficacy are insufficient to warrant recommending their general use.

Acute asthma.

OBJECTIVE: Asthma is the most common medical emergency in children. It is associated with significant morbidity and mortality rates and poses a tremendous societal burden worldwide. Management of the acute attack involves a stepwise approach that includes beta-agonist and steroid therapy, the mainstay of emergency treatment. Most patients will respond to this regime and can be discharged from the emergency department. Failure to respond to treatment necessitates hospital admission and sometimes admission to the intensive care unit (ICU). Management in the ICU involves intensification of pharmacologic therapy, including nonstandard therapies, in an attempt to avoid intubation and ventilation. When needed, mechanical ventilatory support can be rendered fairly safe with little morbidity if the likely cardiorespiratory physiologic derangements are appreciated and if appropriate ventilatory strategies are used. In the past two decades, the availability of newer potent medications and changes in approach to monitoring and ventilatory strategies have resulted in a decrease in ICU morbidity and mortality rates. Research endeavors are presently underway to further characterize the underlying mechanisms of the disease and are likely to lead to novel therapies. This article reviews the approach to management of acute severe asthma.

Corticosteroids for acute severe asthma in hospitalised patients.

Corticosteroids are currently used routinely in the management of acute severe asthma. The optimal dose and route of administration continues to be debated. Some investigators have reported a greater benefit of higher doses of corticosteroids in the management of severe asthma, while others have not. To determine whether higher doses of systemic corticosteroids (oral, intravenous or intramuscular) are more effective than lower doses in the management of patients with acute severe asthma requiring hospital admission. Randomised controlled trials were identified from the Cochrane Airways Group Asthma Register. In addition, primary authors and content experts were contacted to identify eligible studies. Bibliographies from included studies, known reviews and texts were also searched. Studies were selected for inclusion in the review if they met the following broad inclusion criteria: described as randomised controlled trials, included patients with acute severe asthma, compared different doses of corticosteroids (any route) in 2 or more treatment arms, and had a minimum period of follow up of 24 hours. Two reviewers independently assessed the studies for inclusion and disagreement was resolved by third party adjudication. Data were extracted independently by two reviewers if the authors were unable to verify the validity of information. Missing data were obtained from authors or calculated from other data presented in the paper. The data were analysed as weighted mean differences (WMD) for primary pulmonary function outcomes using a fixed effects model. For the purposes of the review, three broad categories of corticosteroid dose (equivalent dose of methylprednisolone in 24 hours) were defined in advance: low dose (< or = 80 mg), medium dose (> 80 mg and < or = 360 mg) and high dose (> 360 mg). There were thus 3 main comparison groups: low versus medium dose, medium versus high dose and low versus high dose. Nine trials were included; a total of 344 adult patients have been studied (96 with low dose, 85 with medium dose and 163 with high dose corticosteroids). Only 6 trials provided sufficient data for the meta-analysis. There were no clinically or statistically significant differences detected in % predicted FEV1 among comparison groups after 24, 48 or 72 hours. At 48 hours, the weighted mean difference was -3.3% predicted (95% confidence interval -12.4 to + 5.8) for the low vs medium dose comparison, -1. 9% predicted (95% CI -8.1 to + 4.3) for the medium vs high dose comparison and + 0.5% predicted (95% CI - 7.8 to + 8.8) for the low vs high dose comparison. There appeared to be no significant differences in side effects or rates of respiratory failure among the varying doses of corticosteroids. No differences were identified among the different doses of corticosteroids in acute asthma requiring hospital admission. Low dose corticosteroids (< or = 80 mg/day of methylprednisolone or < or = 400 mg/day of hydrocortisone) appear to be adequate in the initial management of these adult patients. Higher doses do not appear to offer a therapeutic advantage.

Management of acute severe asthma

Management of acute severe asthma

Immediate management of acute severe asthma in adults.

Asthma is a disease with an increasingly high incidence in the UK, tragically accounting for almost 2000 UK deaths per year (Jones and Morris, 1997). Acute severe asthma is potentially life-threatening, necessitating immediate assessment and management. This article covers the main types of asthma, the pathophysiology of asthma, and the principles and rationale for the immediate management of adults admitted to the accident and emergency department suffering from an acute severe asthma attack. The authors have used the British Thoracic Society (BTS, 1997) guidelines on the management of asthma as the basis for their advice.

Severe acute asthma in the child

OBJECTIVE: To present a current review about diagnosis and treatment of severe acute asthma, based on the reviewed publications and the authorś personal experience. METHODS: We reviewed the most relevant articles about diagnosis and management of severe acute asthma. RESULTS: Severe acute asthma is an important cause of morbidity in children and it can usually lead to respiratory failure. The diagnostic (clinical manifestations and lung function tests) and treatment (oxygen, bronchodilators and steroids) are now well determined by the literature, and are very important for a good prognosis of every patient. CONCLUSIONS: Considering severe acute asthma a prevalent condition in pediatric emergency room and intensive care unit, the ability to make an early diagnosis of this condition, associated with a prompt treatment, are essential for an effective reduction in morbimortality rates.

Randomised controlled trial of aminophylline for severe acute asthma

OBJECTIVESTo determine whether children with severe acute asthma treated with large doses of inhaled salbutamol, inhaled ipratropium, and intravenous steroids are conferred any further benefits by the addition of aminophylline...

The British Asthma Guidelines — Their production, dissemination and implementation: An article for respiratory medicine on behalf of the British Asthma Guidelines co-ordinating committee

The first British guidelines on the management of asthma were published in the British Medical Journal (1,2) in 1990 as two papers, one on the management of chronic persistent asthma and the other on the management of acute severe asthma in adults. Other asthma guidelines had been published previously by a group of respiratory specialists from Australia and New Zealand (3) and by an international group of respiratory paediatricians who made recommendations on the management of asthma in children (4). The initial British guidelines were supported by five fully referenced background papers (5-9). In the same year, the Canadian asthma guidelines were published (10) and since 1990, asthma guidelines have been published in many other countries, including an international consensus report on the diagnosis and management of asthma (11) and a National Heart, Lung and Blood Institute/WHO workshop report The Global Strategy on Asthma Management and Prevention (12). Two of these guidelines have been revised, the International Paediatric Guidelines in 1992 (13) and the British Asthma Guidelines (which now include advice on asthma in children) in 1993 (14) and again in 1997 (15).

Nébulisation dans l'asthme aigu Intérêt de l'association d'un atropinique et d'un bêta 2-sympathomimétique

Nebulization is a basic treatment for the management of severe acute asthma. Three mechanisms are involved in bronchial obstruction: bronchospasms, inflammation and an increase in bronchial secretions. Combination therapy including β 2-sympatheticomimetic and synthetic atropinic drugs is strongly synergistic. In a French multicenter trial including 45 adult patients presenting with asthma, combination of nebulized Berotec ® and Atrovent ® was studied. It proved to be efficacious in two thirds of the patients. Results were even better for younger patients whose initial peak flow rate was high. Tolerance to this combination therapy was as good as that to β 2-sympatheticomimetic monotherapy.

Randomised trial of intravenous salbutamol in early management of acute severe asthma in children

The mainstay of treatment for acute asthma in children is nebulised beta 2-adrenergic agents such as salbutamol, given with corticosteroids. However, penetration of the drug to the small airways is impeded by obstruction so intravenous salbutamol may be more effective. We assessed the use of intravenous salbutamol in the management of children with acute severe asthma in a double-blind randomised study. Children who presented to the Emergency Department of Westmead Hospital, Sydney, Australia with asthma were assessed with a clinical assessment scale, and those with severe acute asthma were given nebulised salbutamol at a dose of 2.5 mg (age < or = 2 years) or 5.0 mg (age > 2 years), made up to 4 mL with saline. Children who did not improve were eligible to enter phase one of the study. In this phase (0 h-2 h) treatment was by a standard protocol: nebulised salbutamol at the above dose: 4 L/min or 6 L/min continuous oxygen until oxygen saturation reached 93% in room air for at least 30 min; a bolus of intravenous hydrocortisone 5 mg/kg given over 3 min; and then 15 micrograms/kg intravenous salbutamol or saline, depending on randomised allocation. In phase two (2 h-24 h) the children were given nebulised salbutamol continuously then at 30 min, 1 h, 2 h, 3 h, and 4 h, according to need. All children were transferred to the ward once they were ready to start hourly nebulisation. All patients were followed up until discharge. The primary endpoints were recovery time (no longer requiring inhaled salbutamol) and persistent moderate to severe asthma 2 h after randomisation. Analyses were by intention-to-treat although no withdrawals occurred. The recovery time (time to cessation of nebulised salbutamol every 30 min) was 4 h in the 14 children allocated intravenous salbutamol compared with 11.5 h for the 15 children in the control group. 2 (14%) of the intravenous salbutamol group compared with 8 (53%) of the control group needed oxygen to maintain oxygen saturation at 93% room air. The intravenous salbutamol group were ready for discharge from the emergency department 9.7 h earlier than the control group. No clinically significant side-effects were found in either group. Addition of a 10 min infusion of salbutamol in the early treatment of children with acute severe asthma has the potential to curtail the clinical progression of asthma, reduce demand placed on hospital resources, and improve the quality of health care provided to the acutely sick child with asthma.

Do accident and emergency senior house officers know the British guidelines on the management of acute asthma?

Avoidable deaths from asthma continue, even in hospital. Since the management of acute severe asthma is often initiated in the Accident and Emergency department, it is crucial that staff there have adequate knowledge. An anonymous questionnaire, containing items based on chart 6 of the UK guidelines, was completed by 66 Accident and Emergency Senior House Officers from the Yorkshire region. The study aim was to establish these doctors' levels of knowledge about the recommended management of acute asthma in Accident and Emergency. The median score was 10 (out of a possible 24) and the interquartile range 8-13. Further efforts are required to implement these guidelines so that the best patient outcomes can be achieved.

A Retrospective Comparative Study of In-hospital Management of Acute Severe Asthma: 1984 vs 1989

Recent controversies examining the management of acute asthma prompted us to investigate whether there had been any significant changes in our management practices. We therefore audited the charts of all patients admitted to a large tertiary-care university-affiliated hospital with a primary diagnosis of acute asthma during the years of 1984 and 1989. A total of 67 patients' charts were reviewed (39 in 1984 and 28 in 1989). The mean age and initial flow rates (FEV1 or peak expiratory flow rate [PEFR]) were similar. In the emergency room, chest radiographs and arterial blood gas analyses were done more frequently than objective measures of flow. Fifty-one percent (20/39) of the patients had no measurement of flow in the emergency room in 1984 and 39 percent (11/28) in 1989 (p > 0.05). In both years, approximately 20 percent of the patients had no record of flow rates during their hospitalization (21 percent [8/39] in 1984 and 18 percent [5/28] in 1989). More studies of the blood were ordered in 1989, including hepatic enzyme and electrolyte measurements for no clear reasons. The clinical utility of chest radiographs was negligible. While the vast majority of patients received systemic corticosteroids in both years (85 percent [33/39] in 1984 and 96 percent [27/28] in 1989), 23 percent (9/39) and 18 percent (5/28) were discharged without oral steroid therapy in 1984 and 1989, respectively (p > 0.05). There was a significant decline in the use of aminophylline (95 percent [37/39] to 54 percent [15/28]; p < 0.05) and an increase in the use of ipratropium bromide (15 percent [6/39] to 75 percent [21/28]; p < 0.05) in 1989. Theophylline levels were less likely to be measured in 1989, and the majority of levels in both years were either subtherapeutic or toxic. No patients were discharged with peak flow meters or recorded action plans, although follow-up arrangements were recorded in 87 percent (34/39) and 96 percent (27/28) of the patients in 1984 and 1989. We conclude that while improvements in in-hospital management of asthma were noted in 1989, suboptimal management practices are still common.

The role of corticosteroids in the management of childhood asthma

ObjectiveTo formulate recommendations for the role of corticosteroid therapy in the management of childhood asthma.Data sourcesThe recommendations are based on a review of the available literature and a variety of review articles on the efficacy and safety of corticosteroid therapy supplemented by personal experience in managing children with asthma.Data synthesis1. Preventive therapy. Sodium cromoglycate should be considered first‐line treatment. Inhaled corticosteroids are indicated in children who fail to achieve control on this therapy or those with severe disease. An initial dosage of 400‐600 pg/day is recommended with subsequent variation in dosage related to clinical response. Large volume spacers can be used to improve aerosol delivery and minimise side effects. Indications for specialist assessment include: use of inhaled corticosteroids in children under 3 years of age; the requirement for high dose therapy (&gt;600 pg/day); or the need for regular oral corticosteroids.2. Acute severe asthma. Systemic corticosteroid therapy is a valuable adjunct in the treatment of acute severe asthma and can be used safely in the short term. The efficacy of high dose inhaled corticosteroids in the management of acute severe asthma requires further evaluation. The need for systemic corticosteroid therapy signals the need for reassessment of that child's usual maintenance therapy.ConclusionThese recommendations are presented as a guide to the use of corticosteroid therapy in childhood asthma. In the individual child, the benefits of therapy need to be weighed against the possible risks, with the aim of maintaining good asthma control with the minimum dose of corticosteroid.

Changes in hospital management of acute severe asthma by thoracic and general physicians in Birmingham and Manchester during 1978 and 1985.

Hospital management of acute severe asthma in 14 large hospitals in Birmingham and Manchester was audited in a random 20% of 1196 patients aged 15-45 years admitted in 1985. Of the 239 admissions randomised, 192 were suitable for study. Results were compared with those from a study in the same hospitals using the same methods in 1978. The age and sex of the patients and their smoking history, duration of asthma, and hospital attendance were similar in 1978 and 1985. A much smaller proportion of patients presented with symptoms of over seven days' duration in 1985 (8.5%) than in 1978 (26%). The inpatient management of asthma appears to have improved in both thoracic and general units, with more thorough functional assessments, more frequent performance of relevant investigations (arterial blood gases and peak expiratory flow rates) and more frequent use of recommended treatment (nebulised bronchodilators, oral and intravenous corticosteroids). Less difference was found in 1985 between units with a specialist thoracic interest and those without, though some differences remained in 1985 in monitoring of peak expiratory flow rate and arterial blood gases, outpatient prescribing, and follow up arrangements. Inhaled preventive medication was prescribed more frequently than in 1978. In 1985 there was a 56% increase in admissions for asthma. The proportion of severely ill patients was similar to that in 1978, but in the most severe functional grade mean arterial carbon dioxide tension was higher in 1985 and more patients were ventilated. Our results suggest that hospital management by thoracic and general physicians has improved over the period 1978-85. Patients presented earlier in 1985, though there seems to have been an increase in asthma of all grades of severity.

Hypophosphatemia Complicating Management of Acute Severe Asthma

Excerpt The correction of acute respiratory acidosis by mechanical ventilation in patients with chronic obstructive pulmonary disease has been shown to induce hypophosphatemia (1-3). In patients wi...

Management of acute severe asthma.

Management of acute severe asthma.