GINA2009

ASSESSMENT OF SEVERITY

MANAGEMENT–COMMUNITY SETTINGS

The severity of the exacerbationFigure (4.4-1 ) determines

Most patients with severe asthma exacerbations shoul

PEF 187

(in patients older than 5 years), pulse rate,

emergency department) where monitoring, including

210

objective measurement of airflow obstruction, oxyge

respiratory rate, and pulse oximetry, should be

monitored during treatment.

saturation, and cardiac function, is possible. Milder

exacerbations, defined by a reduction in peak flow of

than 20%, nocturnal awakening, and increased use of

Figure 4.4-1. Severity of Asthma Exacerbations*

Mild

Moderate

Severe

Respiratory arrest

imminent

Breathless

Walking

Talking

At rest

Infant—softer

Infant stops feeding

shorter cry;

OR

REPRODUCE!

difficulty feeding

Can lie down

Prefers sitting

Hunched forward

Talks in

Sentences

Phrases

Words

Alertness

May be agitated

Usually agitated

Usually agitated

Drowsy or confused

Respiratory rate

Increased

Increased

Often > 30/min

Normal rates of breathing in awake children:

ALTER

Age

Normal rate

< 2 months

< 60/min

2-12 months

< 50/min

1-5 years

< 40/min

6-8 years

< 30/min

NOT

Accessory muscles

Usually not

Usually

DO

Usually

Paradoxical thoraco-

and suprasternal

abdominal movement

retractions

Wheeze

Moderate, often only

-

Usually loud

Absence of wheeze

oud

end expiratory

Pulse/min.

< 100

100-120

>120

Bradycardia

Guide to limits of normal pulse rate in children:

Infants

2-12 months–Normal Rate

< 160/min

Preschool

1-2 years

< 120/min

School age

2-8 years

< 110/min

Pulsus paradoxus

Absent

May be present

Often present

Absence suggests

< 10 mm Hg

10-25 mm Hg

> 25 mm Hg (adult)

respiratory muscle

MATERIAL

20-40 mm Hg (child)

fatigue

PEF

Over 80%

Approx. 60-80%

< 60% predicted or

after initial

personal best

bronchodilator

(< 100 L/min adults)

% predicted or

or

% personal best

response lasts < 2 hrs

PaO

2 (on air)†

Normal

> 60 mm Hg

< 60 mm Hg

Test not usually

and/or

necessary

Possible cyanosis

Pa

†

< 45 mm Hg

< 45 mm Hg

> 45 mm Hg;

2

Possible respiratory

failure (see text)

SaO

2

% (on air) †

> 95%

91-95%

< 90%

COPYRIGHTED

Hypercapnea (hypoventilation) develops more readily in young children than in

adults and adolescents.

ASTHMA MANAGEMENT AND PREVENTION

65

physician may include the use of systemic glucocorticoseverity-

and duration of symptoms, including exerc

of -agonist required will depend on the severity of the

REPRODUCE!

steroids. Patient education and review of maintenancelimitation and sleep disturbance; all current medica

therapy should also be undertaken.

including dose (and device) prescribed, dose usually

taken, dose taken in response to the deterioration, and

Treatment

patientis response (or lack thereof) to this therapy; ti

onset and cause of the present exacerbation; and risk

Bronchodilators. For mild to moderate exacerbations,

factors for asthma-related death.

repeated administration of rapid-acting -inhaledagonists

2

The physical examination should assess exacerbation

(2 to 4 puffs every 20 minutes for the first hour) is usually

severity by evaluating the patientis ability to compl

the best and most cost-effective method of achieving rapid

sentence, pulse rate, respiratory rate, use of accessor

reversal of airflow limitation. After the first hour, the dose

OR

2

muscles, and other signs detailedFigurein4.4-2. Any

complicating factors should be identified (e.g., pneu

exacerbation. Mild exacerbations respond to 2 to 4 puffs

atelectasis, pneumothorax, or pneumomediastinum).

every 3 to 4 hours; moderate exacerbations will require 6

to 10 puffs every 1 or 2 hours. Treatment should also be

Functional assessments such as PEF1 orandFEVarterial

titrated depending upon the individual patientis response,

oxygen saturation measurements are strongly recommend

and if there is a lack of response or other concern about

as physical examination alone may not fully indicate t

how the patient is responding, the patient should be

referred to an acute care facility.

severity of the exacerbation, particularly the degree

hypoxemiaALTER. Without unduly delaying treatment, a

213,214

baseline PEF or FEV1 measurement should be made

Many patients will be able to monitor their PEF after the

initiation of increased bronchodilator therapy.

before treatment is initiated. Subsequent measure

should be made at intervals until a clear response to

Bronchodilator therapy delivered via a metered-dose NOT

treatment has occurred.

inhaler (MDI), ideally with a spacer, produces at least an

equivalent improvement in lung function as the same dose

164,211

DO

Oxygen saturation should be closely monitored, prefera

delivered via nebulizer. At the clinic level,-this route of

mg of prednisolone/kg or equivalentMATERIALduring a 24-hour

In adults a chest X-ray is not routinely required, but

delivery is the most cost212effective,provided patients are

by pulse oximetry. This is especially useful in ch

because objective measurements of lung function m

able to use an MDI. No additional medication is necessary

if the rapid-acting inhaled-agonist produces a complete

difficult. Oxygen saturation in children should no

2

greater than 95%, and oxygen saturation less than 92% is

response (PEF returns to greater than 80% of predicted or

210

a good predictor of the need for hospitalization

personal best) and the response lasts for 3 to 4 hours.(Evidence C

).

Glucocorticosteroids. Oral glucocorticosteroids (0.5 to 1

COPYRIGHTED

be carried out if a complicating cardiopulmonary proces

period) should be used to treat exacerbations, especially if

suspected, in patients requiring hospitalization, a

they develop after instituting the other short-term treatment

those not responding to treatment where a pneumothorax

options recommended for loss of control (see “Stepping up

215

may be difficult to diagnose clinically.Similarly, in children

treatment in response to loss of control” in Component 3).

routine chest X-rays are not recommended unless ther

If patients fail to respond to bronchodilator therapy, as

216

are physical signs suggestive of parenchymal. disea

indicated by persistent airflow obstruction, prompt transfer

to an acute care setting is recommended, especially if they

are in a high risk group.

Although arterial blood gas measurements are not

routinely required, they should be completed in patients

216

with a PEF of 30 to 50% predicted, those who do not

MANAGEMENT–ACUTE CARE SETTINGS

respond to initial treatment, or when there is concern

regarding deterioration. The patient should continue

Severe exacerbations of asthma are life-threatening medical

supplemental oxygen while the measurement is made.

emergencies, treatment of which is often most safely undertaken

in an emergency departmentFigure. 4.4-2

A PaO

2

< 60 mm Hg (8 kPa) and a normal or increased

illustrates the

2

(especially > 45 mm Hg, 6 kPa) indicates the

PaCO

Reassess after 1 Hour

Physical Examination, PEF,2O saturation and other tests as

needed

▼

▼

Criteria for Moderate Episode:

Criteria for Severe Episode:

•

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•

PEF 60-80% predicted/personal best

History of risk factors for near fatal asthma

•

PEF < 60% predicted/personal best

•

Physical exam: moderate symptoms, accessory muscle

use

Physical exam: severe symptoms at rest, chest retraction

Treatment:

•

•

OR

• Oxygen

No improvement after initial treatment

Treatment:

•

Inhaled -agonist and inhaled anticholinergic every

60 min

2

•

Oxygen

• Oral glucocorticosteroids

• Inhaled -agonist and inhaled anticholinergic

• Continue treatment for 1-3 hours, provided there is

improvement

2

• Systemic glucocorticosteroids

• Intravenous magnesium

ALTER

▼

▼

Reassess after 1-2 Hours

NOT

▼

▼

▼

Good Response within 1-2 Hours:

Incomplete Response within 1-2

Poor Response within 1-2 Hours:

Hours:

DO

• Risk factors for near fatal asthma

•

Response sustained 60 min after

last

-

• Physical exam: symptoms severe,

treatment

•

Risk factors for near fatal asthma

•

•

Physical exam: mild to moderate signs

drowsiness, confusion

Physical exam normal: No distress

•

PEF < 60%

•

PEF < 30%

•

PEF > 70%

•

O 2 saturation not improving

• PCO

2

> 45 mm Hg

•

O 2 saturation > 90% (95% children)

•

P O

2

< 60mm Hg

Admit to Acute Care Setting

Admit to Intensive Care

• Oxygen

• Oxygen

• Inhaled 2 -agonist + anticholinergic

• Inhaled -agonist ± anticholinergic

• Intravenous glucocorticosteroids

MATERIAL

2

• Consider intravenous-agonist

• Systemic glucocorticosteroid

• Intravenous magnesium

2

• Consider intravenous theophylline

• Monitor PEF, O 2 saturation, pulse

• Possible intubation and mechanical

ventilation

▼

▼

Reassess at intervals

▼

▼

▼

Improved: Criteria for Discharge Home

Poor Response (see above):

• PEF > 60% predicted/personal best

•

Admit to Intensive Care

• Sustained on oral/inhaled medication

Incomplete response in 6-12 hours

Home Treatment:

•

COPYRIGHTED

(see above)

Continue inhaled-agonist

2

• Consider admission to Intensive

Care

• Consider, in most cases, oral glucocorticosteroids

• Consider adding a combination inhaler

if no improvement within 6-12 hours

• Patient education: Take medicine correctly

▼

Review action plan

▼

Improved (see opposite)

Close medical follow-up

ASTHMA MANAGEMENT AND PREVENTION

67

exacerbation:

may produce better bronchodilation than either drug

217

2

alone231 (Evidence B ) and should be administered before

REPRODUCE!

Oxygen. To achieve arterial oxygen saturation of ≥ 90%

methylxanthines are considered. Combination-

2

nasal cannulae, by mask, or rarely by head box in some

hospitalization rates(Evidence A ) and greater

212,232,233

infants. PaCO2 may worsen in some patients on 100

improvement in PEF and FEV1 233

(Evidence B ). Similar

percent oxygen, especially those with more severe airflow

212

data have been reported in the pediatric literature

obstruction. Oxygen therapy should be titrated against

218

(Evidence A ). However, once children with asthma are

pulse oximetry to maintain a satisfactory oxygen. saturat

on

219

hospitalized following intensive emergency departm

Rapid-acting inhaled ß2–agonists.

Rapid-acting inhaled

treatment, the addition of nebulized ipratropium brom

nebulized-agonist and systemic glucocorticosteroids

-agonists should be administered at regular220-222 intervals

2

234

2

appears to confer no extra benefit.

(Evidence A

). Although most rapid-acting- onists

OR

235

have a short duration of effect, the long-acting broncho-

TheophyllinIn.e view of the effectiveness and relati

dilator formoterol, which has both a rapid onset of action

safety of rapid-acting-agonists, theophylline has a

and a long duration of effect, has been shown to be

2

minimal role in the management of acute asthma.Its

equally effective without increasing side effects, though

it is considerably more expensive. The importance of

use is associated with severe and potentially fatal s

effects, particularly in those on long-term therapy w

148

this feature of formoterol is that it provides support and

reassurance regarding the use of a combination of

sustained-release theophylline, and their bronchodila

effect is less than-thatagonistsof . The benefit as

NOT

ALTER

2

formoterol and budesonide early in asthma exacerbations.

add-on treatment in adults with severe asthma exacer-

bations has not been demonstrated. However, in one

A modestly greater bronchodilator effect has been shown

study of children with near-fatal asthma, intravenou

with levabuterol compared to racemic albuterol in both

adults and children with an asthma exacerbation. In

theophylline provided additional benefit to patients

223-226

receiving an aggressive regimen of inhaled and

large study of acute asthma in children,and in adults not

intravenous-agonists, inhaled ipatropium bromide, and

227

previously treated with glucocorticosteroids, levabuterolDO

2

226

-

intravenous systemic glucocorticosteroids.

MATERIAL

236

treatment resulted in lower hospitalization rates compared

to racemic albuterol treatment, but in children the length of

Systemic

227

Systemic glucocorticosteroids.

hospital stay was no different.

glucocorticosteroids speed resolution of exacerbation

should be utilized in the all but the mildest

Studies of intermittent versus continuous nebulized short237,238-

exacerbations (Evidence A ), especially if:

acting -agonists in acute asthma provide conflicting

results. In a systematic review of,sixtherestudieswere

• The initial rapid-acting inhaled-agonist therapy fails

2

228

no significant differences in bronchodilator effect or

2

COPYRIGHTED

to achieve lasting improvement

hospital admissions between the two treatments. In

• The exacerbation develops even though the patient

229

patients who require hospitalization, onefoundstudy

was already taking oral glucocorticosteroids

that intermittent on-demand therapy led to a significantly

• Previous exacerbations required oral

shorter hospital stay, fewer nebulizations, and fewerglucocorticosteroids.

palpitations when compared with intermittent therapy given

every 4 hours. A reasonable approach to inhaled therapy

Oral glucocorticosteroids are usually as effective as

in exacerbations, therefore, would be the initial use of

administered intravenously and are preferred because

continuous therapy, followed by intermittent on-demand

239,240

route of delivery is less invasive and less. expensi

therapy for hospitalized patients. There is no evidence to

support the routine use of intrave-agonousits in

If vomiting has occurred shortly after administrati

glucocorticosteroids, then an equivalent dose should

2

230

patients with severe asthma exacerbations.

re-administered intravenously. In patients dischar

Epinephrine.

the emergency department, intramuscular administrat

A subcutaneous or intramuscular injection

241

may be helpful, especially if there are concerns about

of epinephrine (adrenaline) may be indicated for acute

treatment of anaphylaxis and angioedema, but is not

compliance with oral therapy. Oral glucocorticosteroids

require at least 4 hours to produce clinical improvemen

routinely indicated during asthma exacerbations.

Daily doses of systemic glucocorticosteroids equival

60-80 mg methylprednisolone as a single dose, or 300-400

Leukotriene modifiers. There is little data to suggest a

mg hydrocortisone in divided doses, are adequate for role for leukotriene modifiers in acute. asthma

258

hospitalized patients, and 40 mg methylprednisolone or

200 mg hydrocortisone is probably adequate in most

Sedatives. Sedation should be strictly avoided during

in children with mild persistent. A 7-dasthmaycourse

REPRODUCE!

association between the use of these drugs and avoida

243

has been demonstrated.

in adults has been found to be as effective as a 14-dayasthma deaths

209,259

course , and a 3- to 5-day course in children is usually

244

considered appropriateEvidence(

B ). Current evidence

Criteria for Discharge from the Emergency Department

suggests that there is no benefit to tapering thevsdose. Hospitalizationof

oral glucocorticosteroids, either in the shortover-term

several weeks(Evidence B

).

245

Criteria for determining whether a patient should be

246

discharged from the emergency department or admitted

Inhaled glucocorticosteroids.

Inhaled glucocortico-

the hospital have been succinctly reviewed and strat

patients with more severe attacks.

assured. Patients with post-treatment lung functi

248

≥ 60% predicted can be discharged.

NOT

ALTER

Inhaled glucocorticosteroids can be as effective as oral

glucocorticosteroids at preventing relapses.Patients

Management of acute asthma in the intensive care uni

249,250

beyond the scope of this document and readers are

discharged from the emergency department on prednisone

referred to recent comprehensive261reviews.

and inhaled budesonide have a lower rate of relapse than

those on prednisone alone(Evidence B ). A high-dose

237

For patients discharged from the emergency departmen

of inhaled glucocorticosteroid (2.4 mg budesonide daily in

-

to 40

four divided doses) achieves a relapse rate similarDO

MATERIAL

• Ipratropium bromide is unlikely to provide addition

mg oral prednisone daily(Evidence ). Cost is a

• At a minimum, a 7-day course of oral glucoco-

251

rticosteroids for adults and a shorter course

significant factor in the use of such high-doses of inhaled

(3-5 days) for children should be prescribed, along wi

glucocorticosteroids, and further studies are required to

document their potential benefits, especially cost

continuation of bronchodilator therapy.

252

• The bronchodilator can be used on an as-needed

effectiveness, in acute. asthma

basis, based on both symptomatic and objective