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Asthma Exacerbation Management in the ERAka: Emergency Management of Asthma Exacerbation

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  1. See Also
    1. Asthma Education
    2. Asthma Management
    3. Asthma Exacerbation Home Management
    4. Emergency Management of Asthma Exacerbation
    5. Asthma Inpatient Management
    6. Status Asthmaticus
  2. Step 1: Initial Assessment
    1. See Asthma Evaluation
    2. Vital Signs
      1. Heart Rate
      2. Respiratory Rate
      3. Peak Expiratory Flow Rate (PEF) or FEV1
      4. Oxygen Saturation
    3. Respiratory Status
      1. Lung auscultation
      2. Assess accessory muscle use
      3. Chest XRay has low yield in acute exacerbations
        1. See Chest XRay in Asthma
    4. Assessment if patient in extremis
      1. Arterial Blood Gas
  3. Step 2a: Initial Management
    1. Inhaled Short-acting Beta Agonist (Nebulized Albuterol)
      1. One dose up to every 20 minutes for one hour
    2. Anticholinergic (Ipratropium Bromide or Atrovent)
      1. Add to Nebulized Albuterol
      2. Indication: FEV1 or PEF <50% of predicted (Severe)
    3. Inhaled Corticosteroids (3 inhalations in <30 min)
      1. Effective for adults and children in acute attacks
      2. Better efficacy than Systemic Corticosteroids
      3. Most effective if used early in treatment plan
      4. Rodrigo (2006) Chest 130:1301
    4. Systemic Corticosteroid PO or IV Indications
      1. Severe episode (FEV1 or PEF <50% predicted)
      2. No immediate response
      3. Oral Corticosteroid recently taken by patient
    5. Oxygen indications
      1. Adults: Oxygen Saturation <91%
      2. Children: Oxygen Saturation <96%
    6. Consider Additional measures for severe exacerbation
      1. See Status Asthmaticus
  4. Step 3: Reassess
    1. Criteria: Repeat measures in step 1
    2. Base management on severity of episode
      1. Moderate episode (PEF 60-80% of predicted)
        1. Nebulized Albuterol hourly
        2. Consider Systemic Corticosteroids
        3. Continue management for 1-3 hours while improving
      2. Severe episode (PEF <60% predicted)
        1. Nebulized Albuterol hourly or continuous
        2. Consider adding ipratroprium bromide to nebulizer
        3. Oxygen
        4. Consider Status Asthmaticus management in Step 2b
        5. Systemic Corticosteroids
          1. Prednisone 1-2 mg/kg/day qd-bid
          2. Maximum: 40-60 mg/day for 5-10 days
          3. No tapering needed if use less than 2 weeks
  5. Step 4a: Good Response
    1. Indications
      1. Response sustained >60 minutes after last treatment
      2. Normal physical examination and no distress
      3. PEF >70%
      4. Oxygen Saturation adequate
        1. Adults: >90%
        2. Children: >95%
    2. Management: Discharge Home
      1. Continue Inhaled Beta Agonist
      2. Corticosteroids
        1. Oral Systemic Corticosteroids or
        2. Methylprednisolone 160 mg IM Depot injection
          1. As effective as 8 day taper on oral steroids
          2. Lahn (2004) Chest 126:362
      3. Patient Education on medications and plan
      4. Establish close follow-up
  6. Step 4b: Incomplete response in 1-3 hours
    1. Indications
      1. PEF 50-70%
      2. High risk patient with mild to moderate symptoms
      3. Oxygen Saturation not improved
    2. Management: Admit to hospital
      1. See Asthma Inpatient Management
  7. Step 4c: Poor response within 1 hour
    1. Indications
      1. High risk patient with severe symptoms
      2. PEF <30%
      3. pCO2 >45 mmHg
      4. pO2 <60 mmHg
    2. Management: Admit to Intensive Care Unit
      1. See Asthma Inpatient Management
      2. Consider Additional measures for severe exacerbation
        1. See Status Asthmaticus
  8. References
    1. (1997) Management of Asthma, NIH 97-4053
    2. (1995) Global Strategy for Asthma, NIH 95-3659

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