1. Management of Asthma Exacerbations: Key Points n Early treatment is best. Important elements include: – A written action plan n Guides patient self-management of exacerbations at home n Especially important for patients with moderate-to- severe persistent asthma and any patient with a history of severe exacerbations – Recognition of early signs of worsening asthma

2. Management of Asthma Exacerbations: Key Points (continued) – Appropriate intensification of therapy – Prompt communication between patient and clinician about: n Serious deterioration in symptoms or peak flow, or n Decreased responsiveness to inhaled beta 2 -agonists, or n Decreased duration of beta 2 -agonist effect

3. Management of Asthma Exacerbations n Inhaled beta 2 -agonist to provide prompt relief of airflow obstruction n Systemic corticosteroids to suppress and reverse airway inflammation – For moderate-to-severe exacerbations, or – For patients who fail to respond promptly and completely to an inhaled beta 2 -agonist

4. Management of Asthma Exacerbations (continued) n Oxygen to relieve hypoxemia for moderate- to-severe exacerbations n Monitoring response to therapy with serial measurements of lung function

5. Risk Factors for Death From Asthma n Past history of sudden severe exacerbations n Prior intubation or admission to ICU for asthma n Two or more hospitalizations for asthma in the past year n Three or more ED visits for asthma in the past year

6. Risk Factors for Death From Asthma (continued) n Hospitalization or an ED visit for asthma in the past month n Use of >2 canisters per month of inhaled short-acting beta 2 -agonist n Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids

7. Risk Factors for Death From Asthma (continued) n Difficulty perceiving airflow obstruction or its severity n Comorbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease n Serious psychiatric disease or psychosocial problems

8. Risk Factors for Death From Asthma (continued) n Low socioeconomic status and urban residence n Illicit drug use n Sensitivity to Alternaria

9. Home Management of Exacerbations: Written Action Plan n Develop a written action plan with each patient, especially those with: – Moderate-to-severe persistent asthma or – History of severe exacerbations

11. Home Management of Exacerbations: Written Action Plan (continued) n The plan should include: – Signs, symptoms, and peak flow levels that indicate deteriorating asthma – How to adjust medications in response to deteriorating asthma – When to seek medical help – Emergency phone numbers

12. Home Management of Exacerbations: What To Teach Patients and Caretakers n Recognize symptoms and signs of deterioration n Monitor peak flow if patient has: – Moderate-to-severe persistent asthma or – History of severe exacerbations

13. Home Management of Exacerbations: What To Teach Patients and Caretakers (continued) n Seek medical help early if: – Exacerbation is severe – Therapy does not give rapid, sustained improvement – Condition worsens n Keep necessary medications and equipment at home and take when traveling

14. Home Management of Exacerbations: Instructions to Patient n Use inhaled short-acting beta 2 -agonist: – Up to three treatments of 2 to 4 puffs by inhaler at 20-minute intervals OR – Single nebulizer treatment n Assess symptoms and/or peak flow after 1 hour

15. Home Management of Exacerbations: Good Response (Mild Exacerbation) n Peak flow >80% predicted or personal best and/or n No wheezing, shortness of breath, cough, or chest tightness and n Response to beta 2 -agonist sustained for 4 hours

16. Home Management of Exacerbations: Instructions for Good Response n May continue 2 to 4 puffs beta 2 -agonist every 3 to 4 hours for 24 to 48 hours PRN n For patients on inhaled corticosteroids, double dose for 7 to 10 days n Contact clinician within 48 hours for instructions

17. Home Management of Exacerbations: Incomplete Response (Moderate Exacerbation) n Peak flow 50% to 80% predicted or personal best or n Persistent wheezing, shortness of breath, cough, or chest tightness

18. Home Management of Exacerbations: Instructions for Incomplete Response n Take 2 to 4 puffs beta 2 -agonist every 2 to 4 hours for 24 to 48 hours PRN n Add oral corticosteroid for 3 to 10 days, at least until symptoms and peak flow are stable n Contact clinician urgently (same day) for instructions

19. Home Management of Exacerbations: Poor Response (Severe Exacerbation) Peak flow <50% predicted or personal best, orPeak flow <50% predicted or personal best, or Marked wheezing, shortness of breath, cough, or chest tightness, orMarked wheezing, shortness of breath, cough, or chest tightness, or Distress is severe and nonresponsive, orDistress is severe and nonresponsive, or Response to beta 2 -agonist lasts <2 hoursResponse to beta 2 -agonist lasts <2 hours

20. Home Management of Exacerbations: Instructions for Poor Response IMMEDIATELY n Take up to three treatments of 4 to 6 puffs beta 2 -agonist every 20 minutes PRN n Start oral corticosteroid n Contact clinician n Go to emergency department or call ambulance or 9-1-1

21. Prehospital Ambulance Management n Administer supplemental oxygen n Administer inhaled beta 2 -agonist n If inhaled therapy is not available, use subcutaneous terbutaline or epinephrine

22. Emergency Department and Hospital Management

23. Emergency Department Functional Assessment Measure FEV 1 or PEF: n Upon presentation (begin treatment as soon as asthma exacerbation is recognized) n After first beta 2 -agonist dose n After third beta 2 -agonist dose n At intervals depending on response to therapy n Before discharge Monitor SaO 2 in patients with severe distress or with FEV 1 or PEF <50% predicted

24. Emergency Department and Hospital Management: Brief History (after treatment is initiated) n Time of onset and cause of exacerbation n Severity of symptoms, especially compared to previous attacks n All current medications and time of last dose

25. Emergency Department and Hospital Management: Brief History (after treatment is initiated) (continued) n Prior hospitalizations and ED visits, especially in past year n Prior episodes of respiratory failure or loss of consciousness due to asthma n Existence of comorbidities

26. Emergency Department and Hospital Management: Brief Physical Exam n Assess severity: Alertness, distress, accessory muscle use, tachycardia, tachypnea, pulsus paradoxus, cyanosis n Identify complications (e.g., pneumonia, pneumothorax, pneumomediastinum) n Identify diseases that affect asthma (otitis, rhinitis, sinusitis) n Rule out upper-airway obstruction

27. Emergency Department and Hospital Management: Laboratory Assessment n Consider ABG in patients with suspected hypoventilation, severe distress, or with FEV 1 or PEF <30% predicted after initial treatment n CBC may be appropriate in patients with fever or purulent sputum n Serum theophylline concentration n Serum electrolytes, chest x-ray, ECG in special circumstances

28. Emergency Department and Hospital Management: Goals n Correction of significant hypoxemia n Rapid reversal of airflow obstruction n Reduction of likelihood of recurrence

29. Emergency Department and Hospital Management: Initial Treatment FEV 1 or PEF >50% n Oxygen to achieve O 2 saturation >90% n Inhaled beta 2 -agonist by metered-dose inhaler or nebulizer, up to three treatments in first hour n Oral corticosteroids if no immediate response or if patient recently took oral corticosteroids n Repeat assessment (Sx, physical exam, PEF, O 2 saturation, other tests as needed)

30. Emergency Department and Hospital Management: Initial Treatment (continued) FEV 1 or PEF <50% n Oxygen to achieve O 2 saturation is >90% n Inhaled high-dose beta 2 -agonist and anticholinergic by nebulization every 20 minutes or continuously for 1 hour n Oral corticosteroid n Repeat assessment (Sx, physical exam, PEF, O 2 saturation, other tests as needed)

31. Emergency Department and Hospital Management: Initial Treatment (continued) Impending or Actual Respiratory Arrest n Intubation and mechanical ventilation with 100% O 2 n Nebulized beta 2 -agonist and anticholinergic n Intravenous corticosteroid n Admit to hospital intensive care

32. Emergency Department and Hospital Management: Treatment After Repeat Assessment FEV 1 or PEF 50% to 80% predicted or personal bestFEV 1 or PEF 50% to 80% predicted or personal best Physical exam: moderate symptomsPhysical exam: moderate symptoms Inhaled short-acting beta 2 -agonist every 60 minutesInhaled short-acting beta 2 -agonist every 60 minutes Systemic corticosteroidSystemic corticosteroid Continue treatment 1 to 3 hours, provided there is improvementContinue treatment 1 to 3 hours, provided there is improvement

33. Emergency Department and Hospital Management: Treatment After Repeat Assessment (continued) FEV 1 or PEF <50% predicted or personal bestFEV 1 or PEF <50% predicted or personal best Physical exam: severe symptoms at rest, accessory muscle use, chest retractionPhysical exam: severe symptoms at rest, accessory muscle use, chest retraction History: high-risk patientHistory: high-risk patient No improvement after initial treatmentNo improvement after initial treatment OxygenOxygen Inhaled short-acting beta 2 -agonist hourly or continuously + inhaled anticholinergicInhaled short-acting beta 2 -agonist hourly or continuously + inhaled anticholinergic Systemic corticosteroidSystemic corticosteroid

34. Emergency Department and Hospital Management: Good Response FEV 1 or PEF >70%FEV 1 or PEF >70% Response sustained 60 minutes after last treatmentResponse sustained 60 minutes after last treatment No distressNo distress Physical exam: normalPhysical exam: normal Discharge HomeDischarge Home

35. Emergency Department and Hospital Management: Incomplete Response FEV 1 or PEF >50% but 50% but <70% Mild-to-moderate symptomsMild-to-moderate symptoms Individualized decision re: hospitalizationIndividualized decision re: hospitalization

36. Emergency Department and Hospital Management: Poor Response FEV 1 or PEF <50%FEV 1 or PEF <50% PCO 2 >42 mm HgPCO 2 >42 mm Hg Physical exam: symptoms severe, drowsiness, confusionPhysical exam: symptoms severe, drowsiness, confusion Admit to hospital intensive careAdmit to hospital intensive care

37. Admit to Hospital Intensive Care –Admit to hospital ward Inhaled beta 2 -agonist hourly or continuously + inhaled anticholinergicInhaled beta 2 -agonist hourly or continuously + inhaled anticholinergic IV corticosteroidIV corticosteroid OxygenOxygen Possible intubation and mechanical ventilationPossible intubation and mechanical ventilation Admit to hospital wardAdmit to hospital ward

38. Emergency Department and Hospital Management: Hospitalization Consider: n Duration and severity of airflow obstruction n Course and severity of prior attacks n Medication use n Access to care n Home conditions and support n Comorbidities

39. Emergency Department and Hospital Management: Hospitalization Admit to Hospital Ward n Inhaled beta 2 -agonist + inhaled anticholinergic n Systemic corticosteroid n Oxygen n Monitor FEV 1 or PEF, O 2 saturation

40. Emergency Department and Hospital Management Not generally recommended: n Methylxanthines n Antibiotics (except for patients with pneumonia, bacterial sinusitis) n “Aggressive” hydration n Chest physical therapy Not recommended: n Mucolytics n Sedation

41. Emergency Department Discharge Criteria n If FEV 1 or PEF  70% predicted and symptoms are minimal, discharge n If FEV 1 or PEF >50% but  70% predicted and symptoms are mild, decision is individualized n If response is prompt, observe for 30 to 60 minutes before discharging

42. Emergency Department and Hospital Discharge Actions n Prescribe sufficient medication and instructions for use –Short acting beta 2 -agonist –Patients given systemic corticosteroids—continue oral corticosteroids for 3 to 10 days n Schedule followup or referral visit within 3 to 5 days –Consider referral to specialist if patient has history of life-threatening exacerbations or multiple hospitalizations

43. Emergency Department and Hospital Discharge Actions (continued) n Instruct in simple action plan: –How to recognize signs and symptoms of deterioration –When to increase medications in response to deterioration n Consider providing peak flow meter n When possible, teach correct inhaler use and trigger avoidance

44. Hospital Discharge Actions n Prior to discharge, adjust medication to an oral and/or inhaled regimen –This is generally done when: Patient is minimally symptomaticPatient is minimally symptomatic Patient has little wheezing on chest examinationPatient has little wheezing on chest examination PEF or FEV 1 >70% predicted or personal bestPEF or FEV 1 >70% predicted or personal best –Observe patient for 24 hours after adjustment

45. Hospital Discharge Actions (continued) n Discharge medications should include: –Short-acting beta 2 -agonist –Sufficient oral corticosteroid to complete course of therapy or to continue therapy until followup appointment –If inhaled corticosteroids are prescribed, start before course of oral corticosteroids is completed

46. Management of Asthma Exacerbations: Special Considerations for Infants n Infants are at greater risk of respiratory failure. n Assessment depends on physical examination rather than objective measurements. n Use oral corticosteroids early in the episode. n Antibiotics are generally not required. Acute wheezing generally results from viral infections and may be accompanied by fever.

47. Management of Asthma Exacerbations: Signs of Serious Distress in Infants n Use of accessory muscles, paradoxical breathing, cyanosis, and a respiratory rate >60 n Oxygen saturation <91% n Lack of response to beta 2 -agonist