IMPORTANT look in the mouth as obstruction might be in the upper airway (epiglottitis angioedema)
Peak Flow (PEFR) if pt is not too dyspneic. Best measure of severity
ABG Look at PaCO2. Resp drive almost always increased in acute asthma hyperventilation decreased PaCO2.
Thus an elevated or normal PaCO2 indicates airway narrowing is so severe that the ventilatory demands cannot be met. Failure is imminent
CXR usually not helpful
Obtain if diagnosis is in doubt patient is high-risk (IVDU immunosuppressed chronic pulmonary disease) or if complications are suspected (pneumothorax)
9 Acute Management
severe hypoxemia is unusual in acute asthma but low flow supplemental O2 carries almost no risk (maintain SaO2gt92)
Inhaled Beta Agonist
Albuterol Neb continuously or 2.5mg Neb q15
Initial goal is to reverse obstruction emergently with the ultimate goal to be sustained improvement
Monitor electrolytes (e.g.... Potassium)
May want to give a bolus of NS for prolonged episode to replace insensible losses
10 Acute Management
2 grams over 20 minutes
Bronchodilator activity inhibits calcium influx into smooth muscle
Methylprednisolone 60-125mg IV or Dexamethasone 6-10mg IV or prednisone 40-60mg po
Early administration dramatically reduces hospitalization and the likelihood of death from acute asthma
Much improves FEV1 at 24 hours
The slowness of its response DOES NOT diminish its importance
11 Additional Treatments
Terbutaline 0.25mg SC q20 x 3 doses
For severe asthma unresponsive to standard therapies give terbutaline OR epinephrine but NOT both
Epinephrine 0.2-0.5mL of 11000 by SC injection
For severe asthma unresponsive to standard therapies once again give terbutaline OR epinephrine but NOT both
Heliox (helium and oxygen)
May improve ventilation and decrease work of breathing with acute severe airflow obstruction.
Be careful not to lower pts oxygen saturation controversial treatment
Decision to intubate in the first few minutes is CLINICAL
In the absence of anticipated intubation difficulty rapid sequence intubation is preferred.
Nasal intubation is not recommended
Goal is to maintain adequate oxygenation and ventilation while minimizing elevated airway pressures therefore
High Inspiratory flow rates (80-100L/min) low tidal volumes (6-8mL/kg) and low respiratory rates (10-14/min)
In some patients permissive hypercapnia is acceptable to avoid barotrauma
It is not established whether ipratropium by inhalation or theophylline by IV adds to the bronchodilation achieved by maximal doses of inhaled beta agonist alone.
Ipratropium bromide some studies state addition of 0.25mg ipratropium to albuterol neb might confer some additive benefit over albuterol alone
Theophylline IV Contradictory results
Some studies show it adds toxicity but has no influence on the course or duration of hospitalization or immediate bronchodilation
Positive results are few and far between
The weight of evidence shows little or no significant benefit for acute bronchodilation and has significant toxicity
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