1 Page Notes : Management of asthma in the hospital environment

Management of asthma in the hospital Severe Attack Life-threatening attack - PEF <50% of predicted or best - RR > 25/min - Pulse rate > 110 bpm - Unable to complete sentences - PEF <33% of predicted or best - Silent chest, cyanosis, feeble respiratory eff ort - Bradycardia or hypotension - Exhaustion, confusion or coma - ABG:Normal/high PaCO2 >5kPa, PaO2 <8 kPa,low pH Immediate Rx - Sit patient up and give high dose O2 :100% via non-rebreathing bag - Salbutamol 5mg (or terbutaline 10mg) plus ipratropium bromide 0.5 mg nebulised with O2 - Hydrocortisone 100mg IV / prednisolone 30 mg PO or both if very ill - CXR to excl ude pneumothorax Life threatening Inform ICU, and seniors Add MgSO4 1.2-2g IV over 20 min Salbutamol nebs every 15 mins, or 10mg continuously per hour Improve – 40-60% O2 - Prednisolone 30-60mg/24h PO - Salbutamol nebs every 4 hr Monitor effects of Rx; - Repeat PEF 15-30 min after initiate Rx - Maintain SaO2 > 92%. Pregnant >95% - Check ABGs - Record PEF pre- and post-β agonist in hosp. at least 4x KEY : 1. Oxygen 2. Bronchodilators 3. Steroids 4. Other therapies Not improved after 15-30min - Continue 100% O2 and steroids. Hydrocortisone 100mg IV or prednisolone 30mg PO if not already given. - Salbutamol nebs every 15mins/10mg continuous per hour - Continue ipratropium 0.5mg every 4-6h Still not improving (discuss with seniors and ICU) - Repeat salbutamol nebs every 15 min - MgSO4 1.2-2g IV over 20 min, unless already given - Theophylline load 5mg/kg IV over 20 min 500µg/mg/h Or - Salbutamol IV (3-20µg/min). may require IPPV . > 2 years < 2 years - Unable to complete sentence in one breath; too breathless to talk or feed - poor vitals : tachycardia, high RR. - more agitated and decline in conscious levels. More wheezing. - Oxygen if sats <92%. - Inhaled β-agonist + adjunct (bolus salbutamol IV : 15µg/kg - Prednisolone 20mg (2-5 yrs), 30-40mg >5 yrs - Ipratropium bromide nebs (250µg/dose) mixed with β2-agonist solution - Aminophylline only in HDU cases. - Routine Abx not recommended. - pMDI and spacer most optimum to deliver β2-agonist - 10mg soluble prednisolone up to 3 days - consider inhaled ipratropium + β2 agonist (severe) In Pregnancy 1. Continu ous fetal moni tori ng 2. Attack duri ng labour(rar e) - ana est hesia? Regio nal blocka de, continue u sual meds - if receiving prednisolone >7.5mg per day for >2 weeks prior to delivery should receive hydrocortisone 100mg 6-8 hourly during labour - use PG F2α with cauti on : bronc hoconstric tion Minci © 2007 Acute Asthma Adult (including pregnant) Children Severe Life-threatening Over 2 years Under 2 years

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8/14/2019 1 Page Notes : Management of asthma in the hospital environment

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Management of asthma in the hospital

Severe Attack Life-threatening attack

- PEF <50% of predicted or best- RR > 25/min- Pulse rate > 110 bpm- Unable to complete sentences

- PEF <33% of predicted or best- Silent chest, cyanosis, feeble respiratory effort- Bradycardia or hypotension- Exhaustion, confusion or coma- ABG:Normal/high PaCO2 >5kPa, PaO2 <8 kPa,low pH

Immediate Rx - Sit patient up and give high dose O2 :100% via non-rebreathing bag

- Salbutamol 5mg (or terbutaline 10mg) plus ipratropium bromide 0.5 mg nebulised with O2

- Hydrocortisone 100mg IV / prednisolone 30 mg PO or both if very ill

- CXR to exclude pneumothorax

Life threatening Inform ICU, and seniors

Add MgSO4 1.2-2g IV over 20 min

Salbutamol nebs every 15 mins, or 10mg continuously per hourImprove – 40-60% O2

- Prednisolone 30-60mg/24h PO- Salbutamol nebs every 4 hr

Monitor effects of Rx;- Repeat PEF 15-30 min after initiate Rx- Maintain SaO2 > 92%. Pregnant >95%- Check ABGs

- Record PEF pre- and post-β agonist in hosp. at

least 4x

KEY :1. Oxygen 2. Bronchodilators

3. Steroids 4. Other therapies

Not improved after 15-30min- Continue 100% O2 and steroids. Hydrocortisone100mg IV or prednisolone 30mg PO if not alreadygiven.

- Salbutamol nebs every 15mins/10mg continuous perhour

- Continue ipratropium 0.5mg every 4-6h

Still not improving (discuss with seniors and ICU)- Repeat salbutamol nebs every 15 min- MgSO4 1.2-2g IV over 20 min, unless already given

- Theophylline load 5mg/kg IV over 20 min

500µg/mg/h Or- Salbutamol IV (3-20µg/min). may require IPPV.

> 2 years < 2 years- Unable to complete sentence in one breath; too breathless to talk or feed- poor vitals : tachycardia, high RR.- more agitated and decline in conscious levels. More wheezing.

- Oxygen if sats <92%.

- Inhaled β-agonist + adjunct (bolus salbutamol IV :

15µg/kg- Prednisolone 20mg (2-5 yrs), 30-40mg >5 yrs- Ipratropium bromide nebs (250µg/dose) mixed with

β2-agonist solution

- Aminophylline only in HDU cases.- Routine Abx not recommended.

- pMDI and spacer most optimum to deliver β2-agonist

- 10mg soluble prednisolone up to 3 days

- consider inhaled ipratropium + β2 agonist (severe)

In Pregnancy1. Continuous fetal monitoring2. Attack during labour(rare)

- anaesthesia? Regional blockade, continue usual meds

- if receiving prednisolone >7.5mg per day for >2 weeks prior to delivery should receive

hydrocortisone 100mg 6-8 hourly during labour- use PG F2α with caution : bronchoconstriction