Lab 3. the Management of

7/24/2019 Lab 3. the Management of

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Lab.3.

THE MANAGEMENT OF

AN ACUTE EPISODE OF ASTHMA

The initial medical assessment of the severity of the current episode is critical to the acute management of

patients. Indicators of severity include:

ASTHMA HISTORY AND EXAMINATION

Increasing wheeze or dyspnoea, or respiratory distress with tachypnoea (>25 reaths!min" are clinical

features of worsening asthma. The patient#s own assessment may e important.Information regarding the

duration of episode, medication used pre$hospital, whether the patient regularly uses corticosteroids and

previous asthma episodes is important.

%ssessment of severity y patient or doctor on clinical oservation alone however, can e misleading and

should e ac&ed up y o'ective measurement. vidence for this comes from studies of perception of

asthma symptoms and from reviews of asthma deaths. %ssessment of all vital signs is important in

estalishing the level of severity of this episode of illness. %lthough the pulse rate may e elevated as aresult of some of the medication which has een administered, its elevation may also e due to the

severity of the underlying asthma episode.

Peak Expiratr! F"# Rate $PEF% Mea&'re(e)t&

These should e compared with either percentage of predicted normal values ()pred" or, if &nown, the

patient#s own est measurement

Ga& Ex*+a),e

*any adults re+uiring treatment for an acute asthma episode are hypoic! -ulse oimetry is a simplified

assessment of oygenation ut gives incomplete information. igh or rising arterial /02 (-a/02"pressures reflecting hypoventilation correlate with life$threatening asthma

There is some evidence to suggest that it may e reasonale to rely on oygen saturation (1p02"

measurement (pulse oimetry" alone at levels of 2 per cent or aove ut the evidence is not yet

conclusive

Therefore any patient in severe distress or who fails to respond to ronchodilator treatment should have

arterial lood gas (%34s" measurement.

C+e&t X-ra!

There is no indication for routine chest rays. /hest ray is re+uired if a respiratory complication issuspected from the clinical eamination (e.g. pneumothora, pneumonia".

"/ Te&t&

There is no indication that routine lood tests should e underta&en. -atients who have een classified as

severe and!or are re+uiring admission to I/6 should have creatinine 7 electrolytes and a full lood count.


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S'((ar! G'i/e t E&tab"i&+i), t+e Le0e" 1 Se0erit! 1 t+i& epi&/e

8inding eamination

8inding

9evel 9evel of severity

1evere *oderate *ild

Triage /ategory ; or 2 < = or 5

/onscious 1tate *ay e altered ormal ormal

1pea&ing %ility ?ords!one -hrases 1entences

@espiratory rate (!min" >25 2A B 25 C2A

1a02 C2) 2 B 5) > 5)

%ir ntry -oor: may have

silent chest

*oderate 4ood

-8 ()pred or est

&nown value"

C2) should e started immediately in all patients.

Initial hypoia can ecome worse temporarily after ronchodilators. asal cannulae, although more

comfortale, deliver a variale level of enrichment. 4as flow provided through udson$type mas&s is

inade+uate when patients are tachypnoeic and a Henturi oygen system should e used. This leads to oth

an increase in the wor& of reathing and reduced inspired oygen concentration levels for the patient.


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Crti*&teri/&

The use of corticosteroids in adults has een shown to improve outcome from acute asthma 6nder$use of

corticosteroids has een found in surveys of asthma deaths. Intravenous hydrocortisone has een shown

to e effective within 2 hours. 8or severe asthma episodes, the initial regimen recommended ishydrocortisone sodium succinate


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1tudies have shown that for adult patients with severe asthma, an infusion of 2g of *g10= in addition to

standard steroid and neulised eta$agonist therapy, reduced admission rates and led to statistically

significant improvements in 8H; at oth ;2A and 2=A minutes.% similar finding for a weight$ased dose

of *g10= was made for children with asthma, not responding to standard therapy. These studies involved

small numers of patients and showed small ut statistically significant improvements in pulmonaryfunction.

-atients with severe asthma may receive *g10= 2g IH as an infusion over


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This is the most convenient method of o'ective assessment. ?hen using -8 to evaluate response,

rememer the following:

L Initial values may overlap and e unreliale. owever, initial values, >5A )pred or patients est &nown

value, are unli&ely to result in admission.

L %fter initial treatment values, >FA )pred or patients est &nown value, will usually result in dischargehome from G.

Re*((e)/ati)& 1r ()itri), re&p)&e t i)itia" treat(e)t

;. 1igns of an inade+uate response $ respiratory rate, heart rate and oygen saturation. In those patients

who are not responding to treatment, arterial lood gas measurements should e initiated if not already

ta&en. (4rade /"

2. -ea& flow monitoring efore and after ronchodilator. (4rade /"

Di&p&iti) 1r( E(er,e)*! Depart(e)t

8rom G, patients may e admitted into acute wards of the hospital or discharged home. The decision to

admit will e ased on the severity of the presenting episode, the patients response to treatment and the

patients support system in the community.

H&pita" a/(i&&i)

ospital admission is more li&ely to e necessary if:

$ -a/02 is elevated at presentationD

$ -rolonged attac& of asthma of > 2= hours durationD

$ -resenting for medical attention, twice or more in a 2= hour periodD

$ 6se of regular oral corticosteroids at homeD

$ %ge > =A yearsD

$ -oor long term control.

I)ter(e/iate Re&piratr! Care U)it $IRCU% A&&e&&(e)t

-atients who present with a moderately severe episode of asthma and have a post treatment -8 of

etween


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Di&*+ar,e 1 patie)t& 1r( t+e E(er,e)*! Depart(e)t t H(e

-atients who respond well to initial treatment will usually e discharged from G to home. *ost patients

suitale for discharge to home will have a -8 greater than FA )pred. or usual est.

-atients who do not respond +uic&ly to treatment or who have presented with a severe episode willusually e admitted into the hospital.

8or patients who are responding well to initial treatment discharge planning should commenceimmediately.

The patient#s previous asthma management should e reviewed and any specific cause of the acute

eaceration identified efore discharge. %ppropriate patient education and attention paid to longer$term

management at this stage are li&ely to reduce the fre+uency of further acute eacerations(5;$5

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Lab 3. the Management of