Acute Asthma

Like in all emergencies - approach patient with an ABCDE-assessment!

Important points in history

• Age group (Asthma is rather a disease of school children and adolescents. Consider bronchiolitis and/or viral induced wheeze if the children are very young)

Acute features

• Breathlessness (what can they no longer do? Did they stop feeding/ talking?)
• Wheeze/ prolonged expiration
• Cough
• Fever (pure asthmatic attack will usually not have fever unless exacerbated by infection)
• Did the child manage to sleep last night

Chronic features

• History of precipitating factors, e.g. URTI, exercise, exposure to pollen or dust, heating system in the house
• History of previous episodes including severity, whether hospitalised, and if so for how long, any admissions needing oxygen
• History of prior treatment and compliance
• History of 'interval symptoms' - cough/wheeze at night, coughwheeze after exercise, prolonged recovery from URTIs, level of activity, school attendance
• Family history of asthma or atopy (hay fever, eczema, allergic rhinitis)

Differential Diagnosis

• Pneumonia
• Inhaled foreign body
• Bronchiolitis (especially infants) or viral induced wheeze (especially toddlers)
• Cardiac disease
• Allergy/Anaphylaxis
• Loeffler's syndrome - treat with albendazole

Complications

• Pneumothorax
• Secondary bacterial infection
• A chest xray will usually not be necessary but should be obtained if
  • The condition worsens, there are unequal chest signs, or
  • There is doubt about the diagnosis

Definitions of severity of asthma

• Audible wheeze
• No respiratory distress
• Feeding well
• O2 sats >92%
• No signs of moderate asthma

• Respiratory distress
• Use of accessory muscles
• Still feeding well
• Sats >92 %
• No signs of severe asthma

• Marked respiratory distress
• Too breathless to talk/ feed
• RR >30 if >5 years
  RR >50 if 2-5 years
  
• Sats <92%

Treatment

(nota bene: if inhalers and spacers cannot be obtained then start with nebulised Salbutamol at below mentioned doses and switch to inhalers later)

• Salbutamol or Albuterol inhaler via spacer (and facemask if <3 years)
  • 2 puffs 4 hourly for 2-3 days
• Discharge with advice:
  • Inhaler and spacer technique
  • Avoid allergens
  • Return if worsens

• Salbutamol or Albuterol inhaler via spacer (and facemask if <3years)
  • <4yrs - 5 puffs every 20 mins x3
    >4 yrs - 10 puffs every 20 mins x3
  • First treatment in Room 4 then next two treatments in Short Stay if during daytime

• Prednisolone:

  • <5 yrs 20mg PO OD x 3/7
    5yrs 30mg PO OD x 3/7
  • ideally 1 mg/kg (max 30 mg OD) for 3/7
• Clinician to review child after three treatments
  OR BEFORE IF ASKED

  Admit if no improvement
  - look carefully for severe or life-threatening features

  Continue 2-4 hourly salbutamol via spacer

REGULAR REASSESSMENT

CONSULT SENIOR

• OXYGEN
  • At 1-2l/min over nasal prongs or at least 5l/min over face mask
• SALBUTAMOL NEBULISER (3 back-to-back to start with)
  • <4 years: 2.5 mg
    >4 years: 5 mg

Think about starting steroids while doing back-to-back Nebs if they don't show effect

CALL FOR SENIOR HELP HERE IF NOT IMPROVING

• STEROIDS

  (steroids need at least 30 min. for the effect to kick in)

  Continue Salbutamol Nebs meanwhile

  • Oral Prednisolone 1-2 mg/kg PO STAT - (max. dose 40 mg)
  • Alternatively: oral Dexamethasone 0.6 mg/kg STAT - (max. 10 mg)
  • OR alternatively: Hydrocortisone IV ( <5 yrs: 50mg; >5 yrs: 100mg IV STAT)

monitor for tachycardia, deterioration or improvement
Give salbutamol every 15 min, then see if you can spread out to 30 min or 60 min according to state of the patient)

• 2/3 maintenance IV fluids plus 20 mmol KCl per litre of fluid
  

Continue Salbutamol Nebs meanwhile

If not improving

Continue Salbutamol Nebs meanwhile

• Consider IV Magnesium-sulphate (see below)
• Consider IV Aminophylline - ONLY WITH SENIOR INPUT (see below)
• Consider chest x-ray (? Pneumothorax? Foreign body)
• Consider ITU

Supportive Care

• Ensure intake of daily maintenance fluids appropriate for age. This can be orally or IV.
• Encourage continued breast feeding

On discharge

• Prescribe salbutamol via spacer 2-4 puffs 4 hourly for 2-3 days, then as required
• To complete 3 days of prednisolone or to give a second dose of dexamethasone (24 hours after the first one) before discharge
• Teach inhaler and spacer technique
• Avoid allergens
• Consider rethinking pre-existent background therapy, may need additional medication

Review in General Clinic (Wednesdays 1:30pm) if needing inhaler >3 times per week or if this is second presentation to hospital

Chronic/ ongoing Asthma

Medication

• 200mcg up to 4 times daily

• patients must come back from pharmacy with the inhaler to work out dosage
• < 2 years: 100 mcg BD
• 2-12 years: 200 mcg BD
• 12-18 years: 200-400 mcg BD

Guardian education

• How and when to take inhalers (this will need to be observed)
• How to use a spacer
• When to seek help (i.e. breathlessness not controlled by inhalers, sudden increase in the need for 'relievers')
• Possible precipitating factors

Follow up

• General clinic (1:30pm Wednesdays) in one months time if new diagnosis
• May need to be sooner if asthma was severe or life-threatening.

How to make and use a SOBO Bottle spacer - 2 options of placing inhaler

• Wash bottle out with soapy water. Shake and leave to dry.
• Cut an X into the end of the bottle with hot wire or razor. If the end of the bottle is too tough to cut, the hole for the inhaler can be cut into the side of the bottle.
• For a tighter fit you can make the hole just a bit too big and then put tape around it for a better seal.

Steps for use

1. Shake inhaler
2. Insert inhaler into the hole in the bottle
3. Teach the child to form a tight seal around the mouthpiece of the bottle
4. Apply a puff from the inhaler into the bottle
5. Count for 10 seconds whilst the child breathes in and out (10 breaths)
6. Take inhaler out of bottle and shake to mix
7. Repeat steps 1-6 to give the number of puffs needed.

For children under 3 years

Attach a face mask to the mouth piece of the bottle. If the mask has holes in it, put tape over these. Follow above steps. Needs 2 people.

Spacer care

Outlook