Beruflich Dokumente
Kultur Dokumente
(exacerbations)
Flare-up
Acute severe asthma
Exacerbation
Attack
Episode
GINA 2015
Self-management
Management in primary care
Management in the emergency department and hospital
Follow-up after any exacerbation
Global Initiative for Asthma
History
Physical examination
Signs of exacerbation severity and vital signs (e.g. level of
consciousness, temperature, pulse rate, respiratory rate, blood
pressure, ability to complete sentences, use of accessory
muscles, wheeze)
Complicating factors (e.g. anaphylaxis, pneumonia,
pneumothorax)
Signs of alternative conditions that could explain acute
breathlessness (e.g. cardiac failure, upper airway dysfunction,
inhaled foreign body or pulmonary embolism).
Objective
Lung function: PEF, FEV1
Oxygen saturation
Arterial blood gas measurement
CXR
NO
YES
MILD or MODERATE
SEVERE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
Short-acting beta2-agonists
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
INITIAL ASSESSMENT
NO
YES
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
MILD or MODERATE
SEVERE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
PEF >50% predicted or best
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF 50% predicted or best
Short-acting beta2-agonists
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
Short-acting beta2-agonists
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral corticosteroids
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat
as
severe and re-assess for ICU
The opportunity
Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patients asthma
management
PRIMARY CARE
MILD or MODERATE
any of:
Unable to speak or drink
Central cyanosis
Confusion or drowsiness
Marked subcostal and/or sub-glottic
retractions
Oxygen saturation <92%
Silent chest on auscultation
Pulse rate > 200 bpm (0-3 yrs)
or >180 bpm (4-5 yrs)
Breathless, agitated
Pulse rate 200 bpm (0-3 yrs) or 180 bpm (4-5 yrs)
Oxygen saturation 92%
START TREATMENT
Salbutamol 100 mcg two puffs by pMDI + spacer
or 2.5mg by nebulizer
Repeat every 20 min for the first hour if needed
Controlled oxygen (if needed and available):
target saturation 94-98%
URGENT
Worsening,
or lack of
improvement
Worsening,
or lack of
improvement
Worsening,
or failure to
respond to
10 puffs
salbutamol
over 3-4 hrs
IMPROVING
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular
controller
Check inhaler technique and adherence
Follow up:within 1-7 days
Provide and explain action plan
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
Risk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including
inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
Schedule next follow up visit
Mild
Severe*
Altered consciousness
No
Oximetry on
presentation (SaO2)**
>95%
<92%
Sentences
Words
<100 beats/min
Central cyanosis
Absent
Likely to be present
Wheeze intensity
Variable
Speech
Pulse rate
Supplemental
oxygen
Inhaled SABA
Systemic
corticosteroids
Supplemental
oxygen
Inhaled SABA
Systemic
corticosteroids
THANK YOU