Analysis of NSWA Asthma Protocol and

Recommendations for Best Practice

– Nicholas Newbury
Assessment of Severity
The assessment of the severity is not described in this protocol but the broad categories of mild,
severe, and life-threatening are essential in determining which treatments are most appropriate. This
protocol does not provide specifics of what presentations constitute which severity and therefore
make clinical judgement errors more likely to affect treatment decisions.
This lack of specificity has led to negative outcomes and its rectification was one of the main
recommendations in a UK coronial review [1]. I would recommend future iterations of this NSWA
protocol do include a framework like the GINA and BTS acute asthma severity criteria [2,3]. These are
moderate, severe, and life-threatening and are based on clinical findings including lung sounds,
SpO2, ETCO2, speech, FEV and PEV scores, reduced perfusion status, hypotension, and
fatigue/accessory muscles. the lack of clarification within this protocol could lead to worse patient
outcomes. These categorisations are used by peak bodies and multiple studies, proving to be
effective for prehospital asthma severity categorisation [2,3,4,5].

SABA + SAAC
The choice early and mixed administration of beta 2 antagonist, anticholinergic administration being
mixed for severe and life-threatening asthma presentations [2,3, 4, 5, 6, 7]. Kirkland et al 2017,
reviewed studies comparing hospitalisation rates for patients that received combined SABA and
anticholinergics vs those only receiving SABAs and found the combination was more effective in
reducing hospitalisations. I would implement the concurrent administration of these via a nebuliser
in my practice.
Additionally, this protocol only administering salbutamol for moderate asthma presentations is in line
with best practice as the addon therapy of SAAC has not been shown to improve outcomes for those
patients [5,6].

Oxygen
While nebulised medications in NSWA are driven by an 8L flow of oxygen there is no further options
to step up oxygen therapy in this protocol. The administration of inhaled SABA and SAAC is possible
with 15L of oxygen if a BVM with inline nebuliser is used, mechanical ventilation can then be
withheld or given as needed.
The issue with that idea is that it only delivers cold, dry air that impacts the airways mucous
clearance and can worsen inflammation [5,6,7]. High flow nasal canula (HFNC) devices have been
shown to rapidly increase PO2 levels, reduce work of breathing and improve clearance of airway
secretions in severe bronchial asthma patients [6]. This is due to the humidification and heating of
the air being provided. Unfortunately, the systems involved require conventional power which is
logistically challenging for ambulance services [7,8]. For best practice and best patient outcomes
including reduced length of hospital admission and effective management of hypoxia in life-
threatening asthma per the GINA and BTS severity guides. I would recommend HFNC alongside
pharmacological interventions.

The complication to this approach is the application of significant oxygen therapy makes it hard to
assess the effectiveness of a beta 2 agonist challenge to support the provisional diagnosis of asthma
[3,6]. According to assessment frameworks by peak bodies confirming that asthma is the most likely
 Analysis of NSWA Asthma Protocol and
Recommendations for Best Practice
– Nicholas Newbury
provisional diagnosis is an essential step and therefore it is important to reassess the patient before
and after SABA before upgrading to HFNC [2,3,5,8].

Corticosteroids
This asthma protocol indicates that corticosteroid prednisolone is only to be given to patients with
moderate asthma. While hydrocortisone is appropriate for patients with severe and life-threatening
asthma. It also restricts hydrocortisone administration to children above 6 years old.
Corticosteroids are effect anti-inflammatory and immunosuppressive medications that have a slower
onset than SABA and SAAC but that last much longer [5,9]. Castillo et al assert that the evidence is
not strong that they are effective in managing the acute presentation of asthma exacerbation but
their effectiveness in managing relapses of asthma considerable [9]. This is not supported by Fishe JN
et al who’s results that the addition of oral corticosteroids did not significantly affect hospital
admission rates or length of ED stay [10], however the studies in their systematic review did show
wide contrast. Some showed significant improvement in those metrics and others did not. Bleecker
et al explain that inhaled corticosteroids have less adverse effects when compared to systemic
corticosteroids (the protocols Oral and IV corticosteroids are systemic) [11].

From the research I’ve gathered it appears that corticosteroids are good for reducing asthma
exacerbations long term and prevent relapse [9,10,11], thus reducing ED length of stay and
accelerating recovery [4].
I agree with their inclusion in all levels of asthma severe treatment. While their onset is slow their
therapeutic effect can last for 12 hours and reduces the root cause of the asthma exacerbation, as
opposed to the short-term symptomatic interventions of SABA and SAACs. It is patient centred and
considers the whole of the patient health journey.

The decision to exclude corticosteroids from children under 6 years old is not inline with
recommendations from GINA and the BTS [2,3]. Additionally, Fishe et al [4] review ED studies
showing that earlier administration of systemic corticosteroids is beneficial and recommended for
any paediatric asthma exacerbations. I could not find current evidence that suggests the withholding
on corticosteroids from children younger than 6yo.
It could a question of adherence due to the NSWA hydrocortisone being a tablet that it may be
difficult to swallow for young children and that could pose a unacceptable risk of airway obstruction.
I would recommend other preparations of corticosteroids like IM dexamethasone that can be given
as an oral liquid or IM prednisolone.

Adrenaline
This protocol calls for IM adrenaline in life threatening asthma only. Four doses and then upgrading
to IV adrenaline if patient is unresponsive to this treatment.

The purpose is to rapidly broncho dilate the restricted airways in patients that do not have sufficient
tidal volume to allow inhaled medications to reach the airways that need them [4,5]. The increase in
airway patency also aids oxygenation and reduces work of breathing. Both the BTS and GINA peak
bodies recommend its use for this presentation [2,3]. However, a 2022 systematic review asserts that
the evidence that efficacy of IM adrenaline in addition to SABA is not strong and requires further
 Analysis of NSWA Asthma Protocol and
Recommendations for Best Practice
– Nicholas Newbury
research [13]. Meanwhile Fishe [4] and Castillo [5] present evidence of its widespread use and
efficacy [3]. I agree with its inclusion in the NSWA protocol.

Magnesium
It is not included in this protocol and its use has been shown to increase hospital admissions post
EMS administration and its lack of benefit is corroborated by Schuh et al’s clinical trials 2020. [10,
12]. I recommend its continued exclusion from EMS asthma protocols.

References:

1. Hayes S, Ms D. HM Area Coroner for Essex [Internet]. 2024 [cited 2024 May 3]. Available
from: https://www.judiciary.uk/wp-content/uploads/2023/12/2023-0511-Response-from-
Association-of-Ambulance-Chief-Executives.pdf
2. Levy ML, Bacharier LB, Bateman E, Boulet LP, Brightling C, Buhl R, et al. Key
recommendations for primary care from the 2022 Global Initiative for Asthma (GINA)
update. NPJ primary care respiratory medicine [Internet]. 2023 Feb 8;33(1):7. Available from:
https://pubmed.ncbi.nlm.nih.gov/36754956/
3. QRG 153 • British guideline on the management of asthma Quick Reference Guide [Internet].
2016. Available from:
https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2019/03/BTS-SIGN-Asthma-
2016-Guidelines.pdf
4. Fishe JN, Blake K. EMS, Pre-Hospital Evaluation and Treatment of Asthma in Children
[Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available
from: https://www.n[2cbi.nlm.nih.gov/books/NBK534210/
5. Castillo JR, Peters SP, Busse WW. Asthma Exacerbations: Pathogenesis, Prevention, and
Treatment. The Journal of Allergy and Clinical Immunology: In Practice [Internet]. 2017
Jul;5(4):918–27. Available from: https3://www.ncbi.nlm.nih.gov/pmc/articles/PMC5950727/
6. Kirkland SW, Vandenberghe C, Voaklander B, Nikel T, Campbell S, Rowe BH. Combined
inhaled beta-agonist and anticholinergic agents for emergency management in adults with
asthma. Cochrane Database of Systematic Reviews. 2017 Jan 11;(1).
7. Chidekel A, Zhu Y, Wang J, Mosko JJ, Rodriguez E, Shaffer TH. The Effects of Gas
Humidification with High-Flow Nasal Cannula on Cultured Human Airway Epithelial Cells.
Pulmonary Medicine. 2012;2012:1–8.
8. Geng W, Batu W, You S, Tong Z, He H. High-Flow Nasal Cannula: A Promising Oxygen Therapy
for Patients with Severe Bronchial Asthma Complicated with Respiratory Failure. Canadian
Respiratory Journal [Internet]. 2020 Feb 20;2020. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054795/
9. Hodgens A, Sharman T. Corticosteroids [Internet]. PubMed. Treasure Island (FL): StatPearls
Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554612/
 Analysis of NSWA Asthma Protocol and
Recommendations for Best Practice
– Nicholas Newbury
10. Fishe JN, Garvan G, Bertrand A, Burcham S, Hendry P, Shah M, et al. Early Administration of
Steroids in the Ambulance Setting: An Observational Design Trial (EASI‐AS‐ODT). Academic
emergency medicine. 2023 Oct 19;
11. Bleecker ER, Al-Ahmad M, Bjermer L, Caminati M, Canonica GW, Kaplan A, et al. Systemic
corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory
Effectiveness Group. World Allergy Organization Journal [Internet]. 2022 Dec 1;15(12).
Available from: https://www.worldallergyorganizationjournal.org/article/S1939-
4551(22)00102-8/fulltext
12. Schuh S, Sweeney J, Rumantir M, Coates AL, Willan AR, Stephens D, et al. Effect of Nebulized
Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With
Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial.
JAMA [Internet]. 2020 Nov 24;324(20):2038–47. Available
from: https://pubmed.ncbi.nlm.nih.gov/33231663/
13. Baggott C, Hardy JK, Sparks J, Sabbagh D, Beasley R, Weatherall M, et al. Epinephrine
(adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a
systematic review and meta-analysis. Thorax. 2021 Sep 30;77(6):thoraxjnl-2021-217124.