Asthma

Definition of Asthma:
1. Chronic airway inflammatory disorder
2. Recurrent episodes of wheezing, chest tightness, shortness of breath, and
coughing at night or in the early morning
3. Reversible airway limitation

Diagnosis of Asthma[5]
1. History:: cough worse at night, recurrent wheezing/chest tightness
recurrent difficult breathing
2. Symptoms occur or worsen at night, awakening the patient
3. Physical examination: wheezing, silent chest when severe asthma
4. Lung function test ( FEV1 and PEFR )
- PEFR increases > 15% after inhalation of short-acting β2 –agonists 15~20
mins
- PEFR varies > 20% from morning to 12 hours later
- PEFR decreases > 15% after 6 mins of exercise
5. Risk factors:
- Allergic IgE-mediated diseases, allergic rhinitis, atopic dermatitis, and
eczema
- Familial members with asthma
- exacerbation associated with weather change, foods, drugs…

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 Classification of Asthma Severity [5]
Clinical Features Before Treatment
Classification Days Symptoms Night-time Lung Function Test
Symptoms
STEP 1: < 1 times/week < 2 times/month -FEV1 or PEF > = 80%
Intermittent predicted
-PEF variability < 20%

STEP 2: > 1 times /week, but > 2 /month -FEV1 or PEF > = 80%
Mild persistent < 1/day predicted
-PEF variability 20-30%

STEP 3: Daily symptoms > 1 /week -FEV1 or PEF in

Moderate persistent 60%~80% predicted
-PEF variability > 30%

STEP 4: Continual symptoms Frequent -FEV1 or PEF < 60%

Severe persistent predicted
-PEF variability > 30%

Stepwise Approach for Managing Asthma in Adult [5]

Quick Relief
All Patients - Short-acting bronchodilator with inhaled β2 -agonists as needed for
symptoms.
- Intensity of treatment will depend on severity of exacerbation.
- Use of bronchodilator > 1/week over a 3 months period in intermittent
asthma may indicate the need to “step-up” therapy
Classification Daily Control Medicines Other Treatment Options
STEP 1: - No daily medication
Intermittent
STEP 2: - Anti-inflammatory: inhaled - Sustained-release theophylline to
Mild persistent corticosteroid (low doses) serum concentration of 5-15
μg/mL

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 - Cromone or
- Leukotriene modifier
STEP 3: - Low~mideum-dose of inhaled - Medium-dose of inhaled
Moderate corticosteroid + long-acting corticosteroid + sustained-release
persistent inhaled β2 –agonist theophylline, or
- Medium-dose of inhaled
corticosteroid + long-acting oral β2
–agonist, or
- High-dose inhaled corticosteroid,
or
- Medium-dose of inhaled
corticosteroid
+ leukotriene modifier
STEP 4: - Inhaled corticosteroid (high
Severe persistent dose) + long-acting inhaled β2 –
agonist + if needed:
• sustained-release theophylline
• leukotriene modifier
• long-acting inhaled β2 –agonist
• oral glucocorticosteroid
* Step down: Review treatment every 1 to 6 months. If control is sustained
for at least 3 months, a gradual stepwise reduction in treatment may be
possible.
* Step up: If control is not achieved, consider step up. Inadequate control is
indicated by increased use of short-acting β2-agonists and in:
- step 1 when patient uses a short-acting β2-agonist more than two times a
week;
- steps 2 and 3 when patient uses short-acting β2-agonist on a daily basis
OR more than three to four times a day.
- But before stepping up: review patient inhaler technique, compliance, and
environmental control (avoidance of allergens or other precipitant factors).

Criteria for Hospitalization [1-2]

1.Any symptoms of asthma with a FEV1 or peak-expiratory flow rate
(PEFR) < 50% of predicted value

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 2.PaCO2 ↑
3.Prolonged attack of asthma of > 24 hours duration
4.Age > 40 years
5.Poor response after 4 hours of bronchodilator therapy
6.Recent or multiple emergency department or hospitalizations for
treatment of asthma that occurred within the last year
7.History of ET intubation for asthma
8.Poor access to medical follow-up
9.Psychiatric conditions that are interfering with medical compliance

The initially quick assessment of ASTHMA in admission [2,5]

Examination finding Level of Severity
Mild Moderate Severe
Conscious State Normal Normal Altered

Speaking Ability Sentences Phrases Words

Respiratory rate <20 20 – 30 >30

(b/min)
ABGs:
PaO2 Normal > 60 mmHg < 60 mmHg, cyanosis
PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg
SaO2 > 95% 91 – 95% <90%

Air Entry Good Moderate Poor may have

silent chest

Recommendations regarding initial treatment of an acute

episode [2]
1. Oxygen therapy at a minimum of 6 L/min via face mask to achieve SaO2 >
95%. (Grade B)
2. Administration of high-dose inhaled bronchodilator (salbutamol 5mg via
nebuliser, q15 minutes up to a maximum of 20mg). (Grade A)
3. Corticosteroids should be given within 1 hour of presentation. (Grade A)
4. Antibiotics are not required unless there is radiological evidence of
pneumonia or proven or suspected bacterial bronchitis. (Grade B)

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Quick Reference Guide - In Hospital Management of Asthma [2]

Initial Assessment
-Clinical Signs: Pulse Rate, Respiratory Rate, PEF, SaO2, level of fatigue
-Action: taking further ABGs, other blood tests and Chest X-ray.

Ward Treatment
1. Start short-acting bronchodilator with:
• Inhaled β2 –agonists ( nebulization preferred ): 1 dose q20 mins X 1 hour
• Salbutamol: MDI (+ spacer if needed) Usually 2 - 4 puffs prn but dosage is
patient response dependent.
2. Oxygen therapy continued until SaO2 > 92%
3. Systemic Corticosteroids: prednisolone of 40-50 mg daily or parenteral
hydrocortisone 100mg Q6H
4. Sedation is contraindicated in the treatment of exacerbation
5. Repeat assessment of good, incomplete, or poor response after pharmaco-therapy.
6. Commence discharge planning on admission

Discharge Planning Poor Response

1. Patient Education • Exhaustion, drowsiness
• Cause of exacerbation ( trigger factors) • Rising arterial PaCO2>45
• Review inhaler device technique • Unable to maintain adequate
(台北總院 2F 氣喘衛教室) PaO2 > 60
• Write a self-management plan
Activities of Daily Living and Social Support
Assessed
3. Medications at Discharge Transfer to ICU for further
• Keep therapy with inhaled β2 –agonists managements
• Tapering of oral corticosteroid therapy
• Review home medication and adjust as
required
4. Discharge Details Faxed Include:
• Discharge summary
• Best and worst PEF
• Asthma Management Plan
• Clear arrangements for clinical review
within 7 days.

Discharge when
• Clinicalstatus: No nocturnal symptoms
• PEF > 70% pred. or patient’s usual best
• SaO2 > 90%
• Able to complete activities of daily living

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References:
1. Status asthmaticus and hospital management of asthma, Spagnolo SV -
Immunol Allergy Clin North Am - Aug; 21(3); 503-533, 2001
2. Guidelines for the Hospital Management of Acute Asthma, Evidence Based
Guidelines in Royal Melbourne Hospital, Review date: October 2000
3. Acute Asthma in Adults-A Review, CHEST 125:1081–1102, 2004
4. BTS/SIGN. British guideline on the management of asthma. Thorax; 58
(Supple I ):i1–94. 2003
5. Global Initiative for Asthma: Guideline for Asthma Management and
Prevention - updated November, 2003.