DANIEL AMAN, MD( ASS’T PROFESSOR OF

EMERGENCY MEDICINE AND CRITICAL

CARE,SPHMMC)
ASTHMA
EXACERBATION

ASTHMA 1 07/31/2022
ASTHMA
•  GINA DEFINE
• "ASTHMA IS A HETEROGENEOUS DISEASE, USUALLY CHARACTERIZED BY CHRONIC
AIRWAY INFLAMMATION. IT IS DEFINED BY THE HISTORY OF RESPIRATORY SYMPTOMS
SUCH AS WHEEZE, SHORTNESS OF BREATH, CHEST TIGHTNESS, AND COUGH THAT VARY
OVER TIME AND IN INTENSITY, TOGETHER WITH VARIABLE EXPIRATORY AIRFLOW
LIMITATION.“

• "REACTIVE AIRWAYS DISEASE“: TRANSIENT SYMPTOMS OF COUGH AND WHEEZE WHEN

CONFIRMATION OF A DIAGNOSIS OF ASTHMA IS LACKING.

ASTHMA 2 07/31/2022
CONT…

• ASTHMA IS A HETEROGENEOUS DISEASE, WITH DIFFERENT UNDERLYING

DISEASE PROCESSES. RECOGNIZABLE CLUSTERS OF DEMOGRAPHIC, CLINICAL
AND/OR PATHOPHYSIOLOGICAL CHARACTERISTICS ARE OFTEN CALLED ‘ASTHMA
PHENOTYPES’.

ASTHMA 3 07/31/2022
ASTHMA DX

• MAKING THE DIAGNOSIS OF ASTHMA IS BASED ON IDENTIFYING BOTH A

CHARACTERISTIC PATTERN OF RESPIRATORY SYMPTOMS SUCH AS WHEEZING,
SHORTNESS OF BREATH (DYSPNEA), CHEST TIGHTNESS OR COUGH, AND
VARIABLE EXPIRATORY AIRFLOW LIMITATION.

• THE PATTERN OF SYMPTOMS IS IMPORTANT, AS RESPIRATORY SYMPTOMS MAY BE

DUE TO ACUTE OR CHRONIC CONDITIONS OTHER THAN ASTHMA

ASTHMA 4 07/31/2022
CONT…
• PATTERNS OF RESPIRATORY SYMPTOMS THAT ARE CHARACTERISTIC OF ASTHMA
• PATIENTS (ESPECIALLY ADULTS) EXPERIENCE MORE THAN ONE OF THESE TYPES OF
SYMPTOMS.
• SYMPTOMS ARE OFTEN WORSE AT NIGHT OR IN THE EARLY MORNING.
• SYMPTOMS VARY OVER TIME AND IN INTENSITY.
• SYMPTOMS ARE TRIGGERED BY VIRAL INFECTIONS (COLDS), EXERCISE, ALLERGEN
EXPOSURE, CHANGES IN WEATHER, LAUGHTER, OR IRRITANTS SUCH AS CAR EXHAUST
FUMES, SMOKE OR STRONG SMELLS.

ASTHMA 5 07/31/2022
CONT…
• THE FOLLOWING FEATURES DECREASE THE PROBABILITY THAT RESPIRATORY
SYMPTOMS ARE DUE TO ASTHMA:
• ISOLATED COUGH WITH NO OTHER RESPIRATORY SYMPTOMS
• CHRONIC PRODUCTION OF SPUTUM
• SHORTNESS OF BREATH ASSOCIATED WITH DIZZINESS, LIGHT-HEADEDNESS OR
PERIPHERAL TINGLING (PARESTHESIA)
• CHEST PAIN
• EXERCISE-INDUCED DYSPNEA WITH NOISY INSPIRATION.

ASTHMA 6 07/31/2022
LUNG FUNCTION TESTING
• INA PATIENT WITH TYPICAL RESPIRATORY SYMPTOMS, OBTAINING EVIDENCE OF
EXCESSIVE VARIABILITY IN EXPIRATORY LUNG FUNCTION IS AN ESSENTIAL COMPONENT
OF THE DIAGNOSIS OF ASTHMA.

• SOME SPECIFIC EXAMPLES ARE:

• AN INCREASE IN LUNG FUNCTION AFTER ADMINISTRATION OF A BRONCHODILATOR, OR AFTER A
TRIAL OF CONTROLLER TREATMENT
• A DECREASE IN LUNG FUNCTION AFTER EXERCISE OR DURING A BRONCHIAL PROVOCATION TEST
• VARIATION IN LUNG FUNCTION BEYOND THE NORMAL RANGE WHEN IT IS REPEATED OVER TIME,
EITHER ON SEPARATE VISITS, OR ON HOME MONITORING OVER AT LEAST 1–2 WEEKS

ASTHMA 7 07/31/2022
CONT…
•  A SYMPTOM PATTERN SUGGESTIVE OF ASTHMA AND AIRFLOW LIMITATION ON
INITIAL SPIROMETRY, WHICH COMPLETELY REVERSES TO NORMAL FOLLOWING
BRONCHODILATOR, VIRTUALLY CLINCH THE DIAGNOSIS OF ASTHMA.

• LIKEWISE,
TYPICAL SYMPTOMS AND A LARGE REVERSIBILITY OF AIRFLOW
OBSTRUCTION ON SPIROMETRY (INCREASE IN FEV1 >15 PERCENT) GENERALLY
CONFIRM THE DIAGNOSIS OF ASTHMA.

ASTHMA 8 07/31/2022
CONT…

• OTHER TESTS
• BRONCHIAL PROVOCATION TEST
• ALLERGY TEST
• NITRIC OXIDE

ASTHMA 9 07/31/2022
COPD
• CHRONIC EXERCISE LIMITATION AND PERSISTENT AIRFLOW OBSTRUCTION IN A
MIDDLE-AGED OR OLDER PERSON WITH A HISTORY OF MORE THAN 20 PACK-
YEARS OF CIGARETTE SMOKING POINT TO A DIAGNOSIS OF COPD.

• IN
COPD, PRE- AND POST-BRONCHODILATOR PULMONARY FUNCTION TESTING
MAY CONFIRM LITTLE OR NO REVERSIBILITY OF THE AIRFLOW OBSTRUCTION.

ASTHMA 10 07/31/2022
ACUTE ASTHMA EXACERBATION
• ARE EPISODES CHARACTERIZED BY A PROGRESSIVE INCREASE IN SYMPTOMS OF
SHORTNESS OF BREATH, COUGH, WHEEZING, OR CHEST TIGHTNESS AND
PROGRESSIVE DECREASE IN LUNG FUNCTION TEST.

• MAYOCCUR IN PATIENTS WITH A PREEXISTING DIAGNOSIS OF ASTHMA OR,

OCCASIONALLY, AS THE FIRST PRESENTATIONS OF ASTHMA.

ASTHMA 11 07/31/2022
DETECTING AN EXACERBATION
• SYMPTOMS
• SYMPTOMS THAT PATIENTS SHOULD RECOGNIZE AS SUGGESTING AN ASTHMA EXACERBATION INCLUDE
BREATHLESSNESS, WHEEZING, COUGH, AND CHEST TIGHTNESS.

• SOME PATIENTS ALSO REPORT REDUCED EXERCISE TOLERANCE AND FATIGUE AS A SYMPTOMS OF AN ASTHMA
EXACERBATION.

• MEASUREMENT OF EXPIRATORY AIRFLOW WITH A PEAK EXPIRATORY FLOW (PEF) METER (OR SPIROMETER)
• MEASUREMENTS TAKE LESS THAN ONE MINUTE TO PERFORM AND
• ARE SAFE AND INEXPENSIVE
• IS PARTICULARLY USEFUL IN PATIENTS WITH POOR PERCEPTION OF ASTHMA SYMPTOMS.

asthma
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SPIROMETRY

asthma
13 07/31/2022
PEF ZONE
• GREEN (80 TO 100 PERCENT OF PERSONAL BEST) SIGNALS "ALL CLEAR.“

• YELLOW (50 TO 80 PERCENT OF PERSONAL BEST) SIGNALS "CAUTION,"

• CAN BE SUBDIVIDED ABOVE AND BELOW THE 65 PERCENT LEVEL IF DESIRED.

• RED (BELOW 50 PERCENT OF PERSONAL BEST) SIGNALS "MEDICAL ALERT

ASTHMA 14 07/31/2022
PEAK EXPIRATORY FLOW (PEF) METER (OR
SPIROMETER)
• NORMAL VALUES FOR PEF DIFFER WITH SEX, HEIGHT, AND AGE .
• EACH PATIENT SHOULD ESTABLISH A BASELINE MEASURE WITH WHICH TO COMPARE FUTURE
READINGS.

• A DECREMENT IN PEAK FLOW OF GREATER THAN 20 PERCENT FROM NORMAL, OR FROM THE
PATIENT'S PERSONAL BEST VALUE, SIGNALS THE PRESENCE OF AN ASTHMA EXACERBATION.

• THE DIFFERENCE IN PEAK FLOW FROM THE PATIENT’S BASELINE HELPS ONE GAUGE THE SEVERITY
OF THE CHANGE.

• A PEF LESS THAN 50 PERCENT OF BASELINE SHOULD BE CONSIDERED A SEVERE ATTACK.

asthma
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ASTHMA EXACERBATION
MILD TO MODERATE EXACERBATION:
TALKS IN PHRASES OR SENTENCES
PREFERS SITTING TO LYING
NOT AGITATED
RESPIRATORY RATE 16 TO 30 BREATHS/MINUTE
HEART RATE 100 TO 120 BEATS/MINUTE
SPO  >90%
2

PEF >50% BUT <80% PREDICTED OR PERSONAL BEST.

asthma
16 07/31/2022
ASTHMA EXACERBATION
SEVERE EXACERBATION:
SPEAKS IN SINGLE WORDS
SITS HUNCHED FORWARD
AGITATED, DIAPHORETIC
RESPIRATORY RATE >30 BREATHS/MINUTE
HEART RATE >120 BEATS/MINUTE
SPO  (ON AIR) <90%
2

PEF ≤50% PREDICTED OR PERSONAL BEST

FEATURES THAT HELP WITH ASSESSMENT OF SEVERITY (MAY OR MAY NOT BE PRESENT):IMPENDING
RESPIRATORY FAILURE:

CYANOSIS, INABILITY TO MAINTAIN RESPIRATORY EFFORT, DEPRESSED MENTAL STATUS, SPO  <90%
2

PACO  >40 MMHG

2

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SEVERITY OF ASTHMA EXACERBATIONS

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asthma
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20 07/31/2022
C/F
• “CLINICAL FEATURES CAN IDENTIFY SOME PATIENTS WITH SEVERE ASTHMA, E.G.
• SEVERE BREATHLESSNESS (INCLUDING TOO BREATHLESS TO COMPLETE SENTENCES IN ONE BREATH),
• TAC HYPNEA,
• TACHYCARDIA,
• SILENT CHEST,
• CYANOSIS,
• ACCESSORY MUSCLE USE,
• ALTERED CONSCIOUSNESS OR COLLAPSE.
• NONE OF THESE SINGLY OR TOGETHER IS SPECIFIC. THEIR ABSENCE DOES NOT EXCLUDE A SEVERE
ATTACK.”

asthma
21 07/31/2022
STATUS ASTHMATICUS (ACUTE SEVERE ASTHMA)

• STATUS ASTHMATICUS IS AN ACUTE SEVERE ASTHMA ATTACK THAT DOES

NOT IMPROVE WITH USUAL DOSES OF INHALED BRONCHODILATORS AND STEROIDS.

• SIGNS AND SYMPTOMS INCLUDE

• HYPOXEMIA,
• TACHYPNEA,
• TACHYCARDIA,
• ACCESSORY MUSCLE USE, AND
• WHEEZING. WHEEZING MAY BE ABSENT WHEN AIRFLOW IS SEVERELY REDUCED

asthma
22 07/31/2022
PRECIPITANTS
• VIRAL RESPIRATORY INFECTIONS
• ALLERGEN EXPOSURE
• OUT DOOR AIR POLLUTION
• SEASONAL CHANGE
• POOR ADHERENCE WITH WITH ICS

ASTHMA 23 07/31/2022
MGT
• THE PRIMARY GOALS OF THERAPY FOR ACUTE SEVERE ASTHMA ARE THE RAPID REVERSAL OF
AIRFLOW LIMITATION AND THE CORRECTION, IF NECESSARY, OF HYPERCAPNIA OR
HYPOXEMIA.

• OXYGEN
• AIM FOR A SPO  ABOVE 92 PERCENT (>95 PERCENT IN PREGNANCY)
2

• INHALED BETA AGONISTS — THE MAINSTAY OF BRONCHODILATOR TREATMENT IS

INHALATION OF SHORT-ACTING BETA-2-SELECTIVE ADRENERGIC AGONISTS (SABA), SUCH AS 
ALBUTEROL, LEVALBUTEROL

ASTHMA 24 07/31/2022
INHALED SHORT-ACTING BETA2-AGONISTS (SABA)
ALBUTEROL (SALBUTAMOL)

• INHALED BETA AGONIST: 

• GIVE ALBUTEROL 2.5 TO 5 MG BY NEBULIZATION EVERY 20 MINUTES FOR THREE
DOSES, THEN 2.5 TO 5 MG EVERY ONE TO FOUR HOURS AS NEEDED, OR

• GIVE 4 TO 8 PUFFS BY METERED DOSE INHALER (MDI) WITH SPACER EVERY 20

MINUTES FOR THREE DOSES, THEN EVERY ONE TO FOUR HOURS AS NEEDED. 

• ALTERNATIVELY,FOR SEVERE EXACERBATIONS, 10 TO 15 MG CAN BE

ADMINISTERED BY CONTINUOUS NEBULIZATION OVER ONE HOUR.

ASTHMA 25 07/31/2022
ASTHMA 26 07/31/2022
MDI WITH SPACER

ASTHMA 27 07/31/2022
MGT
• IPRATROPIUM BROMIDE: 
• GIVE 500 MCG BY NEBULIZATION EVERY 20 MINUTES FOR 3 DOSES, OR 4 TO 8 PUFFS BY MDI WITH
SPACER EVERY 20 MINUTES AS NEEDED FOR UP TO 3 HOURS.

• SYSTEMIC GLUCOCORTICOIDS: 
• FOR PATIENTS WITH IMPENDING RESPIRATORY FAILURE, GIVE METHYLPREDNISOLONE 60 TO 125
MG IV.
• FOR THE MAJORITY OF LESS SEVERE ASTHMA EXACERBATIONS, GIVE PREDNISONE 40 TO 60 MG
ORALLY;
• ALTERNATIVES INCLUDE: DEXAMETHASONE 6 TO 10 MG IV OR HYDROCORTISONE 150 TO 200 MG
IV; GLUCOCORTICOIDS MAY BE GIVEN IM OR ORALLY IF IV ACCESS IS UNAVAILABLE.

ASTHMA 28 07/31/2022
MGT

• MAGNESIUM SULFATE: 
• GIVE 2 G (8 MMOL) IV OVER 20 MINUTES FOR LIFE-THREATENING EXACERBATIONS
AND EXACERBATIONS THAT REMAIN SEVERE AFTER ONE HOUR OF INTENSIVE
BRONCHODILATOR THERAPY

ASTHMA 29 07/31/2022
EPINEPHRINE
• EPINEPHRINE:
• FOR PATIENTS SUSPECTED OF HAVING AN ANAPHYLACTIC REACTION OR UNABLE TO
USE INHALED BRONCHODILATORS FOR SEVERE ASTHMA EXACERBATION, GIVE
EPINEPHRINE 0.3 TO 0.5 MG IM (EG, 0.3 TO 0.5 ML OF 1 MG/ML [ALSO LABELED 1:1000]
SOLUTION);

• IF SEVERE ASTHMA BUT NO EVIDENCE OF ANAPHYLAXIS, CAN GIVE EPINEPHRINE 0.3

TO 0.5 MG SC (EG, 0.3 TO 0.5 ML OF 1 MG/ML [ALSO LABELED 1:1000] SOLUTION); GIVE
EPINEPHRINE OR TERBUTALINE BUT NOT BOTH

ASTHMA 30 07/31/2022
• THANKS
ASTHMA 32 07/31/2022