BRONCHIAL ASTHMA

EMERGENCY MANAGEMENT
BRONCHIAL ASTHMA

 presents with cough, wheeze or breathlessness

 Increase in the symptoms with walking, talking and sleeping indicate worsening of asthma

 Precipitating factors
 exposure to house dust mites, grass pollens and moulds
 Infections – 90% are viral
 Exercise- In older children are due to heat and water loss from the upper airway
 Emotional factors – laughing or excitement
 Drop in temperature
 Exposure to smoke. This is an important factor where prevention is possible
 Chemical irritants (paints, aerosols)
 Differential diagnosis  Bad prognostic features

 Foreign body  Extended duration of illness

 Bronchiolitis  Poor response to treatment
 Heart failure  The course of previous attack
 Mycoplasma
 Pneumonia
 Aspiration and allergy.
Assessment of Severity

 Intensity of wheezing and respiratory rate are poor indications of severity.

 Pulsus paradoxus is difficult to assess.
 Cyanosis is a late sign
 PEFR can be assessed only in children over 5 years
Assessment of Severity
Severe/life
Symptoms Mild Moderate
threatening
Agitated, confused or
Altered LOC No No
drowsy
Use of accessory muscles/
No Minimal Moderate/ Severe
Recession
Pulse oximetry on
>94% 94- 90 % <90%
presentation ( SaO2)*
Talk in Sentences Phrases Words /unable to speak

Pulsus paradoxus Not palpable May be palpable Palpable

< 2yr <110 < 2yr <110 -130 < 2yr >130
Pulse rate/min
> 2yr < 100 > 2yrs < 100- 120 >2yrs > 120
< 2yr < 50 < 2yr < 50 -60 < 2yr > 60
Respiratory rate bpm
> 2yr < 40 > 2yr < 40 - 50 > 2yr > 50
Central cyanosis Absent Absent Likely to be present

Wheeze intensity Variable Moderately loud Often quiet

Peak expiratory flow >60% < 50% <40%

Arterial blood gases Not necessary to test If initial response is poor If initial response is poor
 Life threatening asthma is characterized by silent chest, cyanosis, poor inspiratory effects,
hypotension, exhaustion, confusion and coma.

 Admission to the ward

 All severe and life threatening asthma.

 Child requiring oxygen or bronchodilators more than 3 hourly.
 Past history of severe episodes
 Sudden and labile attacks
 Current use of steroids and bronchodilators
 Poor compliance
 Distance from hospital and social circumstances
EMERGENCY TREATMENT
 All children with severe or life threatening asthma should be admitted to a ward/ICU.
 Oxygen saturation below 92 % in air needs admission and oxygen therapy.

 High flow oxygen (4-6L/minute via mask or 2 L/min via nasal canulae), continue until O2
saturation is above 92% while breathing air
 Nebulise with salbutamol with oxygen.
 Use of oxygen is very important because there is a chance to develop bronchospasm with
the initial nebulization (even with bronchodialators) leading to worsening hypoxia.
 If a nebuliser is not available, as a temporary emergency measure a spacer device could be
used to give 2-4 puffs of salbutamol MDI, increase by 2 puffs every 20 minutes and the
dose can be increased up to 10 puffs.
 In severe and life threatening asthma a combination of ipratropium bromide and Salbutamol
should be used

Drug doses
Salbutamol Ipratropium
bromide
Below 1 year 1.25mg (0.25cc) 125mcg
Below 5 years 2.5mg (0.5cc) 250mcg
Above 5 years 5mg (1cc) 500mcg

 Frequency : For severe and life threatening asthma use three doses in the first hour at 20 minute intervals
followed by six hourly doses
 Steroid
 Oral or IV – effects appear after 4-6 hours
 Prednisolone 1-2 mg/kg daily for 3-5 days (max. dose 60mg)
 Hydrocortisone 4 mg/kg 6 hourly or infusion 1mg/kg/hr if there is a IV line

 If response is poorer than expected 

exclude PNEUMOTHORAX, HEART FAILURE and other possibilities
 If the child is having LIFE THREATENING ASTHMA or is not responding to the
initial treatment :

 admit to ICU/HDU
 Indications to admit to the ICU
 Deteriorating lung functions
 Worsening asthma
 Persisting or worsening hypoxia
 Hypercapnea
 Exhaustion
 Drowsiness, confusion, coma
 Respiratory arrest.

 IV line (if not already in place) & correct hydration if dehydrated

If hydration is adequate provide only two thirds of normal daily requirement because of
Syndrome of Inappropriate ADH secretion.
 Aminophylline or Salbutamol IV

 Aminophylline
Can cause arrhythmias, seizures and severe vomiting.
Bolus only if the child was not on aminophylline/ theophylline preparations during last 24 hrs.

Dose – 5 -10 mg/kg over 20 minutes

Infusion 1mg/kg/hr in usual IV fluid

 Salbutamol
Can cause hypokalaemia.
Potassium (K+) level 12 hrly.

Bolus 5 mcg/kg over 10 minutes

Infusion 0.5 –1 mcg/kg/min

May be useful even if nebulization with salbutamol has failed

 Magnesium Sulphate

Smooth muscle relaxant and a bronchodilator.

Dose 40-100 mg/kg (40mg/kg max 2 gr) as a 20 minute bolus

followed by infusion 30 mg/kg/ hour
( 50 mg/kg = 0.125 ml of 40 % Magnesium sulphate solution/kg)

 Adrenaline
Use when asthma is due to anaphylaxis.
Dose 0.01 ml/kg of 1:1000 every 20 minute up to three doses
 Ventilation

Consider early if the child is weak and going in to respiratory failure.

 Try giving a bag and mask support synchronized with child’s respiration if respiratory failure is
suspected
 Consider mechanical ventilation if PCO2 > 8 kpa, or PO2 < 8 kpa, or worsening metabolic
acidosis or if the child is having worsening life threatening asthma in spite of above treatment or
exhaustion.
 Rapid sequence Intubation and Ventilation is recommended.

 Rapid sequence intubation

Ketamine (Bronchodilator effect 10-20 mcg/kg/min)

Thiopentone 2-3 mg/kg IV bolus
Suxamethonium 1 mg/kg IV
Cricoid pressure
Rapid Intubation
Thank You!