MANAGEMENT OF ACUTE ASTHMA IN ADULTS CRITERIA FOR ADMISSION any feature of a life threatening or near fatal attack. any feature of a severe attack persisting after initial treatment [PEFR > 75% best or predicted one hour after initial treatment → consider discharge] TREATMENT of acute asthma OXYGEN Give O2 to all hypoxaemic patients - target SpO2 94-98%. Lack of pulse oximetry should not prevent the use of O2. In hospital, ambulance and primary care: drive nebs with oxygen. [but don't withold nebuliser treatment if O2 not available] GONIST BRONCHODILATORS Use high dose inhaled β2 agonists first line: and ASAP. Acute asthma with life threatening features → give neb β2 agonists (O2-driven) STEROID THERAPY Give steroids in adequate doses in all cases of acute asthma. Continue prednisolone 40-50 mg daily for at least five days or until recovery. IPRATROPIUM BROMIDE Add nebulised ipratropium (0.5 mg 4-6 hourly) to β2 treatment for patients with acute severe or life threatening asthma or poor initial response to β2 therapy. Routine prescription of antibiotics is not indicated for patients with acute asthma. REFERRAL TO INTENSIVE CARE Refer any patient: 1-requiring ventilatory support 2-with acute severe or life threatening asthma, failing to respond to therapy, evidenced by: - deteriorating PEF - persisting or worsening hypoxia - hypercapnea - ABG analysis showing pH or H+ - exhaustion, feeble respiration - drowsiness, confusion, altered conscious state -respiratory arrest MANAGEMENT OF ACUTE ASTHMA IN children aged over 2 years ACUTE SEVERE SpO2 <92% PEF 33-50% Can’t complete sentences or too breathless to talk or feed Pulse >125 (>5 years) or >140 (2 to 5 years) Respiration >30 (>5 years) or >40 (2 to 5 years) LIFE THREATENING SpO2 <92% PEF<33-50% best or predicted Hypotension Silent chest Exhaustion Cyanosis Confusion Poor respiratory effort Coma CRITERIA FOR ADMISSION β2 agonists should be given as first line treatment. Increase β2 agonist dose by two puffs every two minutes according to response up to ten puffs. Children not improved after 10puffs of β2 agonist → refer to hospital. Give further bronchodilator PRN whilst awaiting transfer Give O2 and β2 neb during the ambulance journey. Children with severe or life threatening asthma → tranfer to hospital urgently Consider intensive inpatient treatment for children with SpO2 <92% on air after initial bronchodilator treatment. The following clinical signs should be recorded: Pulse rate - increasing tachycardia generally denotes worsening asthma; a fall in heart rate in life threatening asthma is a pre-terminal event Respiratory rate and degree of breathlessness - ie too breathless to complete sentences in one breath or to feed Use of accessory muscles of respiration - best noted by palpation of neck muscles Amount of wheezing - which might become biphasic or less apparent with increasing airways
obstruction Degree of agitation and conscious level - always give calm reassurance NB Clinical signs correlate poorly with the severity of airways obstruction. Some children with acute asthma do not appear distressed. TREATMENT of acute asthma OXYGEN Children with life threatening asthma or SpO2 <94% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations. GONIST BRONCHODILATORS Inhaled β2 agonists are the first line treatment for acute asthma A pMDI + spacer is the preferred option in mild to moderate asthma. Stop LABAs when short-acting β2 needed more than 4-hourly. STEROID THERAPY Give prednisolone early in acute asthma attacks. 20mg prednisolone for ages 2 to 5 years and 30-40 mg for children >5 years.
[Those already on maintenance steroid tablets → 2 mg/kg. Max 60 mg] Repeat the dose in children who vomit and consider IV steroids 3 days is usually sufficient [but tailor to number of days needed for recovery]. Weaning unnecessary unless the course > 14 days. OTHER THERAPIES If symptoms are refractory to initial β2 agonist treatment, add ipratropium bromide (250 mcg/dose mixed with the nebulised β2 agonist solution). Repeated doses of ipratropium bromide should be given early to treat children poorly responsive to β2 agonists. Aminophylline is not recommended in children with mild to moderate acute asthma Do not give antibiotics routinely in the management of acute childhood asthma. MANAGEMENT OF ACUTE ASTHMA IN children aged UNDER 2 years The assessment in early childhood can be difficult Intermittent wheezing attacks are usually due to viral infection and the response to asthma medication is inconsistent.
The differential diagnosis of symptoms includes:- aspiration pneumonitis- pneumonia- bronchiolitis- tracheomalacia- complications of underlying conditions such as congenital anomalies and cystic fibrosisNB - Prematurity and low birth weight = risk factors for recurrent wheezing
TREATMENT of acute asthma
β 2 AGONIST BRONCHODILATORS Oral β2 agonists are not recommended for acute asthma in infants. For mild to moderate acute asthma, a pMDI+spacer is advised.
STEROID THERAPY Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital setting. Consider inhaled ipratropium bromide + inhaled β2 agonist for more severe symptoms. ACUTE ASTHMA IN PREGNANCY Give drug therapy for acute asthma as for the non-pregnant patient, including systemic steroids and magnesium sulphate. Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospital Give high flow O2 asap. Target sats 94-98%. Continuous fetal monitoring is recommended for severe acute asthma
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