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Hospital Based Care of Asthma

Management of Asthma Attacks :

Hospital-Based Care

Initial Assessment:

History, Physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate) and Investigations (PEF or FEV1, Oxygen saturation SaO2, arterial blood gas analysis and other tests)

Initial Treatment:

  • Inhaled short-acting b2-agonist, usually by nebulization, one dose every 20 minutes for 1 hour
  • Oxygen to achieve O2 saturation >90% (95% in children)
  • Systemic corticosteroids
  • Sedation is contraindicated in the treatment of attacks. PFT, PEFR, SaO2 and other tests as needed

Repeat Assessment:

PET,PERF,SaO2 and other tests as needed

Moderate episode

Severe episode
 On assessment
• PEFR 50-80% predicted/personal best
 
• Physical exam: moderate symptoms, accessory muscle use
 

 
 On assessment
• PEFR - < 50% of predicted value/personal best
• Physical exam: severe symptoms at rest, chest retraction
• High-risk patient
• No improvement after initial treatment

 
Treatment
• Inhaled b2-agonist every 60 minutes
• Consider corticosteroids
• Continue treatment 1-3 hours, provided there is improvement
 

 
Treatment
• Inhaled b2-agonist, hourly or continuous + inhaled anticholinergic
• Oxygen - 40% (5 Lit/min)
• Systemic corticosteroid
• Consider subcutaneous, intramuscular, or intravenous b2-agonist

 
Good Response Incomplete Response Poor Response
  Response within 1-2 Hours Within 1 hour
     
On assessment
• Response sustained 60 minutes after last treatment
• Physical exam: normal
• PEFR >70%
• No distress
• O2 saturation >90% (95% children)

 
On assessment
• High risk patient
• Physical exam: mild to moderate symptoms
• PEFR >50% but
• O2 saturation not improving
 

 
On assessment
• High risk patient
• Physical exam: symptoms severe, drowsiness, confusion
• PEFR <50%
• PCO2 >45 mm of Hg
• PO2 <60 mm of Hg
• O2 saturation <90%

 
     
Discharge Home
• Continue treatment with inhaled β2 agonist
• Consider , in most cases, corticosteroid tablets or syrup.
• Patient education: Take medicine correctly.
•Review action plan.
• Close medical follow-up

 
Admit to hospital
• Inhaled β2 agonist ± inhaled anticholenergic
• Systemic cortic- steroid
• Oxygen
• Consider intravenous Aminophylline.
• Monitor PERF,O2 saturation,pule

 
 Admit to ICU  
• Inhaled b2-agonist + anticholinergic     
• Inhaled corticosteroid
•Consider sub-cutaneous,  intra-muscular, or intra-venous b2-agonists 
• Oxygen 
• Consider intravenous aminophylline
• Possible intubation and mechanical ventilation

 

 

See Also:

Home Management of Asthma

Step Care Management of Asthma

Emergency Management of Asthma

Concomitant Disease management of Asthma

Pitfalls of Asthma Management

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  • Misconception about Asthma

    There are some common concerns about Asthma prevailing in the society. In majority of cases, these are misconceptions or baseless fears. For optimum control of asthma, these points should be dealt with proper care. Otherwise the management plan may go in vain. It the physicians responsibility to eradicate such worries, if present, from the patient’s mind. Some common concerns and suggested clinicians responses are listed below. Model answers to some frequently asked questions (FAQs) are also given. These will help the physician to deal with such situations more confidently.

  • Asthma Control Plan

    Name of Patient ........................................ Prepared by Dr. .........................................

    This plan will help a patient control his asthma and know what to do if he has an asthma episode. Keeping a patient’s asthma under control will help to :

    • Be active without having asthma symptoms. This includes being active in exercise and sports.
    • Sleep through the night without having asthma symptoms.
    • Prevent asthma episodes (attacks).
    • Have the best possible peak flow number - lungs that work well.
  • Use of Peak Flow Meter

    A peak flow meter is a device that measures how well air moves out of a patient's lungs. During an asthma episode, the airways of the lungs begin to narrow slowly. The peak flow meter can be used to find out if there is narrowing in the airways, hours - even days - before the patient has any symptoms of asthma. By taking the medicine early (before symptoms), your patient may be able to stop the episode quickly and avoid a serious episode of asthma. So its role in preventing severe asthma attack is very important.

    The peak flow meter can also be used to help you:

  • Use and Care of Nebulizer

    A nebulizer is a device driven by a compressed air machine. It allows your patient to take asthma medicine in the form of a mist (wet aerosol). It consists of a cup, a mouthpiece attached to a T-shaped part or a mask, and thin plastic tubing to connect to the compressed air machine. It is used mostly by three types of patients:

    • Young children under age 5.
    • Patients who have problems using metered dose inhalers.
    • Patients with severe asthma

    A nebulizer helps make sure that patients get the required amount of medicine

  • Investigation of Asthma

    Why we investigate asthma patients?

    • For classification and assessment of severity
    • For diagnosis of concomitant illness
    • For exclusion of other causes of cough, wheeze dyspnoea or chest tightness

    What are the investigations for asthma?

    We should do four basic investigations of all patients.

    1. Blood for TC, DC, ESR,
    Hb% and : 

  • Home Management of Asthma

    Why management at home ?

    Since asthma is a chronic disease, it can be and should be managed at home up to a certain level. If home management plan is applied intelligently and skillfully, most asthmatics can lead symptom free normal life, avoid hospitalization thereby cutting down the financial expenditure significantly. All patients of asthma, except those with acute exacerbation, should be treated at home.

    What are the components of home management plan ?

  • Prevention of Asthma

    How to prevent asthma?

    Development of asthma has two distinct bases: Hereditary and Environmental. For the prevention of the development of asthma we should manipulate these two factors. Regarding hereditary factors, we have yet nothing to do practically. Genetic engineering is a future probability. What we can do is to manipulate the environmental factors. Effort should be concentrated on primary prevention of asthma.

    What is primary prevention?