Therapeutic Handbook - GGC Prescribing

Management of Acute Severe Asthmain Adults in A&ERespiratory SystemScottish Intercollegiate Guidelines Network (SIGN). British Guidelines on the Management of Asthma. Edinburgh: SIGN; revisedJan 2012. (no. 101). Available from www.sign.ac.uk. Algorithm adapted with permission from the British Thoracic Society(# denotes minor changes).Measure Peak Expiratory Flow* and Arterial Saturations5 mins15 - 30 mins60 minsPEF > 50 - 75% bestor predictedModerate asthmaSpO 2> 92%PEF > 50-75% best orpredictedNo features of acute severeasthmaGive salbutamol (give 4puffs initially and givea further 2 puffs, every2 minutes according toresponse up to maximumof 10 puffs) preferably viaspacerClinicallystable ANDPEF > 75%PatientrecoveringANDPEF > 75%Clinicallystable ANDPEF < 75%No lifethreateningfeaturesAND PEF50 - 75%Repeat salbutamol 5 mgnebuliserGive prednisolone40 - 50 mg orallyNo signsof severeasthmaAND PEF50 - 75%PEF 33 - 50% bestor predictedAcute severe asthmaFeatures of severe asthma:PEF < 50% best orpredicted.Respiration > 25/minuteSpO 2> 92%Pulse > 110 beats/minute.Cannot complete sentence inone breath.Give salbutamol 5 mg byoxygen-driven nebuliserSigns ofsevereasthma ORPEF < 50%Lifethreateningfeatures ORPEF < 50%PEF < 33% best or predictedLife-threatening asthma:SpO 2< 92%.Silent chest; cyanosis; poor respiratoryeffort.Bradycardia; arrhythmia; hypotension.Exhaustion; confusion; coma.Obtain senior / ICU help now if any lifethreateningfeatures are present.IMMEDIATE MANAGEMENT#Oxygen to maintain SpO 294 - 98%.Give salbutamol 5 mg plus ipratropium0.5 mg via oxygen-driven nebuliserANDprednisolone oral 40 - 50 mg orhydrocortisone IV 100 mg.Measure arterial blood gasesMarkers of severity:Normal or raised PaCO 2(PaCO 2> 4.6 kPa; 35 mmHg)Severe hypoxia(PaO 2< 8 kPa; 60 mmHg)Low pH (or high H + )Patientstable ANDPEF > 50%OBSERVEMonitorSpO 2, heartrate andrespiratoryrate#Signs ofsevereasthma ORPEF < 50%• Give / repeat salbutamol 5 mg withipratropium 0.5 mg via oxygen-drivennebuliser after 15 minutes.• Consider continuous salbutamolnebuliser 5 mg/hour.• Consider IV magnesium sulphate1.2 - 2 g over 20 minutes (seek senioradvice).#• Correct fluid / electrolytes, especially K +disturbances• Chest x-ray• Repeat ABG120 minsPOTENTIAL DISCHARGESee Notes on Potential DischargeADMITPatient should be accompanied by a doctoror nurse at all times.Page 132