Acute exacerbation of asthma pathway_ENG

Acute Asthma
Flow-form for initial management of adults
presenting with acute symptoms in A&E
Disclaimer: Asthma is a clinical diagnosis based on a history of
episodes of shortness of breath, wheeze and cough. It can be
confused with bronchiectasis, heart failure, pulmonary fibrosis
and COPD. Please ensure that this is acute asthma before you
use this clinical template.
Use clinical judgement at all times
Proforma developed from the BTS/SIGN Guideline for the management of asthma
by Thomaella Tsouvaltzidou, MD-PhD.
Adapted by Spiros Markou, MD.
Patient Details
Full name
DoB
Unit Number
Complete initial observations on reverse and box 1
1. PEF (L/min)
Enter best or predicted
PEF value below
If best PEF not known:
Complete information
below:
Life-threatening features (see box 2)?
Yes
No
Severe features (see box 3)?
Yes
PEF
Age in years
Use 24h clock
Time 1st neb given
Time 1st review due
Time of 1st review
Time 2nd neb given
Time 2nd review due
Time of 2nd review
Time 3rd review due
Time of 3rd review
Consider observing for
another hour if patient
had been given
nebuliser
in ambulance
• Record time administered
Repeat observations after
15-20min (record time due;
review sooner if getting worse)
• Salbutamol 5mg neb & Prednisolone 40-50mg PO
• Record when administered
Repeat obs after 30min
(record when review due)
Normal obs and PEF > 75%?
Repeat obs after 1h
(record when review due)
Severe features?
(revisit box 3)
Discharge bundle
(see reverse)
This assessment was carried out by:
Signature
Yes
Yes
No
• Salbutamol via spacer
(give one puff at a time; according to
response, give another puff every 60
seconds up to maximum of 10 puffs)
Life-threatening features (revisit box 2)?
No
PEF < 50%?
No
Normal obs and PEF > 75%?
Severe features
(revisit box 3)?
No
No
Is discharge safe?
(see box 6 on reverse)
Yes
No
No
• Salbutamol 5mg by oxygen -
driven nebuliser within 5 minutes
• Record time administered
Yes
Yes
Νο
Yes
No
Yes
Admit
Patient accompanied by a nurse or
doctor at all times
Admit to critical care
Time of decision to
admit
Manage in resuscitation room
• O2 to maintain SpO2 94 – 98%
• ABCDE approach
• Call ED senior and ITU NOW
• Salbutamol 5mg with Ipratropium 0.5mg
via oxygen-driven nebulizer
• Prednisolone 40-50mg PO or
Hydrocortisone 100mg IV instead
• ABG (see box 4)
Time of decision to
admit
• 5mg salbutamol nebuliser every 15min as
required via oxygen
• 500mcg atrovent nebuliser 4-6 hourly
• Consider, if there is inadequate response,
continuous salbutamol nebulizer 5-10 mg/hr
• No improvement; Consider magnesium
sulphate 2g IV (in 100ml saline) over
20mins
• No improvement; Consider IV
aminophylline infusion (see Pharmacy
guidelines)
• Correct fluid/electrolytes,
especially K+ disturbances
• Obtain CXR
• Repeat ABG (if patient getting worse or
life-threatening/near fatal features initially)
• Requires senior review
Needs critical care (box 5)?
Yes
Date
75%
50%
33%
men
women
2. Life-threatening features?
SpO 2 <92%
Silent chest
Cyanosis
Arrhythmia
Hypotension
Poor respiratory
effort
Exhaustion
Altered consciousness
PEF <33% of
best or predicted
No, as none of the above
3. Severe features?
Respiratory rate ≥25/min
Heart rate ≥110/min
Cannot complete sentences in 1 breath
PEF 33-50% of best or predicted
Yes, as at least one of the above
No, as none of the above
PaO2 <
PaCO2
Height in cm
Predictef PEF
Yes, as at least one of the below
5. Needs critical care bed?
Yes, as at least one of the below
Mechanical ventilation instituted
Deteriorating PEF
Persisting or worsening hypoxia
Hypercapnia on repeat ABG
Exhaustion or altered consciousness
Poor respiratory effort
Respiratory arrest
On arrival
2 nd review
3 rd review
4. Interpretation of ABG
Perform ABG according to flow chart
if severe or life-threatening features
Life - threatening
Life - threatening
PaCO2 > Near fatal
Low pH
Near fatal
Print name Position Time completed

Observations
Time
1.
2.
PEF
3.
SpO 2
Resp
rate
Heart
rate
BP
T
Time
FiO 2
pH
PaCO 2
PaO 2
HCO 3
BE
SaO 2
maximum 1.
2.
3.
ABG
maximum
Perform ONLY if SpO 2 on air <92%
or if other life-threatening features
1.
2.
3.
maximum
1.
2.
3.
maximum
1.
2.
3.
maximum
1.
2.
3.
maximum
Usual asthma medication
State route if not by mouth, e.g. INHAL
6. Will discharge be safe?
No, as at least one of the below
Pulse, BP, RR, or SaO2 abnormal
Significant remaining symptoms
Concerns about compliance
Living alone / socially isolated
Psychological problems
Physical disability
Learning difficulties
Previous near-fatal or brittle asthma
Exacerbation despite adequate PO steroids
2nd ED visit for asthma attack within 24h
Discharge after 22:00
Pregnancy
Discharge bundle
• Prednisolone TTO 40mg PO for 7 days if INITIAL PEF was < 50% or if <75%
and not taking inhaled steroid
• Ensure supply of usual reliever and preventer
• Patient should see GP within 2 working days
• Advise patients to know their best PEFR
• Discharge with PEFR meter
• Advise smoking cessation where appropriate
• Nurses to ascertain inhaler technique is correct
Yes, as none of the above