ACUTE ASTHMA

Asthma attack is a substantial worsening of asthma symptoms. The severity and duration of attacks are variable
and unpredictable. Most attacks are triggered by viral infections. Assess severity using the following table.

Not all features may be present. If the patient says they feel very unwell, listen to them!

Assessment of Severity
CHILDREN BELOW 12 YEARS ADULTS AND CHILDREN
>12 YRS
Mild to moderate
  • Able to talk in sentences
  • Peak flow is ≥ 50% of
    predicted or best
  • Pulse (beats/minute)
    Child > 5 years: ≤ 125 bpm
    Child < 5 years: ≤ 140 bpm
  • Respiratory rate
    Child > 5 years: ≤ 30
    Child < 5 years: ≤ 40
  • SpO2 ≥ 92%
  • Able to talk
  • Pulse < 110 bpm
  • Respiratory rate < 25
  • Peak flow >50% of
    predicted or best
  • SpO2 ≥ 92%
Severe
  • Cannot complete sentences
    in one breath or, too
    breathless to talk or feed
  • Peak flow < 50% of
    predicted or best
  • Pulse (beats/minute)
    Child > 5 years: > 125 bpm
    Child <5 years: > 140 bpm
  • Respiratory rate
    Child > 5 years: > 30
    Child < 5 years: >40
  • Use of accessory muscles
    for breathing (young
    children)
  • SpO2 < 92%
  • Cannot complete
    sentences in one breath
  • Pulse ≥ 110 bpm
  • Respiratory rate >25
  • Peak flow <50% of
    predicted or best
  • SpO2 ≥ 92%
Life threatening (Adults and Children)
  • Silent chest, feeble respiratory effort, cyanosis
  • Hypotension, bradycardia or exhaustion, agitation
  • Reduced level of consciousness
  • Peak flow < 33% of predicted or best
  • Arterial oxygen saturation < 92%

Management of asthma attacks

Mild to moderate

  • Treat as an out-patient
  • Reassure patient; place him in a ½ sitting position
  • Give salbutamol
    • Inhaler 2-10 puffs via a large volume spacer
    • Or 5 mg (2.5 mg in children) nebulisation
    • Repeat every 20-30 min if necessary
  • Prednisolone 50 mg (1 mg/kg for children)

Monitor response for 30-60 min. If not improving or relapse in 3-4 hours

  • Refer to higher level

If improving, send home with

  • Prednisolone 50 mg (1 mg/kg for children) once a day for 5 days (3 days for children)
  • Institute or step up chronic treatment (see next section)
  • Instruct the patients on self treatment and when to come back
  • Review in 48 hours
    • Do not give routine antibiotics unless there are clear signs of bacterial infection

Severe

  • Admit patient; place him in a ½ sitting position
  • Give high flow oxygen continuously, at least 5 litres/minute, to maintain the SpO2 ≥ 94% if
    available
  • Give salbutamol
    • Inhaler 2-10 puffs via a large volume spacer
    • Or 5 mg (2.5 mg in children) nebulisation
    • Repeat every 20-30 min if necessary during the 1st hour
  • Prednisolone 50 mg (1 mg/kg for children) or
  • Or hydrocortisone 100 mg (children 4 mg/kg max 100 mg) IV every 6 hours until patient can
    take oral prednisolone
  • Monitor response after nebulisation

If response poor

  • Ipratropium bromide nebuliser 500 micrograms (250 microgram in children below 12) every 20-
    30 min for the first 2 hours then every 4-6 hours
  • Or aminophylline 250 mg slow IV bolus (child 5 mg/kg) if patient is not taking an oral
    theophylline

Alternatively, if symptoms have improved, respiration and pulse settling, and peak flow >50%

  • Step up the usual treatment
  • And continue with prednisolone to complete
    5 days of treatment
  • Review within 24 hours
    • Monitor symptoms and peak flow
    • Arrange self-management plan

Life threatening

  • Arrange for immediate hospital referral and admission

First aid

  • Admit patient; place him in a ½ sitting position
  • Give high flow oxygen continuously, at least 5 litres/minute, to maintain the SpO2 ≥ 94% if
    available
  • Give salbutamol
    • Inhaler 2-10 puffs via a large volume spacer
    • Or 5 mg (2.5 mg in children) nebulisation
    • Repeat every 20 min for 1 hour
  • Hydrocortisone 100 mg (children 4 mg/kg max 100 mg) IV stat or prednisolone 50 mg (1 mg/kg
    for children)
  • Ipratropium bromide nebuliser 500 micrograms (250 microgram in children below 12) every 20-
    30 minutes for the first 2 hours then every 4-6 hours
  • Monitor response for 15-30 minutes

If response is poor

  • Aminophylline 250 mg slow IV bolus (child 5 mg/kg) if patient is not taking an oral
    theophylline

Note

  • The use of aminophylline and theophylline in the management of asthma exacerbations is discouraged
    because of their poor efficacy and poor safety profile