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Asthma - Management
Children and adults who need admission to hospital: How do I manage?
- Organize urgent hospital admission.
- Give high-flow oxygen (40–60%) with a tight-fitting mask.
- If pulse oximetry is available, adjust the flow rate to maintain an oxygen saturation of 94–98%.
- Lack of pulse oximetry should not prevent the use of oxygen.
- Give a short-acting inhaled beta2-agonist:
- For life-threatening asthma, give via a nebulizer, if available. Repeat every 20–30 minutes according to clinical response.
- Ideally, nebulizers should be oxygen driven (flow rate of 6 L/min usually needed) to avoid worsening hypoxia.
- For severe attacks, give via a nebulizer (preferred for children if available) or use a pressurized metered-dose inhaler with a large-volume spacer.
- For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
- For a child, give 2 puffs every 2 minutes according to response, up to 10 puffs.
- Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response.
- For moderate attacks, use a pressurized metered-dose inhaler with a large-volume spacer.
- Give the first dose of a course of prednisolone.
- Monitor peak expiratory flow rate (if the person can comply) and oxygen saturation (if available) to assess response to treatment.
- If the person does not respond to a beta2-agonist, consider continuous nebulized beta2-agonists or addition of ipratropium bromide (via a nebulizer). However, aim to get the person to hospital urgently.
Clarification / Additional information
- High-flow oxygen: there is very little risk of causing high carbon dioxide retention with high-flow oxygen in people with asthma (unlike chronic obstructive pulmonary disease). Aim to keep the person's oxygen saturation between 94% and 98% (measured by pulse oximetry) by giving 6 L/min or a 40–60% flow rate whilst en route to hospital.
- Inhaled short-acting beta2-agonist:
- In life-threatening asthma, the agent should be delivered ideally by a high-flow oxygen-driven nebulizer. If an oxygen-driven nebulizer is unavailable, deliver by air-driven nebulizer (although be alert that oxygen desaturation may occur). Continuous nebulization is preferred in severe obstruction, but not all nebulizer systems can do this.
- In severe asthma, the agent should be delivered by high-flow oxygen-driven nebulizer (preferred for children) or pressurized metered-dose inhaler with a large-volume spacer. If multiple puffs are needed, they should be given as single puffs into the spacer and inhaled with five tidal breaths after each, repeating until the prescribed number of puffs has been given. A short pause between puffs may be necessary to avoid hyperventilation.
- In moderate asthma, the agent should be delivered by pressurized metered-dose inhaler with a large volume spacer.
- Oral corticosteroids should be given as soon as possible. Oral administration is as effective as the intravenous route, provided that medication can be swallowed. If medication cannot be swallowed, consider intramuscular methylprednisolone 160 mg as an alternative to a course of oral prednisolone.
Table 1. Doses of nebulized bronchodilators used in acute severe exacerbation of asthma.
Drug | 2–5 years old | 6–12 years old (higher dose for more severe) | > 12 years old |
|---|
Salbutamol | 2.5 mg | 2.5–5 mg | 5 mg |
Terbutaline | 5 mg | 5–10 mg | 10 mg |
Ipratropium (every 4 to 6 hours) | 250 micrograms | 250 micrograms | 500 micrograms |
When using intermittent nebulization, repeat beta 2-agonist administration every 10–20 minutes. When using a continuous nebulizer, give the tabulated doses of beta 2-agonist over 30–60 minutes [SIGN and BTS, 2009]. |
Basis for recommendation
- These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline. Because most of the studies were small, had diverse designs, and involved people in secondary care settings, it is difficult to generalize findings to primary care [SIGN and BTS, 2009]:
- If a person does not respond to initial treatment, the main aim is to get the person to hospital urgently for further support, such as intravenous medication and possibly ventilation.
- Oxygen: people with a severe asthma attack are hypoxaemic; this should be corrected urgently with high-flow oxygen. Limited evidence (one randomized controlled trial, n = 74 adults) shows that 100% oxygen may worsen carbon dioxide retention, and improve peak expiratory flow rate to a lesser extent, compared with 28% oxygen [Rodolfo et al, 2005].
- Inhaled beta2-agonists quickly correct bronchospasm with very few adverse effects. The evidence suggests salbutamol and terbutaline do not differ in efficacy. Delivery via a pressurized metered-dosed inhaler with a large-volume spacer appears to be as effective as delivery via a nebulizer. Continuous nebulization is at least as effective as bolus nebulization in relieving acute asthma. However, continuous nebulization appears to be more effective than bolus nebulization in asthma that is severe or unresponsive to treatment [SIGN and BTS, 2009].
- Inhaled ipratropium bromide: the evidence suggests that combining nebulized ipratropium bromide with nebulized beta2-agonists in an acute attack may lead to a faster recovery and shorter duration of admission [SIGN and BTS, 2009].
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