Acute Asthma Exacerbation¶
Stacy Blank
Presentation¶
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History of asthma or a history concerning for asthma
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Progressive worsening of symptoms: dyspnea, chest tightness, wheezing, and cough
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Physical exam with wheezing, poor air movement, tachypnea, increased work of breathing, hypoxemia
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Often use of peak flows is cited in the literature (PEF \<200 L/min or PEF \<50% predicted indicates severe obstruction, PEF \<70% predicted indicates moderate exacerbation)
- May be useful although often does not change management acutely
Evaluation¶
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Generally aimed at ruling out causes for exacerbation and other diagnoses; these are not required but should be considered in pts being admitted for inpatient management:
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EKG, trop, BNP, D-dimer to assess for cardiac cause (ACS, CHF, PE)
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CXR to rule out underlying process (PNA, PTX, atelectasis)
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ABG/VBG not routinely needed unless ill-appearing, tachypneic, or lethargic/altered
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Dangerous signs and possible ICU if:
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Tachypnea >30 and/or significantly increased work-of-breathing
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Hypercapnia or even normocapnia (these pts are usually hyperventilating; a normal CO2 in a severe asthma exacerbation could indicate impending respiratory failure)
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Altered mental status
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Requiring continuous nebulizers
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Management¶
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Continuous pulse ox with oxygen therapy to maintain O2 >92 %
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Continuous albuterol nebulizer or Duonebs until able to space to q1h>>q2h, etc
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Steroids with dosing based on severity of illness (there is no data behind exact dosing of steroids).
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Start with IV methylpred 125mg q6h in severe exacerbation/ICU patients
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Can start with oral prednisone 60mg q12h in less severe exacerbation/floor pts
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Plan to transition from IV to PO and then likely to send pt home to finish course of 40-60 mg pred daily for 5-7 days.
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IV mag sulfate 4g over 20 minutes for severe exacerbation
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Keep pt NPO until off continuous nebs/respiratory effort is improved. Consider IV fluids with pt’s comorbidities (HFrEF, renal disease) vs. increased insensible losses with resp effort
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If pt is not responding to therapies, has worsening respiratory status, or blood gas concerning for respiratory acidosis needs ICU care for BiPAP vs mechanical ventilation
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Note: We do not start empiric antibiotics unless there is concern for bacterial infection
Prior to discharge:¶
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Ensure that pt is on appropriate controller medications (see outpatient management)
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Evaluate for causes of acute exacerbation to prevent future events (noncompliance, resp viruses, allergies, exposures, etc.)