AIMS OF MANAGEMENT

·       Prevent death

·       Restore clinical condition and lung function to best possible levels as soon as possible.

·       Maintain optimal function and prevent early relapse.

·       RECOGNIZE SEVERE ASTHMA- DO NOT GO BY AMOUNT OF WHEEZING!!

PR>110/min, respiratory rate >25/min, Pulsus-paradoxus>10mm of Hg, PEFR<150 or 40% ofexpected/ prior value on the same patient or <1 Sentence / Breath

·       VERY SEVERE ASTHMA

Silent chest with dyspnoea, cyanosis, exhaustion, confusion or unconsciousness Bradycardia

Features on ARTERIAL BLOOD GAS ANALYSIS

-Normal/High PaCO2 in a breathless person

-Hypoxia : PaO2<60 mm Hg irrespective of treatment with Oxygen

-Acidosis

MANAGEMENT

·       Admit, Bed resr

·       Do not sedate

·       Humildified Oxygen             - use the highest concentration

- Set a high flow rate

·       Inhaled Beta 2 agonists

Eg. Salbutamol 2.5-5 mg or Terbutaline 5-10mg

Nebulised with oxygen/ with an air compressor/ by multiple actuations of a metered dose inhaler into a spacer device (2-5 mg i.e..20-50 puffs 5 puffs at a time).

How to administer?

Nebulized Salbutamol (5mg/ml) or Terbutaline (10mg/ml) given as 1 ml in 2-3ml of Normal Saline, toalternate with Ipratropium 0.2-0.5 mg every 4 hourly.

·       Subcutaneous 1:1000 Adrenaline 0.3-0.5 ml, rpt 20-30 mins.x3 doses ECG monitoring

·       Teerbutaline S.C.0.25-0.5ml ( 1mg/ml): repeat 30 mins interval x 2-3 doses

·       If has been steroid dependent, OR FOR ALL CAUSES OF SEVERE ASTHMA give:- I.V Methylprednisolone 120- 180 mg/Q6 Hrly OR Hydrocortisone 100 mg- 200 mg, Q6 Hrly Oral Prednisole 100 mg Q 6 Hrly is as effective as injectable steroid. Patient is to be discharged on oral steroids. Do not taper until evidence of improvement noted objectively. Thereafter a 2 week tapering schedule along with inhaled steroids Slower reduction in patients with history of respiratory failure.

·       Aminophylline drip 0.5-0.9 mg/kg/h

·       Hydration

·       Antibiotics:    prulent    sputum     does    not    mean                          infection, if                suspected, macrolides/tetracyclinescan be started after a blood culture is taken.

INVESTIGATIONS:-

·       Chest Radiograph- look for Pneumothorax, Consolidation and Pulmonary oedema

·       ECG – in older patients

·       Blood leucocyte counts, renal function tests, electrolytes.

·       ABGases to look for onset of respiratory failure.

MAY REQUIRE VENTILATORY SUPPORT IF………..

1)    PEFR <33% of predicted value

2)    Cyanosis, hypoxia (PaO2<60 mm of Hg)

3)    Bradycardia/hypotension

4)    Altered sensorium

5)    High/rising Pa CO2>45 mm of Hg. ( Type II respiratory failure)

6)    Systemic acidosis