Management of asthma in the hospital

Acute Asthma

Adult (including pregnant) Children

Severe Life-threatening Over 2 years Under 2 years

Severe Attack Life-threatening attack

- PEF <50% of predicted or best - PEF <33% of predicted or best
- RR > 25/min - Silent chest, cyanosis, feeble respiratory effort
- Pulse rate > 110 bpm - Bradycardia or hypotension
- Unable to complete sentences - Exhaustion, confusion or coma
- ABG:Normal/high PaCO2 >5kPa, PaO2 <8 kPa,low pH

Immediate Rx - Sit patient up and give high dose O2 :100% via non-rebreathing bag
- Salbutamol 5mg (or terbutaline 10mg) plus ipratropium bromide 0.5 mg nebulised with O2
- Hydrocortisone 100mg IV / prednisolone 30 mg PO or both if very ill
- CXR to exclude pneumothorax
Life threatening  Inform ICU, and seniors
 Add MgSO4 1.2-2g IV over 20 min
 Salbutamol nebs every 15 mins, or 10mg continuously per hour
Improve – 40-60% O2 Not improved after 15-30min
- Prednisolone 30-60mg/24h PO - Continue 100% O2 and steroids. Hydrocortisone
- Salbutamol nebs every 4 hr 100mg IV or prednisolone 30mg PO if not already
given.
Monitor effects of Rx; - Salbutamol nebs every 15mins/10mg continuous per
- Repeat PEF 15-30 min after initiate Rx hour
- Maintain SaO2 > 92%. Pregnant >95% - Continue ipratropium 0.5mg every 4-6h
- Check ABGs
- Record PEF pre- and post-β agonist in hosp. at Still not improving (discuss with seniors and ICU)
least 4x - Repeat salbutamol nebs every 15 min
KEY : - MgSO4 1.2-2g IV over 20 min, unless already given
1. Oxygen 2. Bronchodilators - Theophylline load 5mg/kg IV over 20 min 
3. Steroids 4. Other therapies 500µg/mg/h Or
- Salbutamol IV (3-20µg/min). may require IPPV.

> 2 years < 2 years

- Unable to complete sentence in one breath; too breathless to talk or feed
- poor vitals : tachycardia, high RR.
- more agitated and decline in conscious levels. More wheezing.
- Oxygen if sats <92%. - pMDI and spacer most optimum to deliver β2-agonist
- Inhaled β-agonist + adjunct (bolus salbutamol IV : - 10mg soluble prednisolone up to 3 days
15µg/kg - consider inhaled ipratropium + β2 agonist (severe)
- Prednisolone 20mg (2-5 yrs), 30-40mg >5 yrs
- Ipratropium bromide nebs (250µg/dose) mixed with
β2-agonist solution
- Aminophylline only in HDU cases.
- Routine Abx not recommended.
In Pregnancy
1. Continuous fetal monitoring
2. Attack during labour(rare)
- anaesthesia? Regional blockade, continue usual meds
- if receiving prednisolone >7.5mg per day for >2 weeks prior to delivery should receive
hydrocortisone 100mg 6-8 hourly during labour
- use PG F2α with caution : bronchoconstriction

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