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an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators

Treatment goals
1. reverse airway obstruction rapidly aggressive use of beta2-agonist agents early use of corticosteroids 2. correct hypoxemia monitoring SpO2 administering supplemental O2 3. prevent or treat complications e.g pneumothorax and respiratory arrest

Clinical findings suggestive of severe disease:

use of accessory muscles of inspiration diaphoresis central cyanosis silent chest inability to lie supine due to breathlessness RR>30 breaths/min, HR>120 beats/min Pulsus paradoxus Marked hypoxemia [PaO2] <60 mmHg, [SpO2] <90 %

Hypercarbia [PaCO2]>45 mmHg

Pharmacological Treatment
1. Inhaled short-acting beta agonist - mainstay of bronchodilator treatment - Albuterol (Salbutamol, Ventolin) 2.5-5 mg continuous flow nebulization every 20 minutes for three doses Or continuous nebulization, administering 10- 15 mg over one hour Then 2.5-10 mg every 1-4 hours as needed.

2. Inhaled anticholinergics - reserved for patients: with severe airflow obstruction failing to improve despite repeated administration of inhaled beta agonists with chronic obstructive pulmonary disease with an asthmatic component whose asthma has been triggered by beta-blocker therapy - ipratropium nebulization 500 mcg nebulization every 20 minutes for three doses

3. Systemic glucocorticoids - reduce airway edema, cellular infiltration, and mucus hypersecretion - onset of action not clinically apparent until as long as six hours after administration, but early administration helps to minimize the delay in anticipated improvement - options include: prednisone 40 to 60 mg PO stat or methylprednisolone 60 to 125 mg IV or dexamethasone 6 to 10 mg IV or hydrocortisone 150 to 200 mg IV

4. Magnesium sulphate - has bronchodilator activity - suggested for life-threatening exacerbations and exacerbations that remain severe after 1 hour of intensive bronchodilator therapy - contraindicated in the presence of renal insufficiency 2 g IV infused over 20 min in 0.9% NaCl

Ineffective therapies Methylxanthines intravenous theophylline or aminophylline, in addition to beta-agonists, is not recommended in the treatment of acute asthma exacerbations are not as potent as the beta agonists when used alone for the treatment of asthma, and provide no further bronchodilation beyond that achieved with inhaled beta agonists alone

Inhaled Corticosteroids use of inhaled glucocorticoids instead of oral or intravenous preparations in the emergency department setting have been shown to be relatively ineffective

Empiric antibiotics most respiratory infections that trigger an exacerbation of asthma are viral rather than bacterial

1. ABGs - attention focuses primarily on the Paco2 with a normal value in a breathless asthmatic being a warning sign of impending hypoventilation - hypercarbia and marked hypoxemia indicate a life-threatening attack and probable need for transfer to ICU 2. CXR - not routinely needed - reserved for those who do not respond to initial treatment OR in whom an alternative diagnosis such as pneumothorax or pneumonia is suspected

Mechanical Ventilation
Goal to maintain adequate oxygenation and ventilation while minimizing elevated airway pressures

Indications decision to initiate mechanical ventilation should be based on clinical judgment that considers the entire clinical situation primary indication for mechanical ventilation is acute respiratory failure (ie, insufficient oxygenation and/or alveolar ventilation) slowing of the respiratory rate, depressed mental status, inability to maintain respiratory effort

Intubation approached cautiously because manipulation of the airway can cause increased airflow obstruction due to bronchial hyperresponsiveness rapid sequence intubation is preferred a large-bore (8.0 mm) endotracheal tube is recommended

Ventilator settings

Respiratory rate 10 to 14 breaths/min Tidal volume less than 8 mL/kg Minute ventilation less than 115 mL/kg Inspiratory flow of 80 to 100 L/min Inspiratory : Expiratory ratio 1:3

PEEP 0 cm H2O Inspiratory Pplat less <30 cm H2O and an intrinsic PEEP <10 to 15 cm H2O

Adjustments that may help decrease air trapping:

Increasing the inspiratory flow will shorten the inspiratory time, increase the expiratory time, and allow the patient more time to exhale Decreasing the tidal volume causes less lung inflation and gives the patient a smaller volume to exhale before the next breath Decreasing the respiratory rate increases the expiratory time and allows the patient more time to exhale