Mount Carmel Health Partners Clinical Guidelines Asthma

Asthma Clinical Guideline
Definition: Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, reversible
airflow obstruction, bronchial hyper-responsiveness, and an underlying inflammation. The interaction of these features of asthma determines the
clinical manifestations and severity of asthma and the response to treatment.
Management of Acute Asthma Exacerbation
Quick Guide to
Asthma
Spirometry is
recommended to
establish the diagnosis
of asthma. A stepwise
approach to
pharmacologic
treatment to achieve
and maintain control
of asthma should take
into account the safety
of treatment, potential
for adverse effects,
and the cost of
treatment required to
achieve control.
Initial history (including detailed asthma history) and physical examination
• Vital signs, including oxygen saturation, heart rate, and respiratory rate
• Consider PEF or ETCO2 monitoring
Evaluation
Treatment
Mild
• Mild end-expiratory wheezing only
• Oxygenation >90%
• Minimal to no use of accessory
muscles
• Vital signs within normal limits
• Speaking in full sentences
• FEV1 or PEF >70% predicted Moderate
• Oxygenation >90%
• Accessory muscle usage but still
able to speak
• Elevated respiratory rate
• Elevated heart rate
• FEV1 or PEF 40%-69% predicted
• Give inhaled SABA by nebulizer or
MDI + spacer
• Administer first dose of oral
steroids • High dose SABA + ipratropium by
nebulizer or MDI+ spacer every
20 min. for first hour
• Administer first dose of oral
steroids immediately
No
Yes
Continue to
“moderate” path
• Consider initiating ICS or adjusting
current dose as indicated
• Continue treatment with inhaled
SABA, 2-6 puffs every 3-4 hours, as
needed
• Discharge home with:
- Continued oral steroid therapy for 5
days
- Clear and simple return precautions
- Reliable follow-up
- Instruction on proper technique
for using inhaled medication with
spacer
• High dose SABA + ipratropium
by nebulizer or MDI+ spacer
every 20 min. for first hour
• Consider continuous nebulized
albuterol therapy if no clinical
improvement with intermittent
therapy
• Administer first dose of oral
steroids immediately
• Consider magnesium IV and
adjunctive therapies
Reassess.
Is there
improvement?
Reassess.
Is there
improvement?
Yes
Severe
• Oxygenation <90%
• Significant accessory muscle
usage
• Vital signs with significant
stress
• Altered mental status
• FEV1 or PEF <40% predicted
• Continue current therapy
• Make admit vs. discharge decision
<4 hours from arrival
• If stable in <4 hours and ready for
discharge, refer to “mild” path for
discharge planning
• If worsening, move to “severe” path
Reassess.
Is there
improvement?
No
Yes
No
Admit to hospital
• Admit to hospital
• If worsening,
move to “severe”
path
Evidence of impending or actual
respiratory arrest:
• Prepare for intubation without delay
• Continue inhaled SABA while
preparing for intubation
• Recommended RSI medications:
Ketamine 2 mg/kg + rocuronium or
Succinylcholine
• If not requiring intubation at this
time, consider starting NIPPV
• If not improved, consider admission
to hospital ICU
Abbreviations: ETCO₂, end-tidal carbon dioxide; ICS, inhaled corticosteroids; IV, intravenous; MDI, metered-dose inhaler; NIPPV, noninvasive positive-pressure
ventilation; PEF, peak expiratory flow; RSI, rapid sequence intubation; SABA, short-acting beta agonist; FEV1, forced expiratory volume in 1 second.
October 2017