The aim is to reduce the burden of asthma, both for patients who suffer from this disease and for health-care systems. Years lived with disability YLDs for sequelae of diseases and injuries a systematic analysis for the Global Burden of Disease Study Lancet ; : — European Respiratory Society The European lung white book. Global and regional mortality from causes of death for 20 age groups in and a systematic analysis for the Global Burden of Disease Study The revised GINA strategy report: opportunities for change.
Curr Opin Pulm Med ; 21 : 1—7. Eur Respir J ; 39 : — Global Initiative for Asthma. Global strategy for asthma management and prevention. Updated Global strategy for asthma management and prevention: online appendix. Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study. Prim Care Respir J ; 21 : — Development of the Asthma Control Test: a survey for assessing asthma control. J Allergy Clin Immunol ; : 59— Development and validation of a questionnaire to measure asthma control. Eur Respir J ; 14 : — Eur Respir J ; 43 : — Severe asthma in adults: what are the important questions?
J Allergy Clin Immunol ; : — User error with Diskus and Turbuhaler by asthma patients and pharmacists in Jordan and Australia. Respir Care ; 56 : — Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists.
Knowing the differences between COPD and asthma is vital to good practice
Overdiagnosis of asthma in obese and nonobese adults. CMAJ ; : — Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study.
Fam Pract ; 25 : 86— How often is the diagnosis bronchial asthma correct? Fam Pract ; 16 : — Accuracy of a first diagnosis of asthma in primary health care. Fam Pract ; 19 : — Early intervention with budesonide in mild persistent asthma: a randomised, double-blind trial.
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Benefits of low-dose inhaled fluticasone on airway response and inflammation in mild asthma. Respir Med ; : — Does continuous use of inhaled corticosteroids improve outcomes in mild asthma? A double-blind randomised controlled trial. Prim Care Respir J ; 17 : 39— Patient and physician asthma deterioration terminology: results from the Asthma Insight and Management survey.
Allergy Asthma Proc ; 33 : 47— A qualitative study of patient language about worsening asthma. Med J Aust ; : — It should be given as a single-dose infusion and may be repeated once, but not sooner than 12 hours. Nebulised magnesium sulphate should be administered at a dose of - 1 mg together with a SABA, but this is far less effective than intravenous administration. Intravenous aminophylline is the only theophylline recommended in acute asthma.
It is a theophylline with ethylenediamine to render it water-soluble. It is thought to act by phosphodiesterase inhibition and non-selective adenosine receptor antagonism. Selective phosphodiesterase inhibitors such as roflumilast are not registered for use in acute asthma. The properties of aminophylline are:. Only recommended when there is no response to SABAs, ipratropium bromide and magnesium sulphate i.
This should be increased by one-third 0. Blood levels should be monitored daily and the dose adjusted accordingly. It may, however, be used if no intravenous access is immediately available and the patient is moribund. Subcutaneous adrenaline 0.
Special care must be taken in the elderly and those with or at risk of cardiovascular disease. Glucocorticosteroids are recommended routinely for the treatment of acute asthma evidence A. The key properties of CS are:. There is insufficient evidence that the inhaled route can replace systemic CS in acute asthma. CS are usually given in the form of oral prednisone 0. Intravenous CS hydrocortisone - mg or equivalent, 6-hourly can be used if the patient is vomiting or unable to take oral medication.
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Highly potent CS such as dexamethasone and betamethasone are not recommended in acute asthma. S tandard-dose inhaled CS should be started during the admission and continued on discharge as part of chronic therapy [,] evidence A. Supplemental oxygen must be administered whenever possible in patients with moderate to severe acute asthma. Also, nebulised bronchodilators should whenever possible be delivered by oxygen-driven nebulisers.
Most patients with moderate to severe acute asthma have hypoxia that is readily corrected by supplemental oxygen. Lack of pulse oximetry should not prevent oxygen being administered. The flow rates are determined by the recommendations on the specific facemasks. Intravenous fluids are administered in acute severe asthma based on the clinical setting, taking into account maintenance and replacement requirements and the need for calorie intake in patients unable to take oral fluids.
There are no formal studies of routine fluid administration in acute asthma. Heliox is a mixture of helium and oxygen. It has the advantage of reducing airway resistance and has been used in desperate circumstances in non-responsive severe acute asthma. Leukotriene modifiers are not currently recommended in acute asthma. Anti histamines have no role in acute asthma. Mucolytics , given either systemically or by nebulisation, are contraindicated as they may worsen cough and bronchospasm and only serve to complicate the treatment regimen.
Sedatives should be strictly avoided during asthma attacks because of their respiratory depressant effect. Their use in non-intubated patients has been associated with asthma deaths. Physiotherapy may provoke bronchospasm and worsen the attack. It is only indicated if there is lobar collapse that persists despite initial bronchodilator and CS therapy.
Measurements of pulse rate, respiratory rate, PEF or FEV 1 and arterial oxygen saturation should be made at 15 - minute intervals until a clear response to treatment is achieved. ICU management of acute asthma is described below.
Once a satisfactory response is obtained the patient may:. Ongoing monitoring of baseline parameters such as clinical status, PEF, SpO 2 , arterial blood gas, etc. Table 5. The induction agent is a matter of personal preference. Benzodiazepines cause respiratory depression, so the initial attempt must be rapidly successful. Etomidate 0. The latter has sedative, analgesic and anaesthetic properties without respiratory depression, but increases bronchial secretions and causes hallucinations.
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Succinylcholine remains the agent of choice for acute paralysis despite histamine release. The pressure required to deliver an adequate TV may be quite high when airflow resistance is very high. Considerable expertise is required to manage ventilation in these patients. Auto-PEEP causes hyperinflation and haemodynamic compromise and should be minimised. Auto-PEEP is influenced by respiratory rate, TV, and the inspiratory-to-expiratory time ratio and inspiratory flow rates. Ventilator graphics make the monitoring of PEEP much simpler.
If the pH is less than this, increase the respiratory rate cautiously as this may increase auto-PEEP.
Non-depolarising agents such as vecuronium bromide, rocuronium bromide, cisatracurium besilate and pancuronium bromide may all be used and do not induce bronchospasm. Atracurium besilate and mivacurium chloride cause dose-dependent histamine release, but it is not certain whether this causes clinical deterioration. Stop paralysis as soon as possible, as the combination of steroid and neuromuscular blocking agents is particularly likely to cause critical illness myopathy. A trial of external PEEP is warranted as this may decrease work in spontaneously breathing patients.
Table 6. Criteria for discharge from the emergency unit. Good social factors adequate access to medical care, medicines and transport. Once admitted for poor response, the optimal duration of hospital stay is unclear. There is often major bed pressure to discharge patients too early, but this increases the risk of early relapse. The factors that precipitated the attack should be identified and attempts made to avoid them.
No tapering required if used for this duration. If the patient was already on inhaled CS, careful attention should be paid to reviewing the dose. Consider providing a short course of oral CS to be taken in the event of subsequent exacerbations for frequent exacerbators. Ideally, patients discharged from the emergency unit should be referred to specialist care as they do better than those returned to routine care.
A written asthma action plan should be reviewed or provided. Hospitalised patients are more receptive to information and advice about their illness.
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Global Initiative for Asthma. Changes in peak flow, symptom score, and the use of medications during acute exacerbations of asthma. Effect of pulmonary function testing on the management of acute asthma. Arch Intern Med ; 20 Evaluation of the severity of asthma: Patients versus physicians. Am J Med ;68 1 Evaluation of SaO2 as a predictor of outcome in children presenting with acute asthma. Ann Emerg Med ;23 6 British Thoracic Society. Guideline for emergency oxygen use in adult patients. Thorax ; Arterial blood gas analysis or oxygen saturation in the assessment of acute asthma?