Acute Severe Asthma Management
How to properly make clinical diagnosis of acute severe asthma? There is little doubt of the accuracy of current asthma testing. This is because most patients had bring out an established asthma diagnosis from prior regular asthma treatment, before presenting it to Asthma Emergency Department. We can see that most of patients had physical presentation: sitting up right, had profusely diaphoretic, only manage to speak only a few words at a time, and obvious respiratory distress. We can see varying respiratory rate on most patients. Hyperventilating is common in proportion to the severity of asthma attack. On the other hand, patients with hypoventilation is an indication of impending respiratory arrest.
From initial signs after examination, we can show hyperinflation of lungs, both inspiration and expiration are using accessory muscle and widespread wheezes. Some patients may show “silent chest” which is a worrying signs. A “silent chest” is an indication of patient inability to generate some airflow needed for wheezing. Some common signs like hypertension, tachycardia and pulsus paradoxus are also a firm signal of acute severe asthma.
There are some objective to measure asthma severity:
PEFR (Peak expiratory flow rate) less than a quarter of 120 L/minutes.
FER (Forced Expiratory Volume) in 1 second for an adult.
Patients with severely distressed symptoms who can barely speak.
Patients who had their flow rates very low and in the “severe” range.
ABGs or Arterial blood gases are also seldom necessary, this is because severity of asthma patients is clinically evident. If checked out, at the beginning they may demonstrate respiratory alkalosis with a low Paco2, but the Paco2 will arise as the severity of asthma increases. We can expect that Paco2 increase may be more crucial compare to a single isolated level that does not always relate well with severity of asthma itself. Still, in a severe acute asthma attach, a “normal” Paco2 is considered not normal. It represents CO2 retention and correlates with a worse prognosis and possible need for intubation.
Introduction and continuation of therapy should not await completion of history or physical exam, all of them should be concurrent. Some Significant points in history include particularly ICU admissions, previous hospitalizations, and history of previous medications recently used, started, or discontinued. History of prior intubations also can correlate with predicted asthma severity.
Further diagnostic investigations in patients with acute severe asthma generally include a chest X- ray to exclude other causes for their dyspnea including pulmonary barotrauma or pneumonia. However these are best done as a portable exam or deferred until the most acute phase of bronchospasm has resolved. Basic serum chemistries are appropriate in patients in which admission is anticipated, but commonly only reveal hypokalemia, secondary to the B-agonist use. A 12-lead electrocardiograph (EKG) may occasionally reveal other causes for the patients symptoms, but generally just shows sinus tachycardia and sometimes right heart strain.
Management of Acute Asthma Patients
Patients who experience acute severe asthma should be monitored closely with pulse oximetry and EKG monitor. They also have to be monitored and to be received some estimation/measurement of current blood pressure, respiratory rate, and mental status. In the emergency case, these patients should get supplemental oxygen in the first place.
Reassurance is part of initial acute asthma management. In the condition where patients become very nervous, the first treatment is become critical. A medical squad who had experiences, well organized and preparations can directly take the first step to evaluate patients and take first treatment. Don’t forget that in such emergency condition, a systematic plan and treatment that begins with routine care is necessary. The treatment involving agents that have demonstrated efficacy in acute severe asthma treatment.
Most of patients generally will react to these first line agents. Nevertheless, some may not react and will require the alternate second-line application, which are more aggressive measures. These therapies are those that have in general demonstrated benefit in the care of certain acute severe asthma patients.
How if both first-line and second-line therapies are not successful? In such condition where the condition of patient extends to drop, we need a third-line alternate treatment that should be considered in an effort to keep off from intubation. Each of these options as a special therapies, can also be enforced after intubation when there are on-going problems with enough ventilation. This kind of contingency plans are best considered and organized prior the main treatment.