Foreword
Asthma morbidity and mortality is on the increase in a number of developed countries. Our country, which is rapidly becoming industrialized, is also probably similarly saddled, especially with increased morbidity. It is therefore timely that a guideline on the management of asthma be produced for use of Malaysian doctors. These guidelines will hopefully provide well accepted and well recognized methods for the management of asthma to doctors who see and treat patients with asthma in their practice. The committee which set up to draw these guidelines consisted of chest physicians with many years of experience in managing the asthmatic patients. They have also extensively studied guidelines previously established by other groups on asthma management and modified several aspects to suit the local situation.
It is the sincerest hope of the Malaysian Thoracic Society that
these guidelines will benefit both Malaysian doctors and their patients
who suffer from asthma.
Thank you.
Dr. I. Kuppusamy
President,
Malaysian Thoracic Society
PREFACE
Asthma is a common disease which affects both adults and children. It continues to cause significant mortality and potentially preventable with proper management. Clinicians managing asthma need to keep abreast with the current concept of the disease and its management so that optimal care can be provided. While this may be possible for some, many may not be able to do so because of the constrain of time due to the nature of their work or practice and the difficulty to get access to reading materials. There are guidelines published by a number of societies/countries which are available but some recommendations concerning certain aspects of the management may not be suitable for local patients. Realising these various factors the Malaysian Thoracic Society has initiated the efforts to produce the guidelines on the management of asthma in adults. I am greatly honored to be given the task to gather a group of dedicated and highly knowledgeable people who have spent their invaluable time and experience to produce these guidelines. I would like to express my gratitude and thanks to these members who have patiently worked together until the completion of the guidelines. They include Dr. Aziah Ahmad Mahayuddin, Dr. Hooi Lai Ngor, Dr. I Kuppusamy, Associate Professor C.K. Liam, Dr. George Simon, Associate Professor Dr. A. Wahab Sufarlan, Dr. Wong Wing Kin and Associate Professor Dr. Ismail Yaacob. Without their help I dontt think we could have successfully produced theses guidelines. I am also thankful to members of the Malaysian Thoracic Society who have given their constructive views or comments on the guidelines.
We are also indebted to Astra Pharmaceutical (Malaysia) Sdn Bhd, Boehringer Ingelheim Div. Diethelm Malaysia Sdn Bhd, Glaxo Wellcome (Malaysia) Sdn Bhd and 3M Malaysia Sdn Bhd for their generosity in financially supporting this project. My special thanks also goes to Ms Norhayati Bakri for typing the manuscript.
The completion of these guidelines does not mean the end of our efforts to disseminate information on proper asthma care but rather the beginning of more efforts towards achieving an overall better informed and competent clinicians who are to manage asthma effectively. Obviously more seminars, workshop and round table discussions are needed to achieve this goal and MTS will definitely have a big role play in this respect.
With your support I am sure we can do it.
March 1996 BMZ Zainudin, MD, MRCP, FCCP, AMChairman of the Committee
on Asthma Management GuidelinesMalaysian Thoracic Society
GUIDELINES ON MANAGEMENT OF ADULT ASTHMA
A CONSENSUS STATEMENT OF THE MALAYSIAN THORACIC SOCIETY
INTRODUCTION
Asthma is a common disease with unacceptably high morbidity and mortality. Many deaths and morbidity have been associated with inadequate treatment, underuse of objective measurement of severity and inadequate supervision. Realising the need to improve the management of asthma among doctors in Malaysia, the Malaysian Thoracic Society initiated efforts to produce and publish this consensus statement on the management of asthma. Since consensus on management of asthma in children was initiated at about the same time by the Academy of medicine of Malaysia, this statement by the Malaysian Thoracic Society only covers management of asthma in adults.
We realise that several asthma management guidelines for example those by the British Thoracic Society, those from Australia and New Zealand and the International consensus are already available. However, local factors such as our health care delivery system, diverse socio-cultural background and level of education which are unique to our country need to be addressed. This prompted us to produce these local guidelines.
We regard the publication of guidelines on asthma management as one of the strategies to improve the overall management of asthma in the country. It should complement other programmes such as lectures, workshops, meetings and periodic publications. We hope these guidelines will serve as a useful reference for doctors although we also appreciate that views may differ in certain aspects of management. In certain circumstances, modification in management may have to be carried out.
Although there is no evidence to date that asthma management guidelines
reduce asthma mortality, it is not unreasonable to expect that proper management
will result morbidity and consequently mortality too.
To ensure a spread of opinions the working party was selected among
doctors working in government hospitals, academic institutions and private
hospital.
Participants :
A Proffesor Dr BMZ Zainudin - Chairman
Department of Medicine
Universiti Kebangsaan Malaysia
Kuala Lumpur
Dr A M Aziah
Institute of Respiratory Medicine
Hospital Kuala Lumpur
Dr L N Hooi
Chest Unit
Penang Hospital
Dr I Kuppusamy
Institute of Respiratory Medicine
Hospital Kuala Lumpur
A Professor Dr C K Liam
Department of Medicine
Hospital University
Kuala Lumpur
Dr George Simon
Chest Unit
Hospital Alor Setar
A Professor Dr A W Sufarlan
Department of Medicine
Universiti Kebangsaan Malaysia
Kuala Lumpur
Dr W K Wong
Pantai Medical Centre
Kuala Lumpur
A Professor Dr Ismail Yaacob
Department of Medicine
Universiti Sains Malaysia
Kubang Kerian
CONCEPT OF ASTHMA
Asthma is a chronic inflammatory condition of the airways the cause
of which is not completely understood. The inflammation is characterised
by oedema, infiltration with inflammatory cells especially eosinophils,
hypertrophy of glands and smooth muscle and damaged epithelium. The
inflammation results in the state of hyperresponsiveness where airways
narrow easily in response to a wide range of stimuli.7 This may result
in coughing, wheezing, chest tightness and shortness of breath, which are
often worse at night. These are the symptoms of an attack.
The airway narrowing is usually reversible but in some patients with chronic
asthma the inflammation may lead to irreversible airways obstruction.8
In general the more severe the asthma the more frequent and severe are
the attacks. Sometimes an acute attack can be fatal.
MANAGEMENT OF CHRONIC ASTHMA
Aims of management
The aims of management are:
1. to recognise asthma
2. to abolish symptoms
3. to restore normal or best possible long term airway function
4. to reduce morbidity and prevent mortality
Approach to management
In order to achieve those aims the approach to management should include:
1. Education of patient and family
2. Avoidance of precipitating factors
3. Use of the lowest effective dose of convenient medications
minimising short and long term side effects.
4. Assessment of severity and response to treatment.
Education of patient and family
This is an important but often neglected aspect in the management of
asthma. It is essential in ensuring the patients cooperation and
compliance with therapy. As far as possible patients and their families
should be encouraged and trained to actively participate in the management
of their own asthma. Patient education should include the following
information:
i. Nature of asthma
ii. Preventive measures/avoidance of triggers
iii. Drugs used and their side-effects
iv. Proper use of inhaled drugs
v. Proper use of peak flow meter
vi. Knowledge of the difference between relieving and preventive
medications
vii. Recognition of features of worsening asthma (increase in
bronchodilator requirement, development of nocturnal symptoms, reducing
peak flow rates).
viii. Self management plan for selected, motivated patients or
parents. (appendix 1)
ix. The danger of non prescribed self medication including certain
traditional medicines.
Avoidance of precipitating factors
The following factors may precipitate asthmatic attacks:
i. Beta blockers - contraindicated in all asthmatics
ii. Aspirin and nonsteroidal anti-inflammatory drugs - if known
to precipitate asthma, these drugs should be avoided.
iii. Allergens, e.g. house dust mites, domestic pets, pollen
should be avoided whenever possible.
iv. Occupation - should be considered as a possible precipitating
factor.
v. Smoking - active or passive.
vi. Day to day triggers - such as exercise and cold air.
It is preferable to adjust treatment if avoidance imposes inappropriate
restrictions on lifestyle.
vii. Atmospheric pollution
viii. Food - if known to trigger asthma, should be avoided.
Drug treatment
There are 2 major groups of drugs to treat asthma:
1. Bronchodilator drugs - to relieve bronchospasm and improve
symptoms
2. Anti inflammatory drugs - to treat the airway inflammation
and bronchial hyperresponsiveness, the underlying cause of asthma, i.e.
to prevent attacks.
1. BRONCHODILATORS
These drugs treat symptoms of asthma. They should be used
as required rather than regularly. When asthma is severe and difficult
to control, bronchodilators may be taken on regular basis. There
are 3 main groups of bronchodilators:
i. Beta2 agonists
ii. Anticholinergics
iii. Methylxanthines
i. Beta2 agonists
These drugs are the most effective bronchodilators available.
They are safe drugs with few side effects when taken by inhalation.
The therapeutic effect is felt within a few minutes of inhalation.
The main side effects are tremors and tachycardia. Oral slow release
preparations and inhaled long acting beta2 agonists such as salmeterol/bambuterol
are useful for nocturnal asthma.
Examples: Inhaled beta2 agonist:
salbutamol (Ventolin, Respolin)
terbutaline (Bricanyl)
fenoterol (Berotec)
salmeterol (Serevent) - long acting
Oral long acting beta2 agonist:
salbutamol (Volmax)
terbutaline (Bricanyl durules)
bambuterol (Bambec)
Oral short acting beta2 agonist:
salbutamol
terbutaline etc.
ii. Anticholinergic drugs
Inhaled anticholinergics have lower onset but longer duration
of action. They have very few side effects.
Examples: Ipratropium bromide (Atrovent)
iii. Methylxanthines
These drugs are available in oral and parenteral forms.
Their usefulness is limited by very variable metabolism and a narrow therapeutic
window. Sustained release preparations may be useful in nocturnal
asthma.9
Examples: Nuelin SR, Theodur, Euphylline
Note: Inhaled beta2 agonists are the bronchodilator of choice. As far as possible, avoid using oral beta2 agonists or xanthines as first line bronchodilator drugs.
2. ANTI-INFLAMMATORY DRUGS
As asthma is a chronic inflammatory condition, anti-inflammatory
drugs should be a logical treatment for most patients except for those
with mildest asthma. Reducing the inflammatory will decrease bronchial
hyperresponsiveness. The types of anti-inflammatory drugs include:
i. Corticosteroids
Steroids are the main prophylactic drugs in adult asthmatics.
They should be taken by inhalation and the dosage should be kept to a minimum
to reduce side effects (usually local side effects).10 Oral steroids
maybe required for severe chronic asthma.
Examples:
Beclomethasone dipropionate (Becotide, Becloforte, Beclomet,
Aldecin, Respocort)
Budesonide (Pulmicort)
ii. Sodium cromoglycate (Intal)
This drug is very safe with no significant side effects.
It is given by inhalation (power Spinhaler or metered dose inhaler).
It is of greatest benefit in young, atopic patients.11
Other treatments
Anti-histamines including ketotifen have been proven to be of limited
efficacy in many clinical trials in asthma.12-14 Hyposensitisation
is of limited value in the management of asthma.15
Drug Delivery
The inhaled route is preferred for beta2 agonists and steroids as it
produces the same benefit with fewer side-effects as compared to the oral
route. The pressurised metered dose inhaler (MDI) is suitable for
most patients as long as the inhalation technique is correct.
For patients with poor coordination, alternative methods for durg inhalation
include:
spacer devices, dry powder devices and breath-actuated pressurised
MDI.16-21
Although oral treatment is convenient for most patients, the dose required is higher and therefore side effects are more common.22-23
APPROACH TO DRUG THERAPY - STEPWISE APPROACH
Treatment should be carried out in a stepwise manner. Patients should be started on treatment at the step most appropriate for the initial severity of their condition. Treatment would then be changed (stepped-up or stepped-down) according to their progress.
STEP 1
This treatment is for patients with MILD EPISODIC ASTHMA, characterised
by normal or near normal lung function, infrequent symptoms and no nocturnal
symptoms (Table 1).
A beta2 agonist by inhalation should be used on an as needed basis.
If not well controlled, i.e. requiring usage of beta2 agonist more than
once a day, advance to Step 2.
STEP 2
This treatment is for MODERATE ASTHMA characterised by abnormal lung
function (PEF 60-80% predicted), frequent symptoms requiring beta2 agonist
more than once daily or with night symptoms.
Addition of an inhaled anti-inflammatory agent is required. Low dose inhaled corticosteroids are the drugs of choice (e.g. beclomethasone or budesonide 200-800 mcg daily). Twice daily dosing is preferred to improve compliance. Sodium cromoglycate may also be effective in some patients.
STEP 3
This step is for SEVERE CHRONIC ASTHMA, i.e. patients with persistent
symptoms (especially nocturnal symptoms), a continuing need for inhaled
bronchodilators and peak flow of less than 60% predicted or best.
High dose of inhaled steroid should be used (beclomethasone or budesonide 800-2000 mcg daily) whilst inhaled beta2 agonist should be taken on an as required basis. It may be necessary to add one or more of the following:
1. Regular beta2 agonists - oral beta2 agonists (preferably long
acting) or inhaled long acting beta2 agonist or nebulised beta2 agonists.
2. Inhaled ipratropium bromide (Atrovent) 40mcg 3-4 times a day.
3. Sustained release theophylline. Whenever possible blood
levels should be monitored.
Alternatively, whenever there are problems with high doses of inhaled steroids, these drugs may be added to step 2 medications.
STEP 4
This step is for VERY SEVERE ASTHMA characterised by persistent symptoms
not controlled by the above measures.
Oral steroids should be added and the dose kept to the lowest possible that achieves control.
STEP DOWN
Patients should be reviewed regularly. When the patients condition
has been stable for 3-6 months, drug therapy may be stepped down gradually.
The monitoring of symptoms and peak flow rate should be continued during
drug reduction.
RESCUE COURSE OF STEROID TABLETS
Rescue courses of oral steroids may be needed to control exacerbations
of asthma at any step. Indications may include:
i. symptoms and peak expiratory flow (PEF) get progressively worse
day by day.
ii. PEF falls below 60% of patients best
iii. sleep is disturbed by asthma
iv. morning symptoms persist until midday
v. there is a diminishing response to inhaled bronchodilators
vi. emergency treatment with nebulised or injected bronchodilators
is required.
Method:
Give 30-60 mg of prednisolone immediately. The dose should be
tapered down and stopped within 7-14 days.
ASSESSMENT OF SEVERITY AND RESPONSE TO TREATMENT
Assessment should be done as follows:
1. Clinical assessment. This should include patients symptoms,
sleep disturbances, effort tolerance, disturbance of daily activities and
the frequency of bronchodilator drug and/or rescue courses of steroid used.
2. Measuring peak expiratory flow (PEF). This can either
be measured by Wright peak flow meter or mini-Wright peak flow meter.
Mini-Wright peak flow meters are affordable for many patients.
PEF Measurements
i. During periods of well-being
This allows measurement of patients best PEF value which will provide the target for the doctor and the patient to aim for. Twice daily measurements (morning and evening) before any inhaled bronchodilator treatment will determine the diurnal variability of airway calibre. This is calculated as the range divided by the highest value and expressed as a percentage.
PEF (max) - PEF (min) x 100 = _____________%
PEF (max)
PEF variability of less than 20% is regarded as mild, between 20-30% is moderate and more than 30% is severe. A good control of asthma means PEF variability is maintained at less than 10%.
ii. During symptomatic episodes
During an attack of asthma PEF fairly accurately measures the degree
of bronchospasm. A PEF of less than 50% of normal or best suggests
a severe attach and a PEF of less than 33% suggests a very severe and life
threatening attack. When the best PEF value is not known, a single
reading of less of 200 l/min usually indicates a severe attack.
Hence, in additional to history and physical findings the PEF helps the doctor to decide on the appropriate therapy (besides history and physical findings). As far as possible patients with moderate and severe asthma should regularly measure their PEF twice a day especially when their asthma is worsening or when treatment is altered. Comparison to local normal values should be made24 (appendix 2).
SPECIALIST REFERRAL
Referral to a respiratory physician is appropriate when:
i. there is doubt about the diagnosis
ii. occupational asthma is suspected
iii. management is difficult, e.g. brittle asthma or very severe
asthma not successfully controlled
iv. long term treatment with nebulised bronchodilator is needed
v. asthma is worsening in a pregnant woman
vi. asthma is interfering with patients lifestyle despite changes
in treatment
PREGNANCY AND ASTHMA
During pregnancy asthma in about one-third of women becomes worse,
in one-third better and in one-third remains unchanged. However this
cannot be predicted. Achieving good control of asthma is more important
in order to prevent adverse effects on both fetus and mother than the theoretical
risks of any of the presently used anti-asthma medications. Most
drugs used to treat asthma are safe with the exception of alpha adrenergic
compounds and epinephrine (both are not usually used to treat asthma in
Malaysia). Asthma in pregnancy therefore should be managed as in
other patients. Acute exacerbations should be treated aggressively
in order to avoid fatal hypoxia and maintain maternal well-being.
Treatment should include nebulised beta2-agonists and oxygen, systemic
corticosteroids should be instituted when necessary. Patients should
also have adequate opportunity to discuss the safety of their medication.
TABLE 1 - Disease Severity
Grade History Bronchodilator requirement Variability in PEF Best PEF(percentage
of predicted)
Severe Wakes at night frequently with wheeze, cough; chest tightness
on waking in morning; hospital admission in the last year; previous life
threatening attacks Needed more than four times a day >30% <60%
Moderate Symptoms on most daysNocturnal symptoms > twice a month Needed
on most days 20% - 30% 60% - 80%
Mild Mild occasional symptoms; e.g. only with exercise or infections
Needed occasionally 10% - 20% 80% - 100%
Note : One or more features may be present for any grade of severity.
An individual should be assigned to the most severe grade in which any
feature occurs.
APPENDIX 1
Example of a written asthma management plan.
Name : .
Address :
Tel. Numbers
General Practitioner : .
Specialist : .
Ambulance : . .
Hospital : ..
Usual Medication:
1. .
2. ..
3. ..
4. . .
Best Peak Flow Reading : .L/min.
YOUR ASTHMA IS MODERATELY SEVERE IF:
· You wake up once or twice a night with asthma.
· You need your bronchodilator more than 4 times a day.
· You notice wheeze and difficulty in breathing more than usual
during the day.
· Your peak flow is less than
(80% of best)
You should double the dose of
. for 2 weeks
YOUR ASTHMA IS SEVERE IF:
· You wake up with asthma more than twice a night.
· You need your bronchodilator more than 6 times a day.
· You notice wheeze and difficulty in breathing most of the
day.
· Your peak flow is less than
(60% of best)
You should double the dose of
. for 2 weeks and take
tablets
of prednisolone (
..mg) on the first day and reduce that by 1 tablet
each day.
YOUR ASTHMA IS VERY SEVERE IF:
· You are awake most of the night.
· You are short of breath at rest.
· You can only speak in short sentences of a few words.
· Your peak flow is less than
(50% of best) even after
extra doses of medication.
You should take 5 puffs of . and immediately take tablets of prednisolone ( ..mg) and see your doctor.
CHART 1 : MANAGEMENT OF CHRONIC ASTHMA IN ADULTS
| STEP 1 | STEP 2 | STEP 3 | STEP 4 | ||
| MILD EPISODIC ASTHMA | MODERATE ASTHMA | SEVERE CHRONIC ASTHMA | VERY SEVERE ASTHMA
|
||
| Infrequent symptoms
No nocturnal symptoms PET 80-100% predicted Treatment: inhaled beta2 agonist as needed for symptom relief.
If needed more than once a day, advance to step 2
|
-Frequent symptoms
-Nortunal symptoms present -PEF 60-80% predicted Treatment- inhaled steroids, eg beclomethasone or budesonide 200-800
mcg/day or inhaled sodium cromoglycate plus
|
Frequent nocturnal symptoms PEF 60% predicted or less Treatment: inhaled beclomethasone or budesonide 800-2000 mcg/day plus inhaled beta2 agonist as needed plus, if necessary oral beta2 agonist preferably long acting, or inhaled long acting beta2 agonist, or inhaled ipratropium bromide 40 mcg 3-4 times a day, or oral theophylline (sustained release), or nebulised beta2 agonist, 2-4 times a day |
Persistent symptoms not controlled by step 3 medications
Treatment:as in step 3, plusoral steroids (the lowest dose possible) |
The presentation of a patient with acute asthma requires rapid assessment of its severity so that the appropriate treatment can be instituted.
Although an acute severe attack of asthma may occasionally develop within a few minutes or hours, it usually occurs against a background of long term poorly controlled asthma or asthma that has been worsening for some days or weeks. The severity of acute asthma attacks is usually underestimated by patients, their relatives and their doctors, mainly because of the failure to make objective measurements.25 Inadequate assessment of such attacks or inappropriate treatment with over-reliance on bronchodilators and underuse of steroids contribute to morbidity and deaths.26-29
AIMS OF MANAGEMENT
The aims of management are:
1. To prevent death
2. To relieve respiratory distress
3. To restore the patients lung function to the best possible
level as soon as possible.
4. To prevent early relapse
ASSESSMENT 4,30-32
The severity of the attack should be assessed by:
1. History taking
2. Physical examination
3. PEF measurement
Features of moderately severe asthma
normal speech
pulse rate < 110/min
respiratory rate < 25 breaths/min
PEF > 50% predicted or best value
Features of acute severe asthma
The presence of any of the following indicates a severe attack of asthma:
too breathless to complete sentences in one breath
respiratory rate ³ 25 breaths/min
pulse rate ³ 110/min
PEF £ 50% predicted or best value
Life threatening features
The presence of any of the following indicates a very severe attack
of asthma:
central cyanosis
feeble respiratory effort
silent chest on auscultation
bradycardia or hypotension
exhaustion
confusion or unconsciousness
PEF < 33% predicted or best value (or a single reading of <150
l/min of patients who are not able to blow)
Arterial blood gas (ABG) tensions should be measured if a patient has any of the severe or life threatening features.
ABG markers of a very severe, life threatening attach include:
a normal (5-6 kPa, or 36-45 mmHg) or high PaCO2
severe hypoxaemia: PaO2 < 8kPa (60 mmHg) irrespective of treatment
with oxygen
a low pH
MANAGEMENT OF ACUTE ASTHMA IN ACCIDENT AND EMERGENCY DEPARTMENT
INITIAL PEF > 75% (Mild acute asthma)
Sometimes, patients with mild acute asthma may present at the A&E. This is characterised by an initial PEF of >75% of predicted or best value. In this situation, just given the patients usual inhaled bronchodilator (e.g. salbutamol, terbutaline or fenoterol) from a metered dose inhaler.
Observe for 60 minutes. If the patient is stable and PEF is still >75%, discharge.
Before discharge:
review adequacy of usual treatment and step up if necessary according
to guidelines for treatment of chronic persistent asthma
ensure patient has enough supply of medications
check inhaler technique and correct if faulty
advise patient to return immediately if asthma worsens.
make sure patient has a clinic follow-up appointment
P/S: Patients should be considered for admission if social situations
such as staying
alone, lack of transport for emergency visit to hospital, etc.
INITIAL PEF<75%
Patients who present to the A&E with more severe degrees of acute asthma characterised by an initial PEF <75% predicted or best value, should be managed as follows:
1. IMMEDIATE TREATMENT WITH:
(a) High concentration oxygen (>40%) in cases with initial PEF
<50% at presentation.
(b) High doses of inhaled beta2 agonist (salbutamol 5mg or terbutaline
5mg or fenoterol 5mg) via nebuliser driven by oxygen. If compressed
air nebuliser is used, administration of supplemental oxygen when indicated
should be continued.
Alternatively, beta2 agonist may be given by multiple actuations of
a pressurised aerosol inhaler into a large spacer device (2-5mg, i.e. 20-50
puffs, five puffs at a time)
Consider adding anticholinergic (e.g. ipratropium bromide 0.5mg) to nebulised beta2 agonist for patients with acute severe asthma.
(c) Prednisolone tablets 30-60mg. Very ill patients should be given intravenous hydrocortisone 200mg stat.
NB. Sedatives should not be prescribed.
Antibiotics are indicated only if there is evidence of a bacterial
infection.
Do a chest x-ray if pneumothorax or pneumonia is suspected or
features of acute
severe or life threatening asthma are present.
If life threatening features are present:
(d) Intravenous aminophylline 250mg slowly over 20 minutes or
intravenous terbutaline or salbutamol 250mcg over 10 minutes.
(Bolus aminophylline should not be given to patients already taking
oral theophylline).
* Patients with features of life threatening asthma require admission
preferably to the intensive care unit (ICU) and should be accompanied by
a doctor.
EFFECTS OF TREATMENT
The effects of treatment are monitored by:
the patients assessment of symptoms
physical examination
repeat measurement of PEF 15-30 minutes after starting treatment
Good response to initial treatment
Such patient should
be free of wheezing and dyspnoea
have a clear chest on auscultation
have a postbronchodilator PEF which is >75% of predicted or best
value.
Incomplete response to initial treatment
Such a patient has
persistent wheezing or dyspnoea
rhonchi on chest auscultation
a postbronchodilator PEF which is 50-75% of predicted or best value
Poor response to initial treatment
Such a patient has
persistent, marked wheezing or breathlessness
diffuse rhonchi on chest auscultation and other signs of acute severe
asthma
a postbronchodilator PEF <50% of predicted or best value
The subsequent management of patients with an initial <75% predicted
or best value is summarised in Table 2.
TABLE 2 : EMERGENCY ROOM MANAGEMENT 30 MINUTES AFTER INITIAL TREATMENT
OF ACUTE ASTHMA WITH A PEF <75% PREDICTED OR BEST ON ARRIVAL
Good response and PEF >75% predicted or best value Incomplete response
and PEF 50-75% predicted or best value Poor response and PEF <50% predicted
or best value
Observe for another 60 minutesIf patient is stable or improving and
PEF is still >75%, DISCHARGE. Repeat nebulised beta2 agonistObserve for
60 minutes.(1) If PEF is still £75%, ADMIT(2)
If patient improves and PEF >75%, DISCHARGE. ADMIT
* Patients requiring admission should be
accompanied by a nurse or doctor.
Before discharge:
give prednisolone 30-40mg daily tapering over 7-14 days, plus regular
inhaled steroids and inhaled beta2 agonist to be taken as needed
review adequacy of usual treatment and step up if necessary according
to guidelines for treatment of chronic persistent asthma
ensure patient has enough supply of medications
check inhaler technique and correct if faulty
arrange for follow-up
advise patient to return immediately if asthma worsens
P/S : Patients should be considered for admission if social situations
such as staying
alone, lack of transport for emergency visit to hospital etc.
2. SUBSEQUENT MANAGEMENT IN THE WARD OR ICU
Continue - oxygen at 40%
intravenous hydrocortisone 200mg 6-hourly or prednisolone 30-60mg daily
nebulised beta2-agonist 4-hourly; this can subsequently be changed to metered dose inhaler (It may be necessary to give nebulised beta2-agonist more frequently, up to every 15-30 minutes and to add ipratropium bromide 0.5mg to nebulised beta2-agonist and repeat 6-hourly if patient is not improving.)
If patient is still not improving, also give
aminophylline infusion (0.5-0.9mg/kg/hour); monitor blood levels
(where facility is available) if aminophylline infusion is continued for
more than 24 hours.
terbutaline or salbutamol infusion as an alternative to aminophylline,
at 3-20mcg/min after an initial intravenous bolus dose of 250mcg over 10
minutes..
3. MONITORING THE EFFECTS OF TREATMENT
Repeat measurement of PEF 15-30 minutes after starting treatment.
Maintain arterial oxygen saturation above 92% (if facility for pulse oximetry is available)
Repeat arterial blood gas measurements if initial results are abnormal or if patient deteriorates.
Chart PEF before and 15 minutes after giving nebulised or inhaled
beta2-agonist at least 4 times daily throughout the hospital stay.
4. OTHER INVESTIGATIONS
serum electrolytes (hypokalaemia is a recognised complication of treatment with beta2-agonist and corticosteroids)
electrocardiogram if indicated
5. TRANSFER PATIENT TO THE INTENSIVE CARE UNIT OR PREPARE TO INTUBATE
IF THERE IS:
deteriorating PEF
worsening hypoxaemia, or hypercapnia
exhaustion or feeble respirations
confusion or drowsiness
coma or respiratory arrest
In ICU,
Continue with oxygen supplementation
Continue with intravenous hydrocortisone
If the patient is mechanically ventilated, administer nebulised beta2-agonist
(with or without ipratropium) via the endotracheal tube. This can
be given up to every 15-30 minutes.
Intravenous aminophylline infusion or terbutaline or salbutamol infusion
may also be given.
6. BEFORE DISCHARGE, the patient should be:
started on inhaled steroids for at least 48 hours in addition to a short course of oral prednisolone and bronchodilators.
stable on the medication he is going to take outside the hospital for at least 24 hours.
having PEF of >75% of predicted or best value and PEF diurnal variability of <25%.
taught and checked on the correct inhaler technique and if necessary, alternative inhaler devices should be prescribed.
educated on the discharge medication, home peak flow monitoring and self management plan (for selected, motivated patients), and the importance of regular follow-up
given an early follow-up appointment within 4 weeks for re-assessment
of the condition and for adjustment of the medications.
MANAGEMENT OF ACUTE ASTHMA IN GENERAL PRACTICE
Management is similar to that in the accident and emergency department.
The clinic should have facility for oxygen administration and it is essential
that equipment for resuscitation should be available.
These are indications for immediate referral to hospital
1. Any life threatening features
2. Any features of a severe attack that persist after initial
treatment
3. PEF 15-30 minutes after nebulisation which is <50% of predicted
or best value.
Threshold for referral to hospital should be lowered for patients:4
seen in the afternoon or evening rather than earlier in the day.
with previous severe attacks, especially if the onset of the current
attack was rapid
in whom there is concern over the social circumstances or relatives
ability to respond appropriately.
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ACKNOWLEDGEMENTS
We would like to express our gratitude to the following companies who have contributed to the successful production of these guidelines:
Astra Pharmaceutical (M) Sdn Bhd
Boehringer Ingelheim Division, Diethelm Malaysia Sdn Bhd
GlaxoWellcome (Malaysia) Sdn Bhd
3M Pharmaceuticals, 3M Malaysia Sdn Bhd
We would also like to express our gratitude to Puan Norhayati Bakri
for her help in the preparation of these guidelines.
