Asthma Management Handbook

Managing acute asthma in clinical settings

Overview

  • Wheezing infants younger than 12 months old should not be treated for acute asthma. Acute wheezing in this age group is most commonly due to acute viral bronchiolitis.

Advice should be obtained from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids or inhaled corticosteroids to an infant.

Acute asthma management in children, adolescents and adults is based on:

  • assessing severity (mild/moderate, severe or life-threatening) while starting bronchodilator treatment immediately
  • administering oxygen therapy if peripheral capillary oxygen saturation measured by pulse oximetry (SpO2) is less than 92% in adults or less than 95% in children
  • completing observations and assessments (when appropriate, based on clinical priorities determined by baseline severity)
  • administering systemic corticosteroids within the first hour of treatment
  • repeatedly reassessing response to treatment and either continuing treatment or adding on treatments, until acute asthma has resolved or patient has been transferred to an intensive care unit or admitted to hospital
  • observing the patient for at least 3 hours after respiratory distress or increased work of breathing has resolved
  • providing post-acute care and arranging follow-up to reduce the risk of future flare-ups.

Figure. Managing acute asthma in adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/65

 

Figure. Managing acute asthma in children Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/67

Figure. Initial management of life-threatening acute asthma in adults and children Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/94

Notes: The classification of acute asthma severity differs between clinical settings. The definitions of mild/moderate, severe and life-threatening acute asthma used in this handbook may differ from those of some published clinical trials and other guidelines.

The terms ‘exacerbation’, ‘flare-up’, ‘attack’ and ‘acute asthma’ are used differently by patients and clinicians, and in different contexts.

The classification of flare-ups and the classification of acute asthma overlap (e.g. a flare-up is considered to be at least ‘moderate’ if it is troublesome enough to cause the patient or carers to visit an emergency department or seek urgent treatment from primary care, yet it might be described as ‘mild’ acute asthma within acute services).

Table. Severity classification for flare-ups (exacerbations)

Severity Definition Example/s
Mild Worsening of asthma control that is only just outside the normal range of variation for the individual (documented when patient is well)

More symptoms than usual, needing reliever more than usual (e.g. >3 times within a week for a person who normally needs their reliever less often), waking up with asthma, asthma is interfering with usual activities

A gradual reduction in PEF† over several days

Moderate

Events that are (all of):

  • troublesome or distressing to the patient
  • require a change in treatment
  • not life-threatening
  • do not require hospitalisation.
More symptoms than usual, increasing difficulty breathing, waking often at night with asthma symptoms
Severe Events that require urgent action by the patient (or carers) and health professionals to prevent a serious outcome such as hospitalisation or death from asthma Needing reliever again within 3 hours, difficulty with normal activity

† Applies to patients who monitor their asthma using a peak expiratory flow meter (single PEF measurements in clinic not recommended for assessing severity of flare-ups).

Note: the ATS/ERS Task Force recommended that severe exacerbations should be defined in clinical trials as the use of oral corticosteroids for 3 or more days. However, this definition is not applicable to clinical practice.

Source: Reddel H, Taylor D, Bateman E et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009; 180: 59-99. Available at: http://www.thoracic.org/statements

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In this handbook, the categories of 'mild' and 'moderate' acute asthma have been merged to avoid confusion between terminologies traditionally used at different levels of the health system. Mild acute asthma can usually be managed at home by following the person's written asthma action plan.

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