Asthma Management Handbook

Completing a rapid primary assessment and starting initial treatment

Recommendations

Assess severity of the acute asthma episode (moderate, severe or life-threatening) based on clinical observations and pulse oximetry measured while the person is breathing air, and administer a bronchodilator immediately.

Notes

  • If oxygen therapy has already been started, it is not necessary to cease oxygen to measure pulse oximetry.
  • Pregnancy is not a contraindication for bronchodilators in acute asthma.

Table. Rapid primary assessment of acute asthma in adults and children

Mild/Moderate

Severe

Life-threatening

Can walk, speak whole sentences in one breath

(For young children: can move around, speak in phrases)

Oxygen saturation >94%

Any of these findings:

  • Use of accessory muscles of neck or intercostal muscles or 'tracheal tug' during inspiration or subcostal recession ('abdominal breathing')
  • Unable to complete sentences in one breath due to dyspnoea
  • Obvious respiratory distress
  • Oxygen saturation 90–94%

Any of these findings:

  • Reduced consciousness or collapse
  • Exhaustion
  • Cyanosis
  • Oxygen saturation <90%
  • Poor respiratory effort, soft/absent breath sounds

Notes

The severity category may change when more information is available (e.g. pulse oximetry, spirometry) or over time

The presence of pulsus paradoxus (systolic paradox) is not a reliable indicator of the severity of acute asthma.

If oxygen therapy has already been started, it is not necessary to cease oxygen to measure pulse oximetry.

Oxygen saturation levels are a guide only and are not definitive; clinical judgment should be applied.

Definitions of severity classes for acute asthma used in this handbook may differ from those used in published clinical trials and other guidelines that focus on, are or restricted to, the management of acute asthma within emergency departments or acute care facilities.

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Table. Initial bronchodilator treatment in acute asthma (adults and children 6 years and over)

  • Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.

  • Do not give oral salbutamol.

  • Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with inhaled or IV salbutamol.

Mild/Moderate

Severe

Life-threatening

Give salbutamol 4-12 puffs (100 mcg/actuation) via pMDI and spacer

Repeat every 20-30 minutes for the first hour if required (sooner, if needed to relieve breathlessness)

Give salbutamol 12 puffs (100 mcg/actuation) via pMDI and spacer

If patient unable to breathe through a spacer, give 5 mg nebule via nebuliser

Start oxygen therapy if oxygen saturation <95% and titrate to target:

Adults: 92–95%
Children: 95% or higher

Repeat salbutamol as needed. Give at least every 20 minutes for first hour (3 doses)

Give salbutamol 2 x 5 mg nebules via continuous nebulisation driven by oxygen

Maintain oxygen saturations:

Adults: 92% or higher
Children: 95% or higher

Arrange immediate transfer to higher-level care

When dyspnoea improves, consider changing to salbutamol via pMDI plus spacer or intermittent nebuliser (doses as for severe acute asthma)

† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)

‡ See Table. Using nebulisers in acute asthma

Note: To deliver nebulised bronchodilators in a patient receiving oxygen therapy, use an air-driven compressor nebuliser and administer oxygen by nasal cannulae.

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Table. Initial bronchodilator treatment in acute asthma (children 0–5 years)

  • Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.

  • Do not give oral salbutamol.

  • Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with inhaled or IV salbutamol.

  • Closely monitor level of consciousness, fatigue, oxygen saturation, respiratory rate and heart rate. If symptoms do not respond, contact a paediatrician or senior clinician and reconsider the diagnosis. 

  • In children under 12 months old, asthma is less likely to be the cause of wheezing than other conditions (e.g. bronchiolitis, pneumonia).

Mild/Moderate

Severe

Life-threatening

Give salbutamol 2-6 puffs (100 mcg/actuation) via pMDI and spacer plus mask

Repeat every 20-30 minutes for the first hour if needed (sooner, if needed to relieve breathlessness)

Give salbutamol 6 puffs (100 mcg/actuation) via pMDI and spacer plus mask

If patient unable to breathe through a spacer, give 2.5 mg nebule via nebuliser

Start supplementary oxygen if oxygen saturation <95%

Titrate to 95% or higher

Repeat salbutamol as needed. Give at least every 20 minutes for first hour (3 doses)

Give salbutamol 2 x 2.5 mg nebules via continuous nebulisation driven by oxygen

Maintain  oxygen saturation at 95% or higher

Arrange immediate transfer to higher-level care

When dyspnoea improves, consider changing to salbutamol via pMDI plus spacer or intermittent nebuliser (doses as for severe acute asthma)

† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)

‡ See Table. Using nebulisers in acute asthma

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Table. Using pressurised metered-dose inhalers in acute asthma

Administration of salbutamol by health professionals for a patient with acute asthma

  1. Use a salbutamol pressurised metered-dose inhaler (100 mcg/actuation) with a spacer that has already been prepared (see note).
  2. Shake inhaler and insert upright into spacer.
  3. Place mouthpiece between the person’s teeth and ask them to seal lips firmly around mouthpiece.
  4. Fire one puff into the spacer.
  5. Tell person to take 4 breaths in and out of the spacer.
  6. Remove the spacer from mouth. Shake the inhaler after each puff before actuating again. (This can be done without detaching the pressurised metered-dose inhaler from the spacer.)

Notes

The process is repeated until the total dose is given (e.g 12 puffs for an adult, 6 puffs for a child). Different doses are recommended for patients and carers giving asthma first aid in the community.

New plastic spacers should be washed with detergent to remove electrostatic charge (and labelled), so they are ready for use when needed. In an emergency situation, if a pre-treated spacer is not available, prime the spacer before use by firing at least 10 puffs of salbutamol into the spacer. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.)

Priming or washing spacers to reduce electrostatic charge before using for the first time is only necessary for standard plastic spacers; antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, Breathe Eazy, La Petit E-Chamber, La Grande E-Chamber, OptiChamber Diamond) and disposable cardboard spacers do not require treatment to reduce electrostatic charge.

For small children who cannot form a tight seal with their lips around the spacer mouthpiece, attach a well-fitted mask to the spacer.

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Table. Using nebulisers in acute asthma

Driving nebuliser

Nebulisers can be driven by air, piped oxygen, or an oxygen cylinder fitted with a high-flow regulator capable of delivering >6 L/min.

Intermittent nebulisation

Use one nebule:

Adults: 5 mg nebule

Children 6 years and over: 5 mg nebule

Children 0–5 years: 2.5 mg nebule

Continuous nebulisation using nebules

Put two nebules into nebuliser chamber at a time and repeat to refill when used up.

Adults: use two 5 mg nebules (10 mg) at a time

Children 6 years and over: use two 5 mg nebules (10 mg) at a time

Children 0–5 years: use two 2.5 mg nebules (5 mg) at a time

  • If using oxygen to drive a nebuliser, do not exceed 8–10 L/minute and avoid over-oxygenation (increases risk of hypercapnoea).
  • The use of nebulisers increases the risk (to staff and patients) of nosocomial aerosol infection. If using a nebuliser, follow your organisation’s infection control protocols to minimise spread of respiratory tract infections.

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Karpel et al. 19971
  • Dhuper et al. 20112
  • Cates et al. 20133
  • Ferguson and Gidwani 20064
  • Travers et al. 20125
  • Salmeron et al. 19946
  • Hodder et al. 20117
  • O'Driscoll et al. 20088
  • Global Initiative for Asthma (GINA) 20129
  • British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN) 200810
  • Perrin et al. 201111
  • Cyr et al. 199112
  • Barry and O'Callaghan 199413
  • Rau et al. 199614
  • Ari et al. 201215
  • Laube et al. 201116

Start oxygen therapy for all patients with severe or life-threatening acute asthma. Titrate oxygen saturation to target of 92–95% for adults and at least 95% for children.

  • In adults, avoid over-oxygenation, because this increases the risk of hypercapnoea
  • For children, consider whether humidification of oxygen is indicated
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Brandão et al. 201117
  • O'Driscoll et al. 20088
  • Rodrigo et al. 200618

For patients with life-threatening asthma, arrange immediate transfer to the resuscitation area (or arrange transfer to acute service).

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

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Identify and manage anaphylaxis according to national guidelines or your organisation’s protocols. Give adrenaline if anaphylaxis is suspected or cannot be excluded.

Note: Consider anaphylaxis if patient presents with urticaria or angioedema as well as respiratory signs/symptoms, and in patients with a history of allergies

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Global Initiative for Asthma, 20129
  • Singhi et al. 200619

More information

Anaphylaxis guidelines and resources
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Adrenaline in acute asthma

Systemic adrenaline (intravenous in clinical settings with appropriately trained staff, or intramuscular) is indicated for patients with anaphylaxis and angioedema,920 but current evidence does not support its routine use in the management of acute asthma in the absence of anaphylaxis.9

Nebulised adrenaline does not have a significant benefit over salbutamol or terbutaline in the management of moderate-to-severe acute asthma in adults and children.21

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Assessment of oxygen status in acute asthma

Hypoxia is the main cause of death that is due to acute asthma.7

Routine objective assessment of oxygen saturation at initial assessment of acute asthma is needed because clinical signs may not correlate with hypoxaemia.

Pulse oximetry is the internationally accepted method for routine assessment of oxygen status in patients with acute asthma.9

The risk of hypercapnoea increases when oxygen saturation falls below 92%.22

Pulse oximetry does not detect hypercapnoea, so blood gas analysis is necessary if hypercapnoea is suspected in patients with severe or life-threatening acute asthma.

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Oxygen therapy in acute asthma

Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been shown to improve the sensation of breathlessness in non-hypoxaemic patients.8 When oxygen supplementation is used, pulse oximetry is necessary to monitor oxygen status and titrate to target.

The aim of titrated oxygen therapy in acute care is to achieve normal or near-normal oxygen saturation, except in patients who are at risk of hypercapnoeic respiratory failure,8 such as patients with overlapping asthma and COPD.

Adults

In adults with acute asthma, titrated oxygen therapy using pulse oximetry to maintain oxygen saturation at 93–95% while avoiding hyperoxaemia achieves better physiological outcomes than 100% oxygen at high flow rate (8 L/min).11 High-concentration and high-flow oxygen therapy cause a clinically significant increase in blood CO2 concentration in adults with acute asthma.1123

National guidelines for the management of acute exacerbations of COPD recommend that hypoxic patients should be given controlled oxygen therapy via nasal prongs at 0.5–2.0 L/minute or a venturi mask at 24% or 28%, with target oxygen saturation of over 90% (PaO2 >50 mmHg, or 6.7 kPa).24 Excessive oxygen administration should be avoided because it can worsen hypercapnoea.24

Children

Drying of the upper airway is a potential complication of oxygen therapy in children,2526 which might contribute to bronchoconstriction.26 Humidified oxygen can be considered if necessary. Humidification is usually not needed for low flow oxygen (<4 L/minute in children or 2 L/minute in infants) for short term. Humidification may be considered if the oxygen is required for longer than 48 hours or if the nasal passages are becoming uncomfortable or dry.25

Guidance on oxygen delivery techniques and practical issues is available from  Sydney Children's Hospital Network and The Royal Children's Hospital Melbourne.

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References

  1. Karpel JP, Aldrich TK, Prezant DJ, et al. Emergency treatment of acute asthma with albuterol metered-dose inhaler plus holding chamber: how often should treatments be administered?. Chest. 1997; 112: 348-356. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9266868
  2. Dhuper S, Chandra A, Ahmed A, et al. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011; 40: 247-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19081697
  3. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013; 9: Cd000052. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24037768
  4. Ferguson C, Gidwani S. Delivery of bronchodilators in acute asthma in children. Emerg Med J. 2006; 23: 471-472. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564350/
  5. Travers AH, Milan SJ, Jones AP, et al. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. Cochrane Database Syst Rev. 2012; 12: CD010179. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010179/full
  6. Salmeron S, Brochard L, Mal H, et al. Nebulized versus intravenous albuterol in hypercapnic acute asthma. A multicenter, double-blind, randomized study. Am J Respir Crit Care Med. 1994; 149: 1466-1470. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8004299
  7. Hodder R, Lougheed MD, Rowe BH, et al. Management of acute asthma in adults in the emergency department: nonventilatory management. CMAJ. 2010; 182: E55-67. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2817338/
  8. O’Driscoll BR, Howard LS, Davison AG, British Thoracic Society (BTS) Emergency Oxygen Guideline Development Group. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008; 63 (Suppl 6): vi1-vi68. Available from: http://thorax.bmj.com/content/63/Suppl_6/vi1.full
  9. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
  10. British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Quick Reference Guide. Revised May 2011. BTS, SIGN, Edinburgh, 2008.
  11. Perrin K, Wijesinghe M, Healy B, et al. Randomised controlled trial of high concentration versus titrated oxygen therapy in severe exacerbations of asthma. Thorax. 2011; 66: 937-41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21597111
  12. Cyr TD, Graham SJ, Li KY, Levering EG. Low first-spray drug content in albuterol metered-dose inhalers. Pharm Res. 1991; 8: 658-660. Available from: http://link.springer.com/article/10.1023/A:1015825311750
  13. Barry PW, O'Callaghan C. Multiple actuations of salbutamol MDI into a spacer device reduce the amount of drug recovered in the respirable range. Eur Respir J. 1994; 7: 1707-1709. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7995401
  14. Rau JL, Restrepo RD, Deshpande V. Inhalation of single vs multiple metered-dose bronchodilator actuations from reservoir devices : An in vitro study. Chest. 1996; 109: 969-974. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8635379
  15. Ari A, Fink JB, Dhand R. Inhalation therapy in patients receiving mechanical ventilation: an update. J Aerosol Med Pulm Drug Deliv. 2012; 25: 319-32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22856594
  16. Laube BL, Janssens HM, de Jongh FHC, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011; 37: 1308-1417. Available from: http://erj.ersjournals.com/content/37/6/1308.full
  17. Brandao DC, Britto MC, Pessoa MF, et al. Heliox and forward-leaning posture improve the efficacy of nebulized bronchodilator in acute asthma: a randomized trial. Respir Care. 2011; 56: 947-52. Available from: http://rc.rcjournal.com/content/56/7/947.full
  18. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2006; Issue 4: CD002884. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002884.pub2/full
  19. Singhi S, Mathew JL, Torzillo P. What is the role of subcutaneous adrenaline in the management of acute asthma?. International Child Health Review Collaboration, 2006. Available from: http://www.ichrc.org/cough-or-difficult-breathing
  20. Australasian Society of Clinical Immunology and Allergy (ASCIA). Acute management of anaphylaxis guidelines. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/acute-management-of-anaphylaxis-guidelines
  21. Rodrigo GJ, Nannini LJ. Comparison between nebulized adrenaline and beta2 agonists for the treatment of acute asthma. A meta-analysis of randomized trials. Am J Emerg Med. 2006; 24: 217-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16490653
  22. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  23. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C. Effects of short-term 28% and 100% oxygen on PaCO2 and peak expiratory flow rate in acute asthma: a randomized trial. Chest. 2003; 124: 1312-7. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1081910
  24. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  25. Sydney Children's Hospital. Oxygen therapy and delivery devices – SCH. Practice guideline. Guideline No: 0/C/13:7019-01:00. Sydney Children's Hospital Westmead, Sydney, 2013. Available from: http://www.chw.edu.au/about/policies/alphabetical.htm
  26. The Royal Children's Hospital of Melbourne, Oxygen Delivery. Clinical Guidelines (Nursing), The Royal Children's Hospital 2013. Available from: http://www.rch.org.au/rchcpg/hospitalclinicalguidelineindex/Oxygendelivery/