-
At initial eval of exacerbation severity
Impending/Actual resp arrest: too sick to measure PEF or FEV1 (or <25%), SaO2 <90% w/ PCO2 ≥42 mmHg | no wheeze d/t poor air mvt | too dyspneic to speak, drowsy/confused Intubate immediately/semi-electively, 100% O2, bronchodilators, IV steroids, ICU admit - If apnea/coma, intubate1 immediately; if impending resp failure,2 prep for semi-elective intubation1
- 100% O2, monitor SaO2;3 consider ABG4 to assess PCO2
- SABA5 (albuterol, levalbuterol) NEB q20 min x3 or continuously
- Plus ipratropium6 NEB q20min x3 or continuously
- Steroids IV: 40-80 mg/day7
- Brief hx/exam;8,9 tests10 in select pts: CBC, lytes, theophylline, CXR, ECG
- Admit/transfer to ICU
Repeat eval after 1st & 3rd SABA doses: [A]O2 sat, sx, hx/exam - If unresponsive to initial tx: consider11 MgSO4 or heliox, [B]but don’t delay intubation once deemed necessary1
- Reassess after 3rd SABA dose (60-90 min after initial SABA)
Footnotes 1 Intubation in severe exac is difficult, so don’t delay once deemed necessary, [D]before resp arrest, by physician w/ extensive airway mgmt experience. Ketamine pre-med not shown to benefit in severe exac. Maintain volume status, as initiating ventilation may cause hypotension. Ventilation strategy: permissive hypercapnia [C]to minimize barotrauma. Consider consult for ventilator mgmt.
2 Persistent/increasing hypercapnia, exhaustion, depressed mental status suggest need for ventilator support. [D]Impending resp failure signs: PCO2 ≥42 mmHg, PEF or FEV1 <25% (FEV1 and PEF not required for initial eval of life-threatening exac), [D]bradycardia, absent pulsus paradox (suggesting resp muscle fatigue), absent wheeze d/t poor air mvt, paradoxical thoracoabdominal mvt, intercostal retraction, perspiring, unable to speak, drowsy/confused.
3 Maintain SaO2 ≥90% (≥95% in pregnant women and pts w/ heart dz). Monitor sat until clear bronchodilator response.
4 Consider ABG for suspected hypoventilation, severe distress, or when FEV1 or PEF is ≤25% after initial tx. Given ↑resp drive during exac, a PCO2 of ≥42 mmHg is a sign of severe airflow obstruction/impending resp failure. VBG may serve as a screen (eg, venous PCO2 >45 mmHg), but isn’t a substitute for ABG.
5 SABA [A]NEB options:
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn. OK to mix w/ ipratropium NEB soln
• levalbuterol NEB 1.25-2.5 mg q20 min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
• ipratropium/albuterol NEB 0.5/2.5 mg 3 mL q20min x3 doses, then prn
6 Ipratropium not 1st-line as mono-tx. Use for severe exac [A]in ED/urgent care; not shown to add benefit once hospitalized. May mix w/ albuterol in same NEB or use premixed combo:
• ipratropium NEB 0.5 mg q20min x3 doses, then prn
• ipratropium/albuterol NEB 0.5/2.5 mg 3 mL q20min x3 doses, then prn
7 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, prednisone: 40-80 mg/day in 1 or 2 div doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
8 Brief hx of current/past exac, comorbidities:
• Time of onset, potential causes; severity vs previous exac
• Meds, last dose times, response to recent tx
• # previous asthma ED/hospital visits or unscheduled office visits, esp in last yr
• Hx LOC or intubation
• CV/pulm comorbidities; conditions that may be aggravated by steroids (DM, PUD, HTN, psychosis)
9 Brief exam: RR, HR; alertness, fluid status, cyanosis, distress, accessory muscle use, auscultation.
• Complications (pneumonia, pneumothorax, pneumomediastinum)
• Upper airway obstruction (foreign body, epiglottitis, vocal cord dysfxn, extrinsic/intrinsic tracheal narrowing)
10 Don’t delay tx initiation for tests:
• CBC if fever/purulent sputum; leukocytosis common in asthma exac and w/in 1-2 hrs of steroid tx
• Theophylline: ✓ for toxicity if on drug
• Lytes: ✓ if CV dz or if on diuretics; SABA may cause transient ↓K, Mg, phos
• CXR: ✓ if suspect complicating CV/pulm process (CHF, pneumothorax, pneumomediastinum, pneumonia, lobar atelectasis)
• ECG: ✓ baseline ECG + cardiac monitor if >50 yo or if heart dz or COPD
11 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline,[A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
Severe: PEF or FEV1 25%-39%, SaO2 <90% w/ PCO2 ≥42 mmHg | wheezes throughout insp + exp | severe dyspnea @ rest, speaks w/ single words only O2, bronchodilator NEBs, PO steroids for severe exac12,13 - O2 by cannula/mask, maintain SaO2 ≥90% (≥95% in some pts)14
- SABA15 (albuterol, levalbuterol) high-dose NEB or MDI + spacer q20min or continuously x1 hr
- Plus ipratropium16 NEB or MDI + spacer q20min or continuously x1 hr
- Steroids17 PO 40-80 mg/day
- Brief hx/exam;18,19 FEV1 or PEF;13 tests20 in select pts: CBC, lytes, theophylline, CXR, ECG
- If severe distress, suspected hypoventilation, consider ABG21
Repeat eval after 1st & 3rd SABA doses: [A]PEF or FEV1,13[B]O2 sat, sx, detailed hx/exam - If unresponsive to initial tx: consider22 MgSO4 or heliox [B]
- If ≤25% PEF or FEV113 after initial tx, consider ABG21
- If <40% PEF or FEV113 on repeat eval w/ severe s/sx12 or pt high-risk23 per hx: give O2, hourly/continuous SABA & ipratropium NEBs, consider adjunct tx22
- If 40%-69% PEF or FEV113 on repeat eval w/ mod s/sx:24 SABA q60min x1-3 more hrs (as long as improving), make admit decision w/in 4 hrs
- If ≥70% PEF or FEV113 on repeat eval w/ NL exam, no distress and if response sustained x60 min since last tx, prep for d/c home
Footnotes 12 Severe s/sx: O2 sat <90%, PaO2 <60 mmHg, PCO2 ≥42 mmHg on room air; RR often >30/min, HR >120, accessory muscle use, loud wheezes throughout insp + exp, pulsus paradoxus >25 mmHg; dyspnea @ rest, speaks in single words.
13 Very severe exac may preclude FEV1 or PEF measurement; use clinical eval instead. [D]FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat. FEV1 or PEF values that fluctuate widely = potential indication for ICU admission + close monitoring for resp failure. [C]
14 If pregnant or heart dz, maintain SaO2 ≥95%. Monitor sat until clear bronchodilator response. If sat monitoring not available, give O2 to pts w/ significant hypoxemia or FEV1 or PEF <40%.
15 SABA [A]high-dose options:
• albuterol NEB 5 mg q20min x3 doses (or 15 mg/hr continuously), then 10 mg q1-4h prn. OK to mix w/ ipratropium NEB soln.
• albuterol MDI + spacer 90 mcg 4-12 puffs q20min up to 4 hrs, then q1-4h prn
• levalbuterol NEB 2.5 mg q20min x3 doses, then 5 mg q1-4h prn (has not been evaluated for continuous NEB)
• levalbuterol MDI + spacer 45 mcg 4-12 puffs q20min up to 4 hrs, then q1-4h prn
16 Ipratropium not 1st-line mono-tx. Add to SABA for severe exac [A]in ED/urgent care setting, not shown to add further benefit once pt hospitalized.
• ipratropium NEB 0.5 mg q20min x3 doses, then prn. Mix w/ albuterol in same NEB.
• ipratropium MDI + spacer 18 mcg 8 puffs q20min prn up to 3 hrs
17 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, or prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
18 Brief hx of current/past exac, comorbidities:
• Time of onset, potential causes; severity vs previous exac
• Meds, last dose times, response to recent tx
• # previous asthma ED/hospital visits or unscheduled office visits, esp in last yr
• Hx LOC or intubation
• CV/pulm comorbidities; conditions that may be aggravated by steroids (DM, PUD, HTN, psychosis)
19 Brief exam: RR, HR; alertness, fluid status, cyanosis, distress, accessory muscle use, auscultation.
• Complications (pneumonia, pneumothorax, pneumomediastinum)
• Upper airway obstruction (foreign body, epiglottitis, vocal cord dysfxn, extrinsic/intrinsic tracheal narrowing)
20 Don’t delay tx initiation for tests:
• CBC if fever/purulent sputum; leukocytosis common in asthma exac and w/in 1-2 hrs of steroid tx
• Theophylline: ✓ for toxicity if on drug
• Lytes: ✓ if CV dz or if on diuretics; SABA may cause transient ↓K, Mg, phos
• CXR: ✓ if suspect complicating CV/pulm process (CHF, pneumothorax, pneumomediastinum, pneumonia, lobar atelectasis)
• ECG: ✓ baseline ECG + cardiac monitor if >50 yo or if heart dz or COPD
21 Consider ABG for suspected hypoventilation, severe distress, or when FEV1 or PEF is ≤25% after initial tx. Given ↑resp drive during exac, a PCO2 of ≥40 mmHg is a sign of severe airflow obstruction/impending resp failure. VBG may serve as a screen (eg, venous PCO2 >45 mmHg), but isn’t a substitute for ABG.
22 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
23 Risk factors for asthma-related death:
• Previous severe exac (eg, intubation, ICU admit); in past yr: ≥2 hospitalizations or ≥3 ED visits; in past mo: hospitalization or ED visit
• SABA use >2 containers/mo, difficulty perceiving sx or exac severity, no action plan, Alternaria sensitivity
• Low socioeconomic status/inner-city residence, Illicit drug use, major psychosocial problems
• CV dz, other chronic lung dz, chronic psych dz
24 Mod s/sx: O2 sat <90-95% on room air; HR 100-120, pulsus paradoxus may be present (10-25 mmHg), accessory muscle use, loud pan-exp wheezes; dyspnea interferes w/ usual activity, speaks in phrases - not complete sentences.
Mild/Mod: PEF or FEV1 ≥40%, SaO2 >90% | exp-only wheeze | dyspnea only w/ activity, speaks phrases and sentences O2 and SABA for mild/mod exac25,26 Repeat eval @ 60-90 min after initial SABA [A] - O2 by cannula/mask, maintain SaO2 ≥90% (≥95% in some pts)27
- SABA28 (albuterol, levalbuterol) by NEB or MDI + spacer: up to 3 doses in 1st hr
- If recent hx PO steroid use or if no immediate response to tx: give PO steroids29
- Brief hx/exam;30,31 FEV1 or PEF;32 tests33 in select pts: CBC, lytes, theophylline, CXR, ECG
Repeat eval 60-90 min after initial SABA: [A]PEF or FEV1,32 [B]O2 sat, sx, hx/exam - If <40% PEF or FEV132 on repeat eval w/ severe s/sx34 or if pt high-risk35 per hx: give O2, hourly/continuous SABA & ipratropium NEBs, PO steroids,29 consider adjunct tx36
- If 40%-69% PEF or FEV132 on repeat eval w/ mod s/sx:37 SABA q60min x1-3 more hrs (as long as improving), give PO steroids, make admit decision w/in 4 hrs
- If ≥70% PEF or FEV132 on repeat eval w/ NL exam, no distress and if response sustained x60 min since last tx, prep for discharge home
Footnotes 25 Mild/Mod exac: PEF ≥40%, O2 sat >90%, w/ PCO2 <42 mmHg, increased RR, HR <120, may use accessory muscles, expiratory wheezes, pulsus paradoxus may be present (≤25 mmHg); dyspnea only w/ activity, speaks in phrases/sentences, may be agitated.
26 Exac defined as acute/subacute progressively worsening shortness of breath, cough, wheezing, chest tightness, or combination of these sx.
27 If pregnant or heart dz, maintain SaO2 ≥95%. Monitor sat until clear bronchodilator response. If sat monitoring not available, give O2 to pts w/ significant hypoxemia or FEV1 or PEF <40%.
28 SABA: [A]In mild/mod exac, MDI + spacer as effective as NEB, w/ proper technique:
• albuterol MDI + spacer 90 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn
• levalbuterol MDI + spacer 45 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
29 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
30 Brief hx of current/past exac, comorbidities:
• Time of onset, potential causes; severity vs previous exac
• Meds, last dose times, response to recent tx
• # previous asthma ED/hospital visits or unscheduled office visits, esp in last yr
• Hx LOC or intubation
• CV/pulm comorbidities; conditions that may be aggravated by steroids (DM, PUD, HTN, psychosis)
31 Brief exam: RR, HR; alertness, fluid status, cyanosis, distress, accessory muscle use, auscultation.
• Complications (pneumonia, pneumothorax, pneumomediastinum)
• Upper airway obstruction (foreign body, epiglottitis, vocal cord dysfxn, extrinsic/intrinsic tracheal narrowing)
32 FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat. FEV1 or PEF values that fluctuate widely = potential indication for ICU admission + close monitoring for resp failure. [C]
33 Don’t delay tx initiation for tests:
• CBC if fever/purulent sputum; leukocytosis common in asthma exac and w/in 1-2 hrs of steroid tx
• Theophylline: ✓ for toxicity if on drug
• Lytes: ✓ if CV dz or if on diuretics; SABA may cause transient ↓K, Mg, phos
• CXR: ✓ if suspect complicating CV/pulm process (CHF, pneumothorax, pneumomediastinum, pneumonia, lobar atelectasis)
• ECG: ✓ baseline ECG + cardiac monitor if >50 yo or if heart dz or COPD
34 Severe s/sx: O2 sat <90%, PaO2 <60 mmHg, PCO2 ≥42 mmHg on room air; RR often >30/min, HR>120, accessory muscle use, loud wheezes throughout insp + exp, pulsus paradoxus >25 mmHg; dyspnea @ rest, speaks in single words.
35 Risk factors for asthma-related death:
• Previous severe exac (eg, intubation, ICU admit); in past yr: ≥2 hospitalizations or ≥3 ED visits; in past mo: hospitalization or ED visit
• SABA use >2 containers/mo, difficulty perceiving sx or exac severity, no action plan, Alternaria sensitivity
• Low socioeconomic status/inner-city residence, Illicit drug use, major psychosocial problems
• CV dz, other chronic lung dz, chronic psych dz
36 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary. [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
37 Mod s/sx: O2 sat <90%-95% on room air; HR 100-120, pulsus paradoxus may be present (10-25 mmHg), accessory muscle use, loud pan-exp wheezes; dyspnea interferes w/ usual activity, speaks in phrases - not complete sentences.
-
At repeat assessment 60-90 min after initial bronchodilator tx
Impending/Actual resp arrest: too sick to measure PEF or FEV1 (or <25%), SaO2 <90% | no wheeze d/t poor air mvt | too dyspneic to speak, drowsy/confused Intubate immediately/semi-electively, 100% O2, bronchodilators, IV steroids, ICU admit - If apnea/coma, intubate38 immediately; if impending resp failure,39 prep for semi-elective intubation38
- 100% O2 monitor SaO2;40 consider ABG41 to assess PCO2
- SABA42 (albuterol, levalbuterol) NEB q20min x3 or continuously
- Plus ipratropium43 NEB q20min x3 or continuously
- Steroids IV: 40-80 mg/day44
- Brief hx/exam;45,46 tests47 in select pts: CBC, lytes, theophylline, CXR, ECG
- Admit/transfer to ICU
- If unresponsive to initial tx: consider48 MgSO4 or heliox, [B]but don’t delay intubation once deemed necessary38
Footnotes 38 Intubation in severe exac is difficult, so don’t delay once deemed necessary, [D]before resp arrest, by physician w/ extensive airway mgmt experience. Ketamine pre-med not shown to benefit in severe exac. Maintain volume status, as initiating ventilation may cause hypotension. Ventilation strategy: permissive hypercapnia [C]to minimize barotrauma. Consider consult for ventilator mgmt.
39 Persistent/increasing hypercapnia, exhaustion, depressed mental status suggest need for ventilator support. [D]Impending resp failure signs: PCO2 ≥42 mmHg, PEF or FEV1 <25% (FEV1 and PEF not required for initial eval of life-threatening exac), [D]bradycardia, absent pulsus paradox (suggesting resp muscle fatigue), absent wheeze d/t poor air mvt, paradoxical thoracoabdominal mvt, intercostal retraction, perspiring, unable to speak, drowsy/confused.
40 Maintain SaO2 ≥90% (≥95% in pregnant women and pts w/ heart dz). Monitor sat until clear bronchodilator response.
41 Consider ABG for suspected hypoventilation, severe distress, or when FEV1 or PEF is ≤25% after initial tx. Given ↑resp drive during exac, a PCO2 of ≥42 mmHg is a sign of severe airflow obstruction/impending resp failure. VBG may serve as a screen (eg, venous PCO2 >45 mmHg), but isn’t a substitute for ABG.
42 SABA [A]NEB options:
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn. OK to mix w/ ipratropium NEB soln
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
• ipratropium/albuterol NEB 0.5/2.5 mg 3 mL q20min x3 doses, then prn
43 Ipratropium not 1st-line as mono-tx. Use for severe exac [A]in ED/urgent care; not shown to add benefit once hospitalized. May mix w/ albuterol in same NEB or use premixed combo:
• ipratropium NEB 0.5 mg q20min x3 doses, then prn
• ipratropium/albuterol NEB 0.5/2.5 mg 3 mL q20min x3 doses, then prn
44 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, prednisone: 40-80 mg/day in 1 or 2 div doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
45 Brief hx of current/past exac, comorbidities:
• Time of onset, potential causes; severity vs previous exac
• Meds, last dose times, response to recent tx
• # previous asthma ED/hospital visits or unscheduled office visits, esp in last yr
• Hx LOC or intubation
• CV/pulm comorbidities; conditions that may be aggravated by steroids (DM, PUD, HTN, psychosis)
46 Brief exam: RR, HR; alertness, fluid status, cyanosis, distress, accessory muscle use, auscultation:
• Complications (pneumonia, pneumothorax, pneumomediastinum)
• Upper airway obstruction (foreign body, epiglottitis, vocal cord dysfxn, extrinsic/intrinsic tracheal narrowing)
47 Don’t delay tx initiation for tests:
• CBC if fever/purulent sputum; leukocytosis common in asthma exac and w/in 1-2 hrs of steroid tx
• Theophylline: ✓ for toxicity if on drug
• Lytes: ✓ if CV dz or if on diuretics; SABA may cause transient ↓K, Mg, phos
• CXR: ✓ if suspect complicating CV/pulm process (CHF, pneumothorax, pneumomediastinum, pneumonia, lobar atelectasis)
• ECG: ✓ baseline ECG + cardiac monitor if >50 yo or if heart dz or COPD
48 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
Severe exac: PEF or FEV1 <40%, SaO2 <90% | accessory muscle use, chest retraction, wheezes throughout insp + exp | severe sx @ rest, speaks only in single words O2, bronchodilators, PO steroids for severe exac49 - O2 by cannula/mask, maintain SaO2 ≥90% (≥95% in some pts)50
- SABA51 (albuterol, levalbuterol) NEB hourly/continuously
- Plus ipratropium52 NEB hourly/continuously
- Steroids PO53
- Consider adjunct tx54
Determine disposition based on response to continued tx, factoring risks55 for asthma-related death - If poor response (<40% PEF or FEV1,56 PCO2 ≥42 mmHg, severe sx,49 drowsy, confused): admit to ICU, oxygen, SABA hourly/continuously, IV steroids,53 consider adjuncts,54 possible intubation/ventilation
- If incomplete response (40%-69% PEF or FEV1,56 mild/mod sx):57 individualize decision to admit vs d/c, considering risk factors for asthma-related death55
- If good response (≥70% PEF or FEV1,56 response sustained ≥60 min since last tx, NL exam, no distress): d/c to home w/ SABA, steroid course,58 consider ICS; pt ed59 w/ action plan/follow-up asthma care60 in 1-4 wks [B]
Footnotes 49 Severe s/sx: O2 sat <90%, PaO2 <60 mmHg, PCO2 ≥42 mmHg on room air; RR often >30/min, HR>120, accessory muscle use, chest retractions, loud wheezes throughout insp + exp, pulsus paradoxus >25 mmHg; dyspnea @ rest, speaks in single words.
50 If pregnant or heart dz, maintain SaO2 ≥95%. Monitor sat until clear bronchodilator response. If sat monitoring not available, give O2 to pts w/ significant hypoxemia or FEV1 or PEF <40%.
51 SABA [A]NEB options:
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn. OK to mix w/ ipratropium NEB soln
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
• ipratropium/albuterol NEB 0.5/2.5 mg 3 mL q20min x3 doses, then prn
52 Ipratropium not 1st-line mono-tx. Add to SABA for severe exac [A]in ED/urgent care setting, not shown to add further benefit once hospitalized. May mix w/ albuterol in same NEB. NEB options:
• ipratropium NEB 0.5 mg q20min x3 doses, then prn
• ipratropium/albuterol NEB 0.5/2.5 mg 3 mL q20min x3 doses, then prn
53 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
54 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
55 Risk factors for asthma-related death:
• Previous severe exac (eg, intubation, ICU admit); in past yr: ≥2 hospitalizations or ≥3 ED visits; in past mo: hospitalization or ED visit
• SABA use >2 containers/mo, difficulty perceiving sx or exac severity, no action plan, Alternaria sensitivity
• Low socioeconomic status/inner-city residence, Illicit drug use, major psychosocial problems
• CV dz, other chronic lung dz, chronic psych dz
56 Very severe exac may preclude FEV1 or PEF measurement; use clinical eval instead. [D]FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat. FEV1 or PEF values that fluctuate widely = potential indication for ICU admission + close monitoring for resp failure. [C]
57 Mild/Mod exac: PEF = 40%, O2 sat >90%, increased RR, HR <120, may use accessory muscles, expiratory wheezes, pulsus paradoxus may be present (≤25 mmHg); dyspnea only w/ activity, speaks in phrases/sentences, may be agitated.
58 Total course duration for exac requiring ED visit/hospitalization: 5-10 days; continue until PEF reaches 70% of personal best. No need to taper for courses <7 days; probably no need to taper if <10 days (esp if on concurrent ICS). If on regular steroids, give supplemental doses, even after mild exac. [D]If high risk for nonadherence, consider IM steroid injection. [D]If pt not previously on ICS, considering starting [B]@ any time before PO steroid course ends.
59 Review meds, inhaler technique, [B]action plan. [B]Intensifying tx can reduce likelihood of relapse/recurrence; [A]continue greater use of SABA at home until sx and PEF stable; however, if bronchodilator use is excessive (eg, >12 puffs/day for >24 hrs) pt should seek care. Consider teaching PEF monitoring for pts w/ mod/severe persistent dz or hx severe exac [B]and pts who are poor perceivers of worsening sx. [D]If mod/severe persistent asthma or hx severe exac, have PO steroids and peak flow meter ready for home exac tx; [A]doubling ICS dose is not sufficient for home tx of exac in progress. [B]
60 Refer to asthma specialist if life-threatening exac or multiple hospitalizations. [B]
Mod exac: PEF or FEV1 40%-69%, SaO2 90%-95% | loud exp-only wheeze | dyspnea interferes w/ usual activity, speaks in phrases only SABA, PO steroids for mod exac61 - SABA62,63 (albuterol, levalbuterol) NEB or MDI + spacer q60min
- Steroids PO64
- If hypoxemic, O2 by cannula/mask, maintain sat ≥90% (≥95% for some pts)65
- Continue tx for 1-3 hrs as long as improving
Determine disposition w/in 4 hrs based on response to continued tx, factoring risks66 for asthma-related death - If poor response (<40% PEF or FEV1,67 PCO2 ≥42 mmHg, severe sx,68 drowsy, confused): admit to ICU, oxygen, SABA hourly/continuously, IV steroids,69 consider adjuncts,70 possible intubation/ventilation
- If incomplete response (40%-69% PEF or FEV1,67 mild/mod sx):71 individualize decision to admit vs d/c, considering risk factors for asthma-related death66
- If good response (≥70% PEF or FEV1,67 response sustained ≥60 min since last tx, NL exam, no distress): d/c to home w/ SABA, steroid course;72 consider ICS; pt ed73 w/ action plan, F/U asthma care74
Footnotes 61 Mod s/sx: O2 sat 90%-95% on room air; HR 100-120, pulsus paradoxus may be present (10-25 mmHg), accessory muscle use, loud pan-exp wheezes; dyspnea interferes w/ usual activity, speaks in phrases - not complete sentences.
62 SABA: [A]In mild/mod exac, MDI + spacer as effective as NEB, w/ appropriate technique.
• albuterol MDI + spacer 90 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn
• levalbuterol MDI + spacer 45 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
63 Ipratropium recommended for severe exac in ED. [A]
64 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, or prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
65 If pregnant or heart dz, maintain SaO2 ≥95%. Monitor sat until clear bronchodilator response. If sat monitoring not available, give O2 to pts w/ significant hypoxemia or FEV1 or PEF <40%.
66 Risk factors for asthma-related death:
• Previous severe exac (eg, intubation, ICU admit); in past yr: ≥2 hospitalizations or ≥3 ED visits; in past mo: hospitalization or ED visit
• SABA use >2 containers/mo, difficulty perceiving sx or exac severity, no action plan, Alternaria sensitivity
• Low socioeconomic status/inner-city residence, Illicit drug use, major psychosocial problems
• CV dz, other chronic lung dz, chronic psych dz
67 FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, √ O2 sat. FEV1 or PEF values that fluctuate widely = potential indication for ICU admission + close monitoring for resp failure. [C]
68 Severe s/sx: O2 sat <90%, PaO2 <60 mmHg, PCO2 ≥42 mmHg on room air; RR often >30/min, HR>120, accessory muscle use, chest retractions, loud wheezes throughout insp + exp, pulsus paradoxus >25 mmHg; dyspnea @ rest, speaks in single words.
69 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, or prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
70 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation [B]; though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
71 Mild/Mod exac: PEF ≥40%, O2 sat >90%, increased RR, HR <120, may use accessory muscles, expiratory wheezes, pulsus paradoxus may be present (≤25 mmHg); dyspnea only w/ activity, speaks in phrases/sentences, may be agitated.
72 Total course duration for exac requiring ED visit/hospitalization: 5-10 days; continue until PEF reaches 70% of personal best. No need to taper for courses <7 days; probably no need to taper if <10 days (esp if on concurrent ICS). If on regular steroids, give supplemental doses, even after mild exac. [D]If high risk for nonadherence, consider IM steroid injection. [D]If pt not previously on ICS, considering starting [B]@ any time before PO steroid course ends.
73 Review meds, inhaler technique, [B]action plan. [B]Intensifying tx can reduce likelihood of relapse/recurrence; [A]continue greater use of SABA at home until sx and PEF stable; however, if bronchodilator use is excessive (eg, >12 puffs/day for >24 hrs) pt should seek care. Consider teaching PEF monitoring for pts w/ mod/severe persistent dz or hx severe exac [B]and pts who are poor perceivers of worsening sx. [D]If mod/severe persistent asthma or hx severe exac, have PO steroids and peak flow meter ready for home exac tx; [A]doubling ICS dose is not sufficient for home tx of exac in progress. [B]
74 Refer to asthma specialist if life-threatening exac or multiple hospitalizations. [B]
Mild exac: PEF or FEV1 ≥70%, SaO2 >95% | mod wheeze, often only end-exp | dyspnea absent or only on walking, speaks sentences Assess readiness for d/c to home for pts w/ mild sx;75-77 continue onsite tx if needed - Once good response sustained ≥60 min since last tx, w/ NL exam, no distress, w/ minimal/absent sx: prepare to d/c home
- Until good response is sustained ≥60 min since last tx, continue SABA (albuterol, levalbuterol)78
Prepare for d/c to home once good response sustained ≥60 min post-tx - SABA79 tx continues upon d/c
- Continue steroid course80 [A]if started; consider ICS [B]at d/c
- Educate:81 meds, inhaler technique; [B]action plan; [B]F/U asthma care82 in 1-4 wks [B]
Footnotes 75 Mild s/sx: increased RR, usually not using accessory muscles, wheeze moderate (often only end-exp), HR <100, pulsus paradoxus absent (<10 mmHg); SaO2 >95% (test not usually necessary); dyspnea only w/ activity, prompt relief w/ SABA, able to lie down, talks in sentences, may be agitated.
76 Exac defined as acute/subacute progressively worsening shortness of breath, cough, wheezing, chest tightness or combination of these sx.
77 FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat.
78 SABA: [A]In mild/mod exac, MDI + spacer as effective as NEB, w/ appropriate technique.
• albuterol MDI + spacer 90 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn
• levalbuterol MDI + spacer 45 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
79 SABA tx upon d/c:
• albuterol MDI 90 mcg 2-6 puffs q3-4h prn
• levalbuterol MDI 45 mcg 2-6 puffs q3-4h prn
80 Total course duration for exac requiring ED visit/hospitalization: 5-10 days; continue until PEF reaches 70% of personal best. No need to taper for courses <7 days; probably no need to taper if <10 days (esp if on concurrent ICS). If on regular steroids, give supplemental doses, even after mild exac. [D]If high risk for nonadherence, consider IM steroid injection. [D]If pt not previously on ICS, considering starting [B]@ any time before PO steroid course ends.
81 Review meds, inhaler technique, [B]action plan. [B]Intensifying tx can reduce likelihood of relapse/recurrence; [A]continue greater use of SABA at home until sx and PEF stable; however, if bronchodilator use is excessive (eg, >12 puffs/day for >24 hours) pt should seek care. Consider teaching PEF monitoring for pts w/ mod/severe persistent dz or hx severe exac [B]and pts who are poor perceivers of worsening sx. [D]If mod/severe persistent asthma or hx severe exac, have PO steroids and peak flow meter ready for home exac tx; [A]doubling ICS dose is not sufficient for home tx of exac in progress. [B]
82 Refer to asthma specialist if life-threatening exac or multiple hospitalizations. [B]
-
Awaiting disposition based on response to continued tx
Poor response: PEF or FEV1 <40% (or too sick to measure), PCO2 ≥42 mmHg | drowsy/confused, dyspnea @ rest, speaks only in single words ICU admit for pts w/ severe s/sx:83,84 O2, bronchodilators, +/- additional tx - O2 to achieve SaO2 ≥90% (≥95% in some pts)85
- SABA86,87 (albuterol, levalbuterol) NEB hourly/continuously
- IV steroids88
- Consider adjunct tx89
- Prepare for possible intubation/ventilation90
Footnotes 83 Severe s/sx: O2 sat <90%, PaO2 <60 mmHg, PCO2 ≥42 mmHg on room air; RR often >30/min, HR>120, accessory muscle use, loud wheezes throughout insp + exp, pulsus paradoxus >25 mmHg; dyspnea @ rest, speaks in single words.
84 Very severe exac may preclude FEV1 or PEF measurement; use clinical eval instead. [D]FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat. FEV1 or PEF values that fluctuate widely = potential indication for ICU admission + close monitoring for resp failure. [C]
85 If pregnant or heart dz, maintain SaO2 ≥95%. Monitor sat until clear bronchodilator response. If sat monitoring not available, give O2 to pts w/ significant hypoxemia or FEV1 or PEF <40%.
86 SABA [A]NEB options:
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn. OK to mix w/ ipratropium NEB soln
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
87 Ipratropium recommended for severe exac in ED, [A]but not shown to add benefit once hospitalized.
88 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, or prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
89 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
90 Intubation in severe exac is difficult, so don’t delay once deemed necessary, [D]before resp arrest, by physician w/ extensive airway mgmt experience. Ketamine pre-med not shown to benefit in severe exac. Maintain volume status, as initiating ventilation may cause hypotension. Ventilation strategy: permissive hypercapnia [C]to minimize barotrauma. Consider consult for ventilator mgmt.
Incomplete response: PEF or FEV1 40%-69% | dyspnea interferes w/ activity Individualize admit decision for pts w/ mild/mod s/sx,91,92 based on factors including risks93 for asthma-related death, exac course/severity/duration, care access, home support, etc [C] If admit to hospital ward: - Continue O2 by nasal cannula/mask,94 inhaled SABA95 (w/o ipratropium),96 steroids97 (PO or IV), consider adjunct tx98
- Monitor vitals; O2 sat; PEF or FEV192 15-20 min after bronchodilator tx while acute, then at least daily until d/c: [C]if <25% and improves by <10% after tx (or fluctuates widely), consider ICU admit and resp failure monitoring [C]
- Once improved, d/c home w/ continued SABA,99 steroid course;100 consider ICS. Educate101 (meds, inhaler technique, [B]environment control, action plan); [B]schedule F/U w/ PCP/asthma specialist102 in 1-4 wks [B]
If d/c to home: observe for 30-60 min after last SABA tx; action plan, educate, F/U - SABA99 tx continues upon d/c
- Steroid course for 5-10 days;100 [A]consider ICS [B]at d/c
- Educate:101 meds, inhaler technique; [B]action plan [B]
- F/U w/ PCP or asthma specialist102 in 1-4 wks [B]
Footnotes 91 Mild/Mod exac: PEF ≥40%, O2 sat >90%, increased RR, HR <120, may use accessory muscles, expiratory wheezes, pulsus paradoxus may be present (≤25 mmHg); dyspnea only w/ activity, speaks in phrases/sentences, may be agitated.
92 FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat. FEV1 or PEF values that fluctuate widely = potential indication for ICU admission + close monitoring for resp failure. [C]
93 Risk factors for asthma-related death:
• Previous severe exac (eg, intubation, ICU admit); in past yr: ≥2 hospitalizations or ≥3 ED visits; in past mo: hospitalization or ED visit
• SABA use >2 containers/mo, difficulty perceiving sx or exac severity, no action plan, Alternaria sensitivity
• Low socioeconomic status/inner-city residence, Illicit drug use, major psychosocial problems
• CV dz, other chronic lung dz, chronic psych dz
94 If pregnant or heart dz, maintain SaO2 ≥95%. Monitor sat until clear bronchodilator response. If sat monitoring not available, give O2 to pts w/ significant hypoxemia or FEV1 or PEF <40%.
95 SABA [A]options. In mild/mod exac, MDI + spacer as effective as NEB, w/ proper technique.
• albuterol MDI + spacer 90 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• albuterol NEB 2.5-5 mg q20min x3 doses (or 10-15 mg/hr continuously), then 2.5-10 mg q1-4h prn
• levalbuterol MDI + spacer 45 mcg 4-8 puffs q20min up to 4 hrs, then q1-4h prn
• levalbuterol NEB 1.25-2.5 mg q20min x3 doses, then 1.25-5 mg q1-4h prn (not evaluated for continuous NEB)
96 Ipratropium recommended for severe exac in ED, [A]but not shown to add benefit once hospitalized.
97 Steroids benefit mod/severe exac & initial SABA nonresponders; [A](in alpha order) methylprednisolone, prednisolone, or prednisone: 40-80 mg/day in 1 or 2 divided doses. No known advantage for higher doses in severe exac; nor any advantage for IV vs PO, [A]assuming GI transit + absorption unimpaired. High doses of an ICS may be considered in the ED, but current evidence insufficient, thus PO systemic steroids are recommended. [B]
98 Adjuncts: consider for severe exacerbations unresponsive to initial tx, to decrease likelihood of intubation; [B]though don’t delay intubation once deemed necessary. [B]
• MgSO4 IV 2 g: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx [B]
• Heliox-driven albuterol NEB: consider if life-threatening exac, or if severe exac (PEF <40%) after 1 hr of tx; [B]though don’t delay intubation once deemed necessary [B]
Not recommended: theophylline/aminophylline, [A]antibiotics (except for comorbid conditions), [B]aggressive hydration, [D]chest PT, [D]mucolytics (eg, acetylcysteine), [C]sedatives/anxiolytics, [D]IV isoproterenol. [B]SC epi/terbutaline have no proven advantage over inhaled tx but may be used if NEB or MDI/spacer not available (eg, EMS). Insufficient data on IV β2-agonists, IV/PO LTRAs, noninvasive ventilation as adjuncts. [D]
99 SABA tx upon d/c:
• albuterol MDI 90 mcg 2-6 puffs q3-4h prn
• levalbuterol MDI 45 mcg 2-6 puffs q3-4h prn
100 Total course duration for exac requiring ED visit/hospitalization: 5-10 days; continue until PEF reaches 70% of personal best. No need to taper for courses <7 days; probably no need to taper if <10 days (esp if on concurrent ICS). If on regular steroids, give supplemental doses, even after mild exac. [D]If high risk for nonadherence, consider IM steroid injection. [D]If pt not previously on ICS, considering starting [B]@ any time before PO steroid course ends.
101 Review meds, inhaler technique, [B]action plan. [B]Intensifying tx can reduce likelihood of relapse/recurrence; [A]continue greater use of SABA at home until sx and PEF stable; however, if bronchodilator use is excessive (eg, >12 puffs/day for >24 hrs) pt should seek care. Consider teaching PEF monitoring for pts w/ mod/severe persistent dz or hx severe exac [B]and pts who are poor perceivers of worsening sx. [D]If mod/severe persistent asthma or hx severe exac, have PO steroids and peak flow meter ready for home exac tx; [A]doubling ICS dose is not sufficient for home tx of exac in progress. [B]
102 Refer to asthma specialist if life-threatening exac or multiple hospitalizations. [B]
Good response: PEF or FEV1 ≥70% sustained ≥60 min after last tx | no distress, NL exam Good response: PEF or FEV1 ≥70% sustained ≥60 min after last tx | no distress, NL exam - SABA104 tx continues upon d/c
- If steroids were started, continue course105 for 5-10 days; [A]consider ICS [B]at d/c
- Educate:106 meds, inhaler technique; [B]action plan [B]
- F/U w/ PCP or asthma specialist107 in 1-4 wks [B]
Footnotes 103 FEV1 preferred if readily available, [D]as pts may misreport PEF personal best for % predicted; and PEF can’t distinguish poor effort, obstruction vs restriction. If unable to perform these tests, ✓ O2 sat.
104 SABA tx upon d/c:
• albuterol MDI 90 mcg 2-6 puffs q3-4h prn
• levalbuterol MDI 45 mcg 2-6 puffs q3-4h prn
105 Total course duration for exac requiring ED visit/hospitalization: 5-10 days; continue until PEF reaches 70% of personal best. No need to taper for courses <7 days; probably no need to taper if <10 days (esp if on concurrent ICS). If on regular steroids, give supplemental doses, even after mild exac. [D]If high risk for nonadherence, consider IM steroid injection. [D]If pt not previously on ICS, considering starting [B]@ any time before PO steroid course ends.
106 Review meds, inhaler technique, [B]action plan. [B]Intensifying tx can reduce likelihood of relapse/recurrence; [A]continue greater use of SABA at home until sx and PEF stable; however, if bronchodilator use is excessive (eg, >12 puffs/day for >24 hrs) pt should seek care. Consider teaching PEF monitoring for pts w/ mod/severe persistent dz or hx severe exac [B]and pts who are poor perceivers of worsening sx. [D]If mod/severe persistent asthma or hx severe exac, have PO steroids and peak flow meter ready for home exac tx; [A]doubling ICS dose is not sufficient for home tx of exac in progress. [B]
107 Refer to asthma specialist if life-threatening exac or multiple hospitalizations. [B]
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