Articles
Managing Inpatient Drug Withdrawal Styroke Thrombectomy Pathway Dysphagia Diagnosis, treatment and management of UTI in children (D&G) Hospital at Home (H@H) Infant hip clinic referral form Vaccination referral form Assessment and management of babies who are accidentally dropped in hospital DGRI NNU Guideline for Management of Cord Blood Gas Results NNU Admission Criteria Antenatal Drugs for NAS Monitoring Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – Methadone/Buprenorphine Prescribing Advice on Admission – Corticosteroids Prescribing Advice on Admission – Items Not Prescribed by GP Prescribing Advice on Admission – Patients on Chemotherapy Regimes Prescribing Advice on Admission – Medication for Parkinson’s Disease Prescribing Advice on Admission – Insulin Prescribing Advice on Admission Medical Emergencies in Eating Disorders (MEED) Gentamicin & Vancomycin HIV Testing Guidelines Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Greener Inhaler Prescribing C4 Predischarge Beds Handover Safe and Secure Handling of Medicines Blood Glucose & Steroids IV Fentanyl & Morphine for Acute Pain in Adults Assessment & Management of Acute Pain Hospitalised and Has Coronavirus19 Infection (No suspected Viral Pneumonia Syndrome) Hospitalised Due to Coronavirus19 with Likely Viral Pneumonia Bi-Level NIV S/T Guidelines for CCU Phase Bi-Level NIV S/T Guidelines for ED Phase Adults With Incapacity Premenstrual Syndrome Pelvic USS Boarding Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Acute Kidney Injury (AKI) SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Pneumothorax – ACP Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Kidney Transplantation Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social Assessment Breathlessness with Abnormal CXR Polymyalgia Rheumatica Rheumatoid Arthritis Ureteric Colic & Renal Stones Intravascular Catheter Related Blood Stream Infection Care of Vascular Access Urinary Incontinence Peritoneal Dialysis Related Peritonitis The First Seizure Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry The Diabetic Foot Subcutaneous Insulin Diabetes and Acute Coronary Syndrome Hyperosmolar Hyperglycaemic State Multiple Sclerosis Coma
 
 
In this section Close
Home | Articles | Respiratory | Acute Asthma

Acute Asthma

Last updated 14th September 2022

Risk of Dying From Asthma

  1. Most asthma deaths are preventable. Disease factors, poor medical management and patient’s behaviour/psychosocial status all predict a poor outcome
  2. Disease factors – most deaths occur in chronic severe asthma
  3. Poor medical management – inadequate assessment, treatment, follow up and referral. Beware inappropriate prescription of Beta blockers and NSAIDs
  4. Behavioural/psychosocial factors -see section below

SIGN/BTS Recognise 5 Categories of Acute Asthma As Follows

1 Near Fatal Asthma

  • Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

2 Life Threatening Asthma

Any one of the following in a patient with severe asthma

  • Altered conscious level
  • Exhaustion
  • Hypotension
  • Cyanosis
  • Silent chest
  • Poor respiratory effort
  • PEF <33% of best or predicted
  • SpO2 <92%
  • PaO2 <8kPa
  • “normal” PaCO2 4.6-6.0kPa

3 Acute Severe Asthma

Any one of:

  • inability to complete sentences in one breath
  • PEF 33-50% best or predicted
  • RR >25/min
  • HR > 110/min

4 Moderate Asthma

Increasing symptoms but…

  • No features of acute severe asthma and…
  • PEF 50-75% best or predicted

5 Brittle Asthma

  • Type 1 – wide PEF variabilty >40% diurnal variation for >50% of the time over a period of >150 days despite intensive therapy
  • Type 2 – sudden severe attacks on a background of apparently well controlled asthma

Investigations

  1. PEFR or FEV1 – PEFR easier during acute attack
  2. SpO2 – noting whether on or off oxygen
  3. Gases if SpO2 <92% on or off oxygen
  4. CXR – to exclude pneumothorax and consolidation
  5. Routine bloods including WCC and CRP

Interpretation of Arterial Blood Gases

  1. Hydrogen ions >45 indicates acidosis
  2. Normal PaO2 >10.6 kPa – significantly hypoxic if < 8 kPa
  3. Normal PaCO2 4.7-6.0 kPa isn’t normal in the context of acute asthma – indicates potentially life threatening asthma
  4. CO2 retention if >6.0 kPa – indicates near fatal asthma

Immediate Management Acute Severe Asthma

  1. Oxygen – for all hypoxaemic patients with acute severe asthma using face mask, venturi mask or nasal cannulae to maintain SpO2 94-98%
  2. Salbutamol – 5mg 4-6 hourly by oxygen driven nebuliser.
  3. Ipratropium – 0.5mg 4-6 hourly by oxygen driven nebuliser
  4. Prednisolone – 40-50mg od unless tabs cannot be swallowed and retained in which case Hydrocortisone 100 mg qds IV. Continue Prednisolone at 40-50mg daily for at least 5 days or until recovery. Doses do not need tapering unless on maintenance steroid or steroid required for three or more weeks
  5. Do not give antibiotics routinely and avoid sedatives

If Life Threatening Features Present

  1. Discuss further options with senior clinician ± intensivists
  2. Consider single dose Magnesium 1.2-2.0g IV (which is 2.4 – 4.0ml of 50% magnesium sulfate injection) in 50ml or 100ml of 0.9% sodium chloride over 20 minutes.
  3. Consider nebulised Salbutamol more frequently eg 5mg up to every 15-30 minutes or continuously at 5-10mg/hr using an appropriate nebuliser.

Additional Measures if Not Settling

  1. Discuss with senior clinician, consider magnesium if not already given, more frequent nebulised salbutamol as above
  2. Senior clinician may recommend IV salbutamol, IV aminophylline or progression to NIV/full ventilation. If NIV should be on ICU because of risk of cardiovascular collapse.
  3. IV salbutamol – use infusion formulation 5mg/ml. Add 5ml solution to 500ml Dextrose 5% or Saline 0.9% to give concentration 10 micrograms/ml and infuse at 5 micrograms/min (30ml/hr) adjusting according to response and heart rate , in range 3-20 micrograms/min (18-120ml/hr)
  4. IV Aminophylline – 5mg/kg (usually 250mg) in 5% dextrose over 20 min unless already taking oral theophylline. Can be continued as infusion of 500 micrograms/kg/hr, adjusted to maintain plasma concentration 10-20mg/L, if necessary

When to Call The Anaesthetist

  1. If any features if life threatening asthma present.
  2. Or if PaO2 < 6kPa despite high flow O2, or if PaCO2 > 6 kPa or rising.

Referral to Respiratory Nurse Specialist

  1. All patients with asthma should be referred to a respiratory nurse specialist within 48 hours of admission.
  2. Those based at DGRI are Phyllis Murphie (33860) and Yvonne Scott (32007)

Asthma Discharge Bundle

  1. The Respiratory Team have prepared an asthma discharge bundle which can be accessed by clicking on the link below.  If printing this for a patient, please ensure you send to the COLOUR print queue – “followyou_colour” as there is coloured text on the reverse.
  2. It has a tear-off slip at the bottom which is double sided.  This provides the patient with a temporary asthma action plan, worsening advice, advice on when to see their GP and links to asthma education.

Behavioural/Psychosocial Factors Predicting Poor Outcome

These are one or more of:

  • Poor compliance
  • Failure to attend appoinments
  • Fewer GP contacts
  • Frequent home visits
  • Self discharge from hospital
  • Psychosis, depression, self harm
  • Major tranquilliser use
  • Denial
  • Alcohol or drug abuse
  • Learning difficulties
  • Employment/income problems
  • Social isolation

Aspirin, NSAIDs and Asthma

  1. A significant number of asthmatics are allergic to aspirin/NSAIDs
  2. Avoid in patients with previous asthmatic reaction to aspirin/NSAIDs and in those at high risk ie asthma with nasal polyps or chronic rhinitis.
  3. For all other asthmatics in whom aspirin or NSAID indicated, inform patient of risk and observe for 3 hours after first dose

Links

Content updated by Yvonne Scott & Alison Moore