Mount Carmel Health Partners Clinical Guidelines Asthma

Asthma Clinical Guideline Definition: Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, reversible airflow obstruction, bronchial hyper-responsiveness, and an underlying inflammation. The interaction of these features of asthma determines the clinical manifestations and severity of asthma and the response to treatment. Management of Acute Asthma Exacerbation Quick Guide to Asthma Spirometry is recommended to establish the diagnosis of asthma. A stepwise approach to pharmacologic treatment to achieve and maintain control of asthma should take into account the safety of treatment, potential for adverse effects, and the cost of treatment required to achieve control. Initial history (including detailed asthma history) and physical examination • Vital signs, including oxygen saturation, heart rate, and respiratory rate • Consider PEF or ETCO2 monitoring Evaluation Treatment Mild • Mild end-expiratory wheezing only • Oxygenation >90% • Minimal to no use of accessory muscles • Vital signs within normal limits • Speaking in full sentences • FEV1 or PEF >70% predicted Moderate • Oxygenation >90% • Accessory muscle usage but still able to speak • Elevated respiratory rate • Elevated heart rate • FEV1 or PEF 40%-69% predicted • Give inhaled SABA by nebulizer or MDI + spacer • Administer first dose of oral steroids • High dose SABA + ipratropium by nebulizer or MDI+ spacer every 20 min. for first hour • Administer first dose of oral steroids immediately No Yes Continue to “moderate” path • Consider initiating ICS or adjusting current dose as indicated • Continue treatment with inhaled SABA, 2-6 puffs every 3-4 hours, as needed • Discharge home with: - Continued oral steroid therapy for 5 days - Clear and simple return precautions - Reliable follow-up - Instruction on proper technique for using inhaled medication with spacer • High dose SABA + ipratropium by nebulizer or MDI+ spacer every 20 min. for first hour • Consider continuous nebulized albuterol therapy if no clinical improvement with intermittent therapy • Administer first dose of oral steroids immediately • Consider magnesium IV and adjunctive therapies Reassess. Is there improvement? Reassess. Is there improvement? Yes Severe • Oxygenation <90% • Significant accessory muscle usage • Vital signs with significant stress • Altered mental status • FEV1 or PEF <40% predicted • Continue current therapy • Make admit vs. discharge decision <4 hours from arrival • If stable in <4 hours and ready for discharge, refer to “mild” path for discharge planning • If worsening, move to “severe” path Reassess. Is there improvement? No Yes No Admit to hospital • Admit to hospital • If worsening, move to “severe” path Evidence of impending or actual respiratory arrest: • Prepare for intubation without delay • Continue inhaled SABA while preparing for intubation • Recommended RSI medications: Ketamine 2 mg/kg + rocuronium or Succinylcholine • If not requiring intubation at this time, consider starting NIPPV • If not improved, consider admission to hospital ICU Abbreviations: ETCO₂, end-tidal carbon dioxide; ICS, inhaled corticosteroids; IV, intravenous; MDI, metered-dose inhaler; NIPPV, noninvasive positive-pressure ventilation; PEF, peak expiratory flow; RSI, rapid sequence intubation; SABA, short-acting beta agonist; FEV1, forced expiratory volume in 1 second. October 2017