The acute asthma attack

Question 1

Red flags

Answer 1

Most imp;
Silent chest
bradycardia
Anaphylaxis
Pregnancy

PEFR
Oxygen saturation (SpO2)
Inability to talk
Cyanosis
Feeble respiratory effort, exhausted
Hypotension

Question 2

Levels of severity of acute asthma exacerbation

Answer 2

Question 3

Adult dosage

Answer 3

Continuous nebulised salbutamol with O2 8 L/min

if nebuliser not available:

• 6–12 puffs of B-agonist inhaler, preferably with spacer, using one loading puff at a time following by 4–6 breaths

Aim to maintain SpO2 > 95% with O2.

Insert IV line

Question 4

If slow response

Answer 4

A second nebuliser using salbutamol 2 mL

Ipratroprium bromide 2 ml, with 4 ml, N saline

Hydrocortisone 250 mg IV statim

Question 5

If poor response or if in extremis

Answer 5

Magnesium sulfate 25–100 mg/kg (max. 1.2–2 g) IV over 20 minutes

Adrenaline 0.5 mg 1:1000 IM or 1:10 000 IV (1 mL, over 30 seconds) with monitor

or Salbutamol 200–400 mcg IV over 2 mins

CXR to exclude complications

ABG /pulse oximetry then

IV infusion of salbutamol and hydrocortisone

Question 6

Children

Answer 6

Should be referred to an intensive care unit:

< 6 yrs: salbutamol, 6 puffs (can repeat 3 times), if severe add ipratropium bromide 4 puffs

≥ 6 yrs: Salbutamol 12 puffs (can repeat 3 times), if severe add ipratropium 8 puffs

Continuous nebulised 0.5% salbutamol via mask

Oxygen flow 6–8 L/min through nebuliser (best option)

IV infusion of:

• –salbutamol 5 mg/kg/min
• –hydrocortisone 4 mg/kg statim, then 1–2 mg/kg for 2 more days

Question 7

Common mistakes in children

Answer 7

Using assisted mechanical ventilation (can be dangerous—main indications are physical exhaustion and cardiopulmonary arrest)

Not giving high flow oxygen

Giving excessive fluid

Giving suboptimal bronchodilator therapy

Question 8

Criteria for referral to hospital and/or hospital admission

Answer 8