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ASTHMA EXACERBATION, Does not require admission:, While awaiting…

- - - - No features of acute severe or life-threatening
  - - - AND / OR they have had a previous near-fatal asthma attack. Consider admission if they have factors that warrant a lower threshold for admission, such as:
        
        Age under 18 years.
        
        Poor adherence
        
        Psychological i.e. depression, alcohol misuse
        
        Lives alone, social isolation
        
        Exacerbation despite adequate dose of steroids prior
        
        1 more item...
        
        NOT NICE CKS --- If completely resolved: observe for 1 hour (4 hours if lives far from the health centre) then advise salbutamol for 24 to 48 hours (2 to 4 puffs every 4 to 6 hours depending on clinical evolution) and prednisolone PO to complete 3 days of treatment.
        – If only partially resolved, continue with salbutamol 2 to 4 puffs every 3 to 4 hours if the attack is mild; 6 puffs every 1 to 2 hours if the attack is moderate, until symptoms subside, then when the attack is completely resolved, proceed as above.
- - - - HR at least 110/min in > 12 years, 125 in 5 - 12 years, and 140 in 2 - 5 years old
        
        Inability to complete sentences in one breath, or accessory muscle use
        
        inability to feed (infants), with sats of at least 92%.
        
        MANAGEMENT
        
        ADMIT if symptoms persist after initial bronchodilator treatment :red_flag:
        
        ? nebs or just SABA inhaler
- - - - Altered consciousness, or exhaustion, or confusion.
        
        cardiac arrhythmia, or hypotension
        
        cyanosis, or poor respiratory effort, or silent chest,
- - - - Once symptoms subsided, return to SABA PRN --up to QDS (not exceeding 4-hourly).
        
        Monitor PEFR and symptoms, and seek medical advice if either worsening
        
        ? how often to monitor
- - - - Consider advising quadrupling ICS at the onset of an asthma attack.
        
        For those people who are suitable for quadrupled ICS give the first dose of a course of prednisolone (40–50 mg for adults, 30–40 mg for > 5 years, 20 mg for 2–5 years, and 10 mg for < 2 years).
        
        If medication cannot be swallowed, consider IM methylprednisolone 160 mg as an alternative in adults, or IV hydrocortisone 100 mg if > 5 years, and 50 mg if 2–5 years.
        Monitor PEFR and SATS to assess response
        
        how to quadruple??
    - - CHILD: 1 puff every 30-60 seconds - up to 10 puffs
        
        If the response is poor, give further doses while awaiting hospital admission, and switch to a nebulizer if available.
    - - A short pause between puffs may be necessary to avoid hyperventilation with puffs given one at a time and inhaled with five normal tidal breaths
- - - - Address preventable causes i.e. exposure to trigger factors or non-compliance
        
        Lifestyle advice - vaccinations, diet, exercise, and smoking.
        
        Advise on recognizing poor asthma control (worsening symptoms or peak flow readings), early signs of an exacerbation (sudden persistent worsening symptoms), what to do at the early signs of an exacerbation (increasing beta-2 agonist and starting oral corticosteroids), and seeking medical help if symptoms are not controlled.
        
        Consider rx supply of oral steroids for rescue - and written information advising to start taking them during early signs of an exacerbation, and to contact a primary healthcare professional if they start treatment or are uncertain about whether to start treatment.
        Ensure that the person has received self-management education and a personalised asthma action plan.
        
        For people > 18 years with a history of asthma attacks, who are not well-controlled with either medium dose ICS or a combination ICS/LABA inhaler, a combined LABA/ICS can be used as reliever therapy when required, in addition to a regular preventer.
        
        However, people taking rescue doses of their combination inhaler once daily or more on a regular basis should have their treatment reviewed.
        
        Consider referral to respiratory if 2 asthma attacks within 12 months. :silhouettes: