Importance of immediate assessment of acute severe asthma

The most efficacious form of treatment for acute episodes of asthma are aerosolized beta agonists. These drugs provide three to four times more relief than intravenous aminophylline.


In emergency situations, they can be given every 20 minutes by hand held nebulizer for three doses. Thereafter, the frequency can be reduced to every 2 h until the attack has subsided.

Aminophylline can be added to the regimen after the first hour in an attempt to speed resolution.Acute episodes of bronchial asthma represent one of the most common respiratory emergencies seen in the practice of medicine and it is essential that the physician recognize which episodes of airway obstruction are life threatening and which patients demand what level of care.

This can be readily accomplished by assessing selected clinical parameters in combination with measures of expiratory flow and gas exchange.

The presence of a paradoxical pulse, use of accessory muscles, and marked hyperinflation of the thorax signify severe airway obstruction, and failure of these signs to remit.

Within short order following aggressive therapy mandates objective monitoring of the patient using arterial blood gases and the peak expiratory flow rate or FEV.

In general, there is a direct correlation between the severity of the obstruction with which the patient presents and the time that it takes to resolve it.

Those individuals with the most impairment typically require the most extensive therapy for resolution. If the PEFR or FEV is equal to or less than 20 percent of predicted on presentation and does not double within an hour of receiving the preceding therapy.

The patient is likely to require extensive treatment including glucocorticoids before the obstruction dissipates. In such circumstances, if the clinical signs of a paradoxical pulse and accessory muscle use of are diminishing, and if PEFR is increasing, there is no need to change medications or doses.

One need only to continue to follow the patient. If, however, PEFR is falling or the magnitude of the pulsus paradoxicus is increasing, serial measures of arterial blood gas are required as well as a reconsideration of the therapeutic modalities being employed.

If the patient has hypocarbia, one can afford to continue the current approaches a while longer. On the other hand, if the PaCO2 is within the normal range or is elevated.

The patient should be monitored in an intensive care setting, and therapy should be intensified in order to reverse or arrest the patient’s respiratory failure.

The goal of chronic therapy is to achieve a stable, asymptomatic state with the best pulmonary function possible. As in the acute situation, first line therapy should be a beta agonist by inhalation.

In patients who have difficulty-coordinating inhalation with activation of a metered dose inhaler, a spacing device should be incorporated. If nocturnal complaints continue, a long acting theohylline compound given at night may be included.

In patients with persistent symptoms and unstable lung function despite adequate bronchodilator therapy, treatment with inhaled steroids and mast cell stabilizing agents should be instituted.

Since these agents frequently take weeks to lower airway reactivity, it may be efficacious to start a short but intense course of oral glucocorticoids to speed the remission.

During this process, PEFR should be monitored and medication adjustments should be based on objective changes in lung function as well as the patient’s symptoms.

Once the asthma has stabilized, there should be a systematic reduction in medication, beginning with the most toxic, to find the minimum required to maintain the patient’s well being. The mortality from asthma is small.

The most recent figures indicate less than 5000 deaths per year out of a population approximately 10 million in patients at risk. Death rates, however, appear to be rising in inner city areas where there is limited availability of health care.

Information on the clinical course of asthma suggests a good prognosis for 50 – 80 percent of all patients, particularly those whose disease is mild and develops in childhood.

The number of children still having asthma 7 to 10 years after the initial diagnosis varies from 26 – 78 percent, with an average of 46 percent; however, the percentage who continue to have severe disease is relatively low.

Unlike the other airway diseases such as chronic bronchitis, asthma is not progressive. Although there are reports of patients with asthma developing irreversible changes in lung function.

These individuals frequently have comorbid stimuli such as cigarette smoking that could account for these finding. Even when untreated, asthmatics do not continuously move from mild to severe disease with time.

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