Asthma exacerbations {middle dot} 5: Assessment and management of severe asthma in adults in hospital

Guideline for the management of acute asthma in adults: 2013 update

“…[41,42] Note that yellowish sputum is frequent in acute asthma and is due to the high eosinophil content and not a sign of infection on its own. Intravenous fluids are administered in acute severe asthma based on the clinical setting, taking into account maintenance and replacement requirements and the need for calorie intake in patients unable to take oral fluids.…”

“…Their use in non-intubated patients has been associated with asthma deaths. [42,47,48] Physiotherapy may provoke bronchospasm and worsen the attack. It is only indicated if there is lobar collapse that persists despite initial bronchodilator and CS therapy.…”

Management of acute asthma in adults in the emergency department: nonventilatory management

“…Increasing heart rate is closely correlated with increasing severity of asthma, 104 and it is incorrect to assume that tachycardia is caused by use of a β 2 -adrenergic bronchodilator. 1 There is little correlation among the signs listed in Table 2, which develop independently, and their presence is not generally predictive of adverse outcomes. 2,13,102,103,105 The absence of these symptoms and signs does not guarantee that the exacerbation is unimportant, as patients who appear well may have severe airflow obstruction.…”

“…3,103,105 Patients who present with pretreatment FEV 1 or peak expiratory flow less than 25%-30% of predicted and those with values after treatment that are less than 40% of predicted should usually be admitted to hospital. 1,2,84,161 Patients who achieve FEV 1 or peak expiratory flow of at least 60% of predicted can usually be discharged safely, 84,162,163 provided adequate postdischarge care and follow-up are assured. For patients with intermediate FEV 1 or peak expiratory flow values (i.e., 40%-60% of predicted) after treatment, decision-making must be individualized on the basis of the examining physician's knowledge of the patient's previous ability to manage an exacerbation, the likelihood that the patient will be adherent with medications and instructions, and the home or environmental circumstances to which the patient will return.…”

“…1,2,84,161 Patients who achieve FEV 1 or peak expiratory flow of at least 60% of predicted can usually be discharged safely, 84,162,163 provided adequate postdischarge care and follow-up are assured. For patients with intermediate FEV 1 or peak expiratory flow values (i.e., 40%-60% of predicted) after treatment, decision-making must be individualized on the basis of the examining physician's knowledge of the patient's previous ability to manage an exacerbation, the likelihood that the patient will be adherent with medications and instructions, and the home or environmental circumstances to which the patient will return. If there are concerns about adherence, particularly historical features suggesting that the patient has a high risk of fatal asthma (Table 1), a cautious approach is prudent and a short admission (one or two days) may be indicated.…”