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Managing acute asthma in clinical settings
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HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT
Managing acute asthma in clinical settings
Overview
Acute asthma management is based on:
• assessing severity (mild/moderate, severe or life-threatening) while starting bronchodilator treatment immediately
• administering oxygen therapy, if required, and titrating oxygen saturation to target of 92–95% (adults) or at least 95%
(children)
• completing observations and assessments (when appropriate, based on clinical priorities determined by baseline
severity)
• administering systemic corticosteroids within the first hour of treatment
• repeatedly reassessing response to treatment and either continuing treatment or adding on treatments, until acute
asthma has resolved, or patient is transferred to an intensive care unit or admitted to hospital
• observing the patient for at least 1 hour after dyspnoea/respiratory distress has resolved, providing post-acute care and
arranging follow-up.
Figure. Managing acute asthma in adults
Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/65
Figure. Managing acute asthma in children
Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/67
Figure. Initial management of life-threatening acute asthma in adults and children
Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/94
Note: Definitions of severity classes for acute asthma used in this handbook may differ from those used in published clinical trials and
other guidelines that focus on, are or restricted to, the management of acute asthma within emergency departments or acute care
facilities. In this handbook, the severity of flare-ups and acute asthma is defined consistently across all Australian clinical settings (including
community-based clinics and emergency departments). Accordingly, the classification of flare-ups and the classification of acute asthma
overlap (e.g. a flare-up is considered to be at least ‘moderate’ if it is troublesome enough to cause the patient or carers to visit an
emergency department or seek urgent treatment from primary care, yet it might be assessed as ‘mild’ acute asthma within acute services). Table. Severity classification for flare-ups (exacerbations)
Severity
Mild
Definition
Example/s
Worsening of asthma control that is only
More symptoms than usual, needing
just outside the normal range of variation
reliever more than usual (e.g. >3 times
for the individual (documented when
within a week for a person who normally
patient is well)
needs their reliever less often), waking up
with asthma, asthma is interfering with
usual activities
A gradual reduction in PEF† over several
days
Moderate
Events that are (all of):
1
Severity
Definition
• troublesome or distressing to the
patient
• require a change in treatment
Example/s
More symptoms than usual, increasing
difficulty breathing, waking often at night
with asthma symptoms
• not life-threatening
• do not require hospitalisation.
Severe
Events that require urgent action by the
Needing reliever again within 3 hours,
patient (or carers) and health
difficulty with normal activity
professionals to prevent a serious
outcome such as hospitalisation or death
from asthma
† Applies to patients who monitor their asthma using a peak expiratory flow meter (single PEF measurements in clinic not
recommended for assessing severity of flare-ups).
Note: the ATS/ERS Task Force recommended that severe exacerbations should be defined in clinical trials as the use of
oral corticosteroids for 3 or more days. However, this definition is not applicable to clinical practice.
Source: Reddel H, Taylor D, Bateman E et al. An official American Thoracic Society/European Respiratory Society
statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J
Respir Crit Care Med 2009; 180: 59-99. Available at: http://www.thoracic.org/statements
Asset ID: 35
In this handbook, the categories of ‘mild’ and ‘moderate’ acute asthma have been merged to avoid confusion between terminologies
traditionally used at different levels of the health system. Mild acute asthma can usually be managed at home by following the person’s
written asthma action plan.
See: Preparing written asthma action plans for adults See: Providing asthma management education for parents and children In this section
Primary assessment
Completing a rapid primary assessment and starting initial treatment
http://www.asthmahandbook.org.au/acute-asthma/clinical/primary-assessment
Bronchodilators
Giving bronchodilator treatment according to severity and age
http://www.asthmahandbook.org.au/acute-asthma/clinical/bronchodilators
Secondary assessment
Completing secondary assessments and reassessing severity
http://www.asthmahandbook.org.au/acute-asthma/clinical/secondary-assessment
Corticosteroids
Starting systemic corticosteroid treatment
http://www.asthmahandbook.org.au/acute-asthma/clinical/corticosteroids
Response
2
Assessing response to treatment
http://www.asthmahandbook.org.au/acute-asthma/clinical/response
Add-on treatment
Continuing treatment and considering additional treatment
http://www.asthmahandbook.org.au/acute-asthma/clinical/add-on-treatment
Post-acute care
Providing post-acute care
http://www.asthmahandbook.org.au/acute-asthma/clinical/post-acute-care
3
Figure. Managing acute asthma in adults
For more details on the initial management of life-threatening acute asthma, see Initial management of life-threatening acute asthma in adults and children
4
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5
Figure. Managing acute asthma in children
For more details on the initial management of life-threatening acute asthma, see Initial management of life-threatening acute asthma in adults and children
6
7
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8
Figure. Initial management of life-threatening acute asthma in adults and children
Initial management of life-threatening acute asthma. This figure shows in more detail the first stages (‘immediate’ and ‘within minutes’) shown in the figures Managing acute asthma in adults
and Managing acute asthma in children
9
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10
HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > PRIMARY ASSESSMENT
Completing a rapid primary assessment and starting initial
treatment
Recommendations
Assess severity of the acute asthma episode (moderate, severe or life-threatening) based on clinical observations and
pulse oximetry measured while the person is breathing air, and administer a bronchodilator immediately.
Notes
• If oxygen therapy has already been started, it is not necessary to cease oxygen to measure pulse oximetry.
• Pregnancy is not a contraindication for bronchodilators in acute asthma.
Table. Rapid primary assessment of acute asthma in adults and children
Mild/Moderate
Can walk, speak whole
Severe
Any of these findings:
Life-threatening
Any of these findings:
sentences in one breath
• Use of accessory muscles of
• Reduced consciousness or
(For young children: can move
neck or intercostal muscles
around, speak in phrases)
or 'tracheal tug' during
• Exhaustion
Oxygen saturation >94%
inspiration or subcostal
• Cyanosis
recession ('abdominal
• Oxygen saturation <90%
breathing')
• Poor respiratory
• Unable to complete
sentences in one breath due
collapse
effort, soft/absent breath
sounds
to dyspnoea
• Obvious respiratory distress
• Oxygen saturation 90–94%
Notes
The severity category may change when more information is available (e.g. pulse oximetry, spirometry) or over time
The presence of pulsus paradoxus (systolic paradox) is not a reliable indicator of the severity of acute asthma.
If oxygen therapy has already been started, it is not necessary to cease oxygen to measure pulse oximetry.
Oxygen saturation levels are a guide only and are not definitive; clinical judgment should be applied.
Definitions of severity classes for acute asthma used in this handbook may differ from those used in published clinical
trials and other guidelines that focus on, are or restricted to, the management of acute asthma within emergency
departments or acute care facilities.
Asset ID: 74
Table. Initial bronchodilator treatment in acute asthma (adults and children 6 years and over)
• Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.
• Do not give oral salbutamol.
11
• Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with
inhaled or IV salbutamol.
Mild/Moderate
Severe
Life-threatening
Give salbutamol† 4-12 puffs (100
Give salbutamol† 12 puffs (100
Give salbutamol 2 x 5 mg nebules
mcg/actuation) via pMDI and
mcg/actuation) via pMDI and
via continuous nebulisation
spacer
spacer
driven by oxygen‡
Repeat every 20-30 minutes for
If patient unable to breathe
Maintain oxygen saturations:
the first hour if required (sooner,
through a spacer, give 5 mg
if needed to relieve
nebule via nebuliser‡
Children: 95% or higher
Start oxygen therapy if oxygen
Arrange immediate transfer to
saturation <95% and titrate to
higher-level care
breathlessness)
target:
Adults: 92% or higher
When dyspnoea improves,
Adults: 92–95%
consider changing to salbutamol
Children: 95% or higher
via pMDI plus spacer or
Repeat salbutamol as needed.
intermittent nebuliser‡ (doses as
Give at least every 20 minutes
for severe acute asthma)
for first hour (3 doses)
† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)
‡ See Table. Using nebulisers in acute asthma
Note: To deliver nebulised bronchodilators in a patient receiving oxygen therapy, use an air-driven compressor
nebuliser and administer oxygen by nasal cannulae.
Asset ID: 80
Table. Initial bronchodilator treatment in acute asthma (children 0–5 years)
• Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.
• Do not give oral salbutamol.
• Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with
inhaled or IV salbutamol.
• Closely monitor level of consciousness, fatigue, oxygen saturation, respiratory rate and heart rate. If symptoms do
not respond, contact a paediatrician or senior clinician and reconsider the diagnosis. • In children under 12 months old, asthma is less likely to be the cause of wheezing than other conditions (e.g.
bronchiolitis, pneumonia).
Mild/Moderate
Severe
Life-threatening
Give salbutamol† 2-6 puffs (100
Give salbutamol† 6 puffs (100
Give salbutamol 2 x 2.5 mg
mcg/actuation) via pMDI and
mcg/actuation) via pMDI and
nebules via continuous
spacer plus mask
spacer plus mask
nebulisation driven by oxygen‡
Repeat every 20-30 minutes for
If patient unable to breathe
Maintain oxygen saturation at
the first hour if needed (sooner, if
through a spacer, give 2.5 mg
95% or higher
needed to relieve
breathlessness)
‡
nebule via nebuliser
Arrange immediate transfer to
Start supplementary oxygen if
higher-level care
oxygen saturation <95%
12
Mild/Moderate
Severe
Life-threatening
Titrate to 95% or higher
When dyspnoea improves,
Repeat salbutamol as needed.
Give at least every 20 minutes
for first hour (3 doses)
consider changing to salbutamol
via pMDI plus spacer or
‡
intermittent nebuliser (doses as
for severe acute asthma)
† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)
‡ See Table. Using nebulisers in acute asthma
Asset ID: 81
Table. Using pressurised metered-dose inhalers in acute asthma
Administration of salbutamol by health professionals for a patient with acute asthma
1. Use a salbutamol pressurised metered-dose inhaler (100 mcg/actuation) with a spacer that has
already been prepared (see note).
2. Shake inhaler and insert upright into spacer.
3. Place mouthpiece between the person’s teeth and ask them to seal lips firmly around mouthpiece.
4. Fire one puff into the spacer.
5. Tell person to take 4 breaths in and out of the spacer.
6. Remove the spacer from mouth. Shake the inhaler after each puff before actuating again. (This can
be done without detaching the pressurised metered-dose inhaler from the spacer.)
Notes
The process is repeated until the total dose is given (e.g 12 puffs for an adult, 6 puffs for a child). Different doses are
recommended for patients and carers giving asthma first aid in the community.
New plastic spacers should be washed with detergent to remove electrostatic charge (and labelled), so they are ready
for use when needed. In an emergency situation, if a pre-treated spacer is not available, prime the spacer before use by
firing 20 puffs of salbutamol into the spacer.
Priming or washing spacers to reduce electrostatic charge before using for the first time is only necessary for plastic
spacers; polyurethane spacers (e.g. E-Chamber, AeroChamber Plus), disposable cardboard spacers and metal spacers
do not require treatment to reduce electrostatic charge.
For small children who cannot form a tight seal with their lips around the spacer mouthpiece, attach a well-fitted mask
to the spacer.
Asset ID: 62
Table. Using nebulisers in acute asthma
Driving nebuliser
Nebulisers can be driven by air, piped oxygen, or an oxygen cylinder fitted with a high-flow regulator
capable of delivering >6 L/min.
Intermittent nebulisation
Use one nebule:
Adults: 5 mg nebule
Children 6 years and over: 5 mg nebule
13
Children 0–5 years: 2.5 mg nebule
Continuous nebulisation using nebules
Put two nebules into nebuliser chamber at a time and repeat to refill when used up.
Adults: use two 5 mg nebules (10 mg) at a time
Children 6 years and over: use two 5 mg nebules (10 mg) at a time
Children 0–5 years: use two 2.5 mg nebules (5 mg) at a time
• If using oxygen to drive a nebuliser, do not exceed 8–10 L/minute and avoid over-oxygenation (increases risk of
hypercapnoea).
• The use of nebulisers increases the risk (to staff and patients) of nosocomial aerosol infection. If using a nebuliser,
follow your organisation’s infection control protocols to minimise spread of respiratory tract infections.
Asset ID: 73
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Karpel et al. 19971
• Dhuper et al. 20112
• Cates et al. 20133
• Ferguson and Gidwani 20064
• Travers et al. 20125
• Salmeron et al. 19946
• Hodder et al. 20117
• O'Driscoll et al. 20088
• Global Initiative for Asthma (GINA) 20129
• British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN) 200810
• Perrin et al. 201111
• Cyr et al. 199112
• Barry and O'Callaghan 199413
• Rau et al. 199614
• Ari et al. 201215
• Laube et al. 201116
For patients with life-threatening asthma, arrange immediate transfer to the resuscitation area (or arrange transfer to
acute service).
Figure. Initial management of life-threatening acute asthma in adults and children
Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/94
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Start oxygen therapy if patient shows respiratory distress or oxygen saturation <95% on pulse oximetry. Titrate oxygen
saturation to target of 92–95% for adults and at least 95% for children.
• In adults, avoid over-oxygenation, because this increases the risk of hypercapnoea
14
• For children, consider whether humidification of oxygen is indicated
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Brandão et al. 201117
• O'Driscoll et al. 20088
• Rodrigo et al. 200618
Identify and manage anaphylaxis according to national guidelines or your organisation’s protocols. Give adrenaline if
anaphylaxis is suspected or cannot be excluded.
Note: Consider anaphylaxis if patient presents with urticaria or angioedema as well as respiratory signs/symptoms, and in patients
with a history of allergies
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Global Initiative for Asthma, 20129
• Singhi et al. 200619
More information
Anaphylaxis guidelines and resources
Go to: Australasian Society of Clinical Immunology and Allergy (ASCIA)’s Acute management of anaphylaxis guidelines
Go to: Australasian Society of Clinical Immunology and Allergy (ASCIA)’s Anaphylaxis Health Professional Information
Paper
Go to: Australasian Society of Clinical Immunology and Allergy (ASCIA)’s Anaphylaxis Resources for fact sheets and
action plan templates Adrenaline in acute asthma
Systemic adrenaline (intravenous in clinical settings with appropriately trained staff, or intramuscular) is indicated for
patients with anaphylaxis and angioedema,9, 20 but current evidence does not support its routine use in the management
of acute asthma in the absence of anaphylaxis.9
Nebulised adrenaline does not have a significant benefit over salbutamol or terbutaline in the management of moderateto-severe acute asthma in adults and children.21
Go to: Australasian Society of Clinical Immunology and Allergy (ASCIA)’s Acute management of anaphylaxis guidelines
Assessment of oxygen status in acute asthma
Hypoxia is the main cause of death that is due to acute asthma.7
Routine objective assessment of oxygen saturation at initial assessment of acute asthma is needed because clinical signs
may not correlate with hypoxaemia.
Pulse oximetry is the internationally accepted method for routine assessment of oxygen status in patients with acute
asthma.9
The risk of hypercapnoea increases when oxygen saturation falls below 92%.22
15
Pulse oximetry does not detect hypercapnoea, so blood gas analysis is necessary if hypercapnoea is suspected in patients
with severe or life-threatening acute asthma.
Oxygen therapy in acute asthma
Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been shown to improve the sensation of
breathlessness in non-hypoxaemic patients.8 When oxygen supplementation is used, pulse oximetry is necessary to
monitor oxygen status and titrate to target.
The aim of titrated oxygen therapy in acute care is to achieve normal or near-normal oxygen saturation, except in patients
who are at risk of hypercapnoeic respiratory failure,8 such as patients with overlapping asthma and COPD.
Adults
In adults with acute asthma, titrated oxygen therapy using pulse oximetry to maintain oxygen saturation at 93–95% while
avoiding hyperoxaemia achieves better physiological outcomes than 100% oxygen at high flow rate (8 L/min).11 Highconcentration and high-flow oxygen therapy cause a clinically significant increase in blood CO2 concentration in adults
with acute asthma.11, 23
National guidelines for the management of acute exacerbations of COPD recommend that hypoxic patients should be
given controlled oxygen therapy via nasal prongs at 0.5–2.0 L/minute or a venturi mask at 24% or 28%, with target oxygen
saturation of over 90% (PaO2 >50 mmHg, or 6.7 kPa).24 Excessive oxygen administration should be avoided because it can
worsen hypercapnoea.24
Go to: The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary
Disease
Children
Drying of the upper airway is a potential complication of oxygen therapy in children,25, 26 which might contribute to
bronchoconstriction.26 Humidified oxygen can be considered if necessary. Humidification is usually not needed for low
flow oxygen (<4 L/minute in children or 2 L/minute in infants) for short term. Humidification may be considered if the
oxygen is required for longer than 48 hours or if the nasal passages are becoming uncomfortable or dry.25
Guidance on oxygen delivery techniques and practical issues is available from Sydney Children's Hospital Network and
The Royal Children's Hospital Melbourne.
Go to: Sydney Children's Hospitals Network resource on oxygen therapy and delivery devices
Go to: The Royal Children's Hospital Melbourne guideline on Oxygen delivery References
1. Karpel JP, Aldrich TK, Prezant DJ, et al. Emergency treatment of acute asthma with albuterol metered-dose inhaler
plus holding chamber: how often should treatments be administered?. Chest. 1997; 112: 348-356. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/9266868
2. Dhuper S, Chandra A, Ahmed A, et al. Efficacy and cost comparisons of bronchodilatator administration between
metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011; 40:
247-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19081697
3. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute
asthma. Cochrane Database Syst Rev. 2013; 9: Cd000052. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/24037768
4. Ferguson C, Gidwani S. Delivery of bronchodilators in acute asthma in children. Emerg Med J. 2006; 23: 471-472.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564350/
5. Travers AH, Milan SJ, Jones AP, et al. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute
asthma. Cochrane Database Syst Rev. 2012; 12: CD010179. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010179/full
6. Salmeron S, Brochard L, Mal H, et al. Nebulized versus intravenous albuterol in hypercapnic acute asthma. A
multicenter, double-blind, randomized study. Am J Respir Crit Care Med. 1994; 149: 1466-1470. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/8004299
7. Hodder R, Lougheed MD, Rowe BH, et al. Management of acute asthma in adults in the emergency department:
nonventilatory management. CMAJ. 2010; 182: E55-67. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2817338/
16
8. O’Driscoll BR, Howard LS, Davison AG, British Thoracic Society (BTS) Emergency Oxygen Guideline Development
Group. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008; 63 (Suppl 6): vi1-vi68. Available from:
http://thorax.bmj.com/content/63/Suppl_6/vi1.full
9. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available
from: http://www.ginasthma.org
10. British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. Quick Reference Guide. Revised May 2011. BTS, SIGN, Edinburgh, 2008.
11. Perrin K, Wijesinghe M, Healy B, et al. Randomised controlled trial of high concentration versus titrated oxygen
therapy in severe exacerbations of asthma. Thorax. 2011; 66: 937-41. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21597111
12. Cyr TD, Graham SJ, Li KY, Levering EG. Low first-spray drug content in albuterol metered-dose inhalers. Pharm Res.
1991; 8: 658-660. Available from: http://link.springer.com/article/10.1023/A:1015825311750
13. Barry PW, O'Callaghan C. Multiple actuations of salbutamol MDI into a spacer device reduce the amount of drug
recovered in the respirable range. Eur Respir J. 1994; 7: 1707-1709. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/7995401
14. Rau JL, Restrepo RD, Deshpande V. Inhalation of single vs multiple metered-dose bronchodilator actuations from
reservoir devices : An in vitro study. Chest. 1996; 109: 969-974. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/8635379
15. Ari A, Fink JB, Dhand R. Inhalation therapy in patients receiving mechanical ventilation: an update. J Aerosol Med Pulm
Drug Deliv. 2012; 25: 319-32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22856594
16. Laube BL, Janssens HM, de Jongh FHC, et al. What the pulmonary specialist should know about the new inhalation
therapies. Eur Respir J. 2011; 37: 1308-1417. Available from: http://erj.ersjournals.com/content/37/6/1308.full
17. Brandao DC, Britto MC, Pessoa MF, et al. Heliox and forward-leaning posture improve the efficacy of nebulized
bronchodilator in acute asthma: a randomized trial. Respir Care. 2011; 56: 947-52. Available from:
http://rc.rcjournal.com/content/56/7/947.full
18. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst
Rev. 2006; Issue 4: CD002884. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002884.pub2/full
19. Singhi S, Mathew JL, Torzillo P. What is the role of subcutaneous adrenaline in the management of acute asthma?.
International Child Health Review Collaboration, 2006. Available from: http://www.ichrc.org/cough-or-difficultbreathing
20. Australasian Society of Clinical Immunology and Allergy (ASCIA). Acute management of anaphylaxis guidelines. ASCIA,
Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/acute-management-ofanaphylaxis-guidelines
21. Rodrigo GJ, Nannini LJ. Comparison between nebulized adrenaline and beta2 agonists for the treatment of acute
asthma. A meta-analysis of randomized trials. Am J Emerg Med. 2006; 24: 217-22. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16490653
22. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.britthoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
23. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C. Effects of short-term 28% and 100% oxygen on PaCO2 and
peak expiratory flow rate in acute asthma: a randomized trial. Chest. 2003; 124: 1312-7. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1081910
24. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the
management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic
Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
25. Sydney Children's Hospital. Oxygen therapy and delivery devices – SCH. Practice guideline. Guideline No: 0/C/13:701901:00. Sydney Children's Hospital Westmead, Sydney, 2013. Available from:
http://www.chw.edu.au/about/policies/alphabetical.htm
26. The Royal Children's Hospital of Melbourne, Oxygen Delivery. Clinical Guidelines (Nursing), The Royal Children's
Hospital 2013. Available from: http://www.rch.org.au/rchcpg/hospitalclinicalguidelineindex/Oxygendelivery/
17
HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > BRONCHODILATORS
Giving bronchodilator treatment according to severity and age
Recommendations
Give initial salbutamol by inhalation, using doses, routes of administration and dosing schedules according to the
patient’s age and the severity of acute asthma.
Table. Rapid primary assessment of acute asthma in adults and children
Mild/Moderate
Can walk, speak whole
Severe
Any of these findings:
Life-threatening
Any of these findings:
sentences in one breath
• Use of accessory muscles of
(For young children: can move
around, speak in phrases)
Oxygen saturation >94%
neck or intercostal muscles
• Reduced consciousness or
collapse
or 'tracheal tug' during
• Exhaustion
inspiration or subcostal
• Cyanosis
recession ('abdominal
• Oxygen saturation <90%
breathing')
• Poor respiratory
• Unable to complete
sentences in one breath due
effort, soft/absent breath
sounds
to dyspnoea
• Obvious respiratory distress
• Oxygen saturation 90–94%
Notes
The severity category may change when more information is available (e.g. pulse oximetry, spirometry) or over time
The presence of pulsus paradoxus (systolic paradox) is not a reliable indicator of the severity of acute asthma.
If oxygen therapy has already been started, it is not necessary to cease oxygen to measure pulse oximetry.
Oxygen saturation levels are a guide only and are not definitive; clinical judgment should be applied.
Definitions of severity classes for acute asthma used in this handbook may differ from those used in published clinical
trials and other guidelines that focus on, are or restricted to, the management of acute asthma within emergency
departments or acute care facilities.
Asset ID: 74
Table. Initial bronchodilator treatment in acute asthma (adults and children 6 years and over)
• Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.
• Do not give oral salbutamol.
• Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with
inhaled or IV salbutamol.
Mild/Moderate
Severe
Life-threatening
18
Mild/Moderate
Severe
Life-threatening
Give salbutamol† 4-12 puffs (100
Give salbutamol† 12 puffs (100
Give salbutamol 2 x 5 mg nebules
mcg/actuation) via pMDI and
mcg/actuation) via pMDI and
via continuous nebulisation
spacer
spacer
driven by oxygen
Repeat every 20-30 minutes for
If patient unable to breathe
Maintain oxygen saturations:
the first hour if required (sooner,
through a spacer, give 5 mg
if needed to relieve
breathlessness)
‡
‡
Adults: 92% or higher
nebule via nebuliser
Children: 95% or higher
Start oxygen therapy if oxygen
Arrange immediate transfer to
saturation <95% and titrate to
higher-level care
target:
When dyspnoea improves,
Adults: 92–95%
consider changing to salbutamol
Children: 95% or higher
via pMDI plus spacer or
Repeat salbutamol as needed.
intermittent nebuliser‡ (doses as
Give at least every 20 minutes
for severe acute asthma)
for first hour (3 doses)
† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)
‡ See Table. Using nebulisers in acute asthma
Note: To deliver nebulised bronchodilators in a patient receiving oxygen therapy, use an air-driven compressor
nebuliser and administer oxygen by nasal cannulae.
Asset ID: 80
Table. Initial bronchodilator treatment in acute asthma (children 0–5 years)
• Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.
• Do not give oral salbutamol.
• Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with
inhaled or IV salbutamol.
• Closely monitor level of consciousness, fatigue, oxygen saturation, respiratory rate and heart rate. If symptoms do
not respond, contact a paediatrician or senior clinician and reconsider the diagnosis. • In children under 12 months old, asthma is less likely to be the cause of wheezing than other conditions (e.g.
bronchiolitis, pneumonia).
Mild/Moderate
Severe
Life-threatening
Give salbutamol† 2-6 puffs (100
Give salbutamol† 6 puffs (100
Give salbutamol 2 x 2.5 mg
mcg/actuation) via pMDI and
mcg/actuation) via pMDI and
nebules via continuous
spacer plus mask
spacer plus mask
nebulisation driven by oxygen‡
Repeat every 20-30 minutes for
If patient unable to breathe
Maintain oxygen saturation at
the first hour if needed (sooner, if
through a spacer, give 2.5 mg
95% or higher
needed to relieve
breathlessness)
‡
nebule via nebuliser
Arrange immediate transfer to
Start supplementary oxygen if
higher-level care
oxygen saturation <95%
When dyspnoea improves,
Titrate to 95% or higher
consider changing to salbutamol
via pMDI plus spacer or
19
Mild/Moderate
Severe
Life-threatening
Repeat salbutamol as needed.
intermittent nebuliser‡ (doses as
Give at least every 20 minutes
for severe acute asthma)
for first hour (3 doses)
† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)
‡ See Table. Using nebulisers in acute asthma
Asset ID: 81
Table. Using pressurised metered-dose inhalers in acute asthma
Administration of salbutamol by health professionals for a patient with acute asthma
1. Use a salbutamol pressurised metered-dose inhaler (100 mcg/actuation) with a spacer that has
already been prepared (see note).
2. Shake inhaler and insert upright into spacer.
3. Place mouthpiece between the person’s teeth and ask them to seal lips firmly around mouthpiece.
4. Fire one puff into the spacer.
5. Tell person to take 4 breaths in and out of the spacer.
6. Remove the spacer from mouth. Shake the inhaler after each puff before actuating again. (This can
be done without detaching the pressurised metered-dose inhaler from the spacer.)
Notes
The process is repeated until the total dose is given (e.g 12 puffs for an adult, 6 puffs for a child). Different doses are
recommended for patients and carers giving asthma first aid in the community.
New plastic spacers should be washed with detergent to remove electrostatic charge (and labelled), so they are ready
for use when needed. In an emergency situation, if a pre-treated spacer is not available, prime the spacer before use by
firing 20 puffs of salbutamol into the spacer.
Priming or washing spacers to reduce electrostatic charge before using for the first time is only necessary for plastic
spacers; polyurethane spacers (e.g. E-Chamber, AeroChamber Plus), disposable cardboard spacers and metal spacers
do not require treatment to reduce electrostatic charge.
For small children who cannot form a tight seal with their lips around the spacer mouthpiece, attach a well-fitted mask
to the spacer.
Asset ID: 62
Table. Using nebulisers in acute asthma
Driving nebuliser
Nebulisers can be driven by air, piped oxygen, or an oxygen cylinder fitted with a high-flow regulator
capable of delivering >6 L/min.
Intermittent nebulisation
Use one nebule:
Adults: 5 mg nebule
Children 6 years and over: 5 mg nebule
Children 0–5 years: 2.5 mg nebule
20
Continuous nebulisation using nebules
Put two nebules into nebuliser chamber at a time and repeat to refill when used up.
Adults: use two 5 mg nebules (10 mg) at a time
Children 6 years and over: use two 5 mg nebules (10 mg) at a time
Children 0–5 years: use two 2.5 mg nebules (5 mg) at a time
• If using oxygen to drive a nebuliser, do not exceed 8–10 L/minute and avoid over-oxygenation (increases risk of
hypercapnoea).
• The use of nebulisers increases the risk (to staff and patients) of nosocomial aerosol infection. If using a nebuliser,
follow your organisation’s infection control protocols to minimise spread of respiratory tract infections.
Asset ID: 73
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Camargo et al. 20031
• Cates et al. 20132
• Chandra et al. 20053
• Dhuper et al. 20114
5
• Direkwatanachai et al. 2011
6
• Emerman et al. 1999
• Fayaz et al. 20097
• Kaashmiri et al. 20108
• Karpel et al. 19979
• Travers et al. 201210
• Yasmin et al. 201211
For patients with severe acute asthma who are unable to breathe through a spacer, salbutamol can be given by
intermittent nebulisation.
Table. Using nebulisers in acute asthma
Driving nebuliser
Nebulisers can be driven by air, piped oxygen, or an oxygen cylinder fitted with a high-flow regulator
capable of delivering >6 L/min.
Intermittent nebulisation
Use one nebule:
Adults: 5 mg nebule
Children 6 years and over: 5 mg nebule
Children 0–5 years: 2.5 mg nebule
Continuous nebulisation using nebules
Put two nebules into nebuliser chamber at a time and repeat to refill when used up.
Adults: use two 5 mg nebules (10 mg) at a time
21
Children 6 years and over: use two 5 mg nebules (10 mg) at a time
Children 0–5 years: use two 2.5 mg nebules (5 mg) at a time
• If using oxygen to drive a nebuliser, do not exceed 8–10 L/minute and avoid over-oxygenation (increases risk of
hypercapnoea).
• The use of nebulisers increases the risk (to staff and patients) of nosocomial aerosol infection. If using a nebuliser,
follow your organisation’s infection control protocols to minimise spread of respiratory tract infections.
Asset ID: 73
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Camargo et al. 20031
For patients with life-threatening asthma, deliver salbutamol via continuous nebulisation driven by oxygen until
breathing improves, then consider changing to a pressurised metered-dose inhaler plus spacer or intermittent nebuliser.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Camargo et al. 20031
If using a nebuliser, follow your organisation’s infection control protocols to minimise spread of respiratory tract
infections.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Hui, 201312
To deliver intermittent nebulised bronchodilators in a patient receiving oxygen therapy, use an air-driven compressor
nebuliser and administer oxygen by nasal cannulae. Titrate to oxygen saturation target of 92–95% in adults or at least
95% in children.
If needed, salbutamol can be delivered by piped (‘wall’) oxygen or an oxygen cylinder fitted with a high-flow regulator
capable of delivering >6 L/min. The patient should be changed back to their original oxygen mask once nebulisation is
complete.
s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• O'Driscoll et al. 200813
To deliver salbutamol in a patient undergoing non-invasive ventilation, either of the following options can be used:
22
• Deliver salbutamol by nebuliser via an attachment to the ventilator circuit. For optimal delivery of salbutamol, the
nebuliser should be attached with the expiration port between the facemask and nebuliser.
• Briefly interrupt ventilation to deliver salbutamol via pressurised metered-dose inhaler and spacer.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Calvert et al. 200614
Do not give oral salbutamol.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Do not use IV short-acting beta2 agonists routinely.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Travers et al. 201210
• Travers et al. 201215
More information
Salbutamol in acute asthma: dosing regimens
One placebo-controlled study showed that, for patients who showed clear improvement after the first dose of salbutamol
via pressurised metered-dose inhaler and spacer, there was no advantage in repeating the dose more often than every 60
minutes until full recovery (extra doses can be given as needed).9
However, in patients who did not show a clear response to the first salbutamol dose, repeating the dose at intervals of 30
minutes or less was more effective than every 60 minutes.9
Salbutamol in acute asthma: route of administration
Inhaler plus spacer, or nebuliser
Salbutamol delivered via a pressurised metered-dose inhaler with spacer is at least as effective as salbutamol delivered
via nebuliser in patients with moderate-to-severe acute asthma who do not require ventilation.4, 2, 17 The use of nebulisers
increases the risk of transmitting respiratory infections to staff and other patients.
Intravenous salbutamol
Overall, intravenous short-acting beta2 agonists do not appear to be superior to inhaled short-acting beta2 agonist.10
Benefits have not been demonstrated in adults.10 Very limited evidence from one study suggested that the addition of IV
salbutamol to inhaled salbutamol reduced recovery time in children with severe acute asthma in the emergency
department.10
However, there is a lack of consensus on the appropriate dose of IV salbutamol for children.18 Recommendations differ
between guidelines in Australia19 and elsewhere.18 Doses have not been calculated based on age-specific
23
pharmacokinetic and pharmacodynamic data. The doses recommended in guidelines are generally relatively higher than
for adults on a micrograms per kilogram body weight basis.
Compared with inhaled salbutamol, intravenous salbutamol is associated with increased risk of adverse effects including
tremor and hypokalaemia.10, 18 Concomitant use of the inhalation and IV routes may increase the risk of salbutamol
toxicity.20
Note: Salbutamol concentrate for infusion is available in 5 mL ampoules containing salbutamol sulfate equivalent to 5 mg (1 mg/mL)
salbutamol in a sterile isotonic solution (Ventolin obstetric injection). Salbutamol for injection is also available in ampoules of salbutamol
sulphate equivalent to 500 mcg salbutamol in 1 mL sterile isotonic solution (Ventolin injection).
Technical notes: pressurised metered-dose inhalers with spacers
Manufacturers of most delivery devices recommend shaking the device before actuating. The physical characteristics of
each formulation, including the effects of shaking, differ widely,21 but for simplicity it is best always to recommend
shaking.
When a spacer is used with a pressurised metered-dose inhaler, delivery of the medicine to the patient’s airways is
maximised when the patient inhales from the spacer after each actuation.22, 23 Multiple actuations of a pressurised
metered-dose inhaler into a spacer can reduce the amount of respirable medicine available because aerosol particles can
agglomerate into larger particles or become attached to the spacer walls.22
Therefore, the ideal way to deliver salbutamol via pressurised metered-dose inhaler and spacer is to shake the device, fire
a single actuation into the spacer, and have the person inhale each from the spacer before repeating the process until the
total intended number of actuations is taken. Patients should be trained to follow these instructions when using their
inhalers, and first aid instructions should include these instructions.
In practice, however, optimal delivery of inhaled medicines involves a balance between maximising the proportion of
respirable medicine and maximising efficiency of inhalation by the patient within real-world constraints. The optimal
delivery of salbutamol in real-world circumstances is not well defined.
Many available in vitro studies of aerosol particle deposition in the airways were performed using older CFC-propelled
formulations, which are now obsolete. For some brands of spacers, two rapid actuations of a CFC-pressurised metereddose inhaler into a spacer, followed by a breath, was likely to result in only a small loss of total dose, compared with single
actuations followed by a breath.23 Three rapid actuations at once resulted in a loss of efficiency so that the delivered dose
was not significantly greater than if only two actuations were given.23 Similar studies have not been performed for current
non-CFC pressurised metered-dose inhalers, so the maximum number of actuations that can be fired into the spacer
before loss of efficacy occurs is unknown.
Inhaling slowly with a single breath maximises delivery of the medicine to the lungs and minimises deposition in the upper
airways when using a conventional pressurised metered-dose inhaler with or without a spacer, or when using a breathactivated pressurised metered-dose inhaler.24 However, slow breathing may not be possible for patients with acute
asthma. Tidal breathing through the spacer (e.g. four breaths in and out without removing the spacer) is used in acute
asthma.
Assessment of oxygen status in acute asthma
Hypoxia is the main cause of death that is due to acute asthma.25
Routine objective assessment of oxygen saturation at initial assessment of acute asthma is needed because clinical signs
may not correlate with hypoxaemia.
Pulse oximetry is the internationally accepted method for routine assessment of oxygen status in patients with acute
asthma.26
The risk of hypercapnoea increases when oxygen saturation falls below 92%.27
Pulse oximetry does not detect hypercapnoea, so blood gas analysis is necessary if hypercapnoea is suspected in patients
with severe or life-threatening acute asthma.
Oxygen therapy in acute asthma
Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been shown to improve the sensation of
breathlessness in non-hypoxaemic patients.13 When oxygen supplementation is used, pulse oximetry is necessary to
monitor oxygen status and titrate to target.
The aim of titrated oxygen therapy in acute care is to achieve normal or near-normal oxygen saturation, except in patients
who are at risk of hypercapnoeic respiratory failure,13 such as patients with overlapping asthma and COPD.
24
Adults
In adults with acute asthma, titrated oxygen therapy using pulse oximetry to maintain oxygen saturation at 93–95% while
avoiding hyperoxaemia achieves better physiological outcomes than 100% oxygen at high flow rate (8 L/min).28 Highconcentration and high-flow oxygen therapy cause a clinically significant increase in blood CO2 concentration in adults
28, 29
with acute asthma.
National guidelines for the management of acute exacerbations of COPD recommend that hypoxic patients should be
given controlled oxygen therapy via nasal prongs at 0.5–2.0 L/minute or a venturi mask at 24% or 28%, with target oxygen
saturation of over 90% (PaO2 >50 mmHg, or 6.7 kPa).30 Excessive oxygen administration should be avoided because it can
worsen hypercapnoea.30
Go to: The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary
Disease
Children
Drying of the upper airway is a potential complication of oxygen therapy in children,31, 32 which might contribute to
bronchoconstriction.32 Humidified oxygen can be considered if necessary. Humidification is usually not needed for low
flow oxygen (<4 L/minute in children or 2 L/minute in infants) for short term. Humidification may be considered if the
oxygen is required for longer than 48 hours or if the nasal passages are becoming uncomfortable or dry.31
Guidance on oxygen delivery techniques and practical issues is available from Sydney Children's Hospital Network and
The Royal Children's Hospital Melbourne.
Go to: Sydney Children's Hospitals Network resource on oxygen therapy and delivery devices
Go to: The Royal Children's Hospital Melbourne guideline on Oxygen delivery Non-invasive positive pressure ventilation in acute asthma
Efficacy
Few randomised clinical trials have evaluated non-invasive positive pressure ventilation (biphasic positive airway
pressure or continuous positive airway pressure) for adults with severe acute asthma.33 This technique has not been
shown to reduce risk of death or the need for intubation, but may reduce hospital admissions, length of hospital stay and
length of ICU stay.33 It may also improve lung function, but evidence is inconsistent.33
Delivering bronchodilators in patients undergoing noninvasive positive-pressure ventilation
When delivering nebulised salbutamol while using noninvasive positive-pressure ventilation set at pressures commonly
used in clinical practice, the amount of salbutamol inhaled is likely to be significantly higher than with a nebuliser alone
(based on a bench model of a spontaneously breathing adult). This increase may be because the ventilator tubing acts as a
spacer.14
The position of the nebuliser in the ventilator circuit significantly affects the total dose of salbutamol inhaled. Salbutamol
is delivered most effectively when the nebuliser is positioned immediately after the expiration port (i.e. starting from the
facemask, the expiration port is positioned before the nebuliser).14
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nonventilatory management. CMAJ. 2010; 182: E55-67. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2817338/
Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available
from: http://www.ginasthma.org
British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.britthoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
Perrin K, Wijesinghe M, Healy B, et al. Randomised controlled trial of high concentration versus titrated oxygen
therapy in severe exacerbations of asthma. Thorax. 2011; 66: 937-41. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21597111
26
29. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C. Effects of short-term 28% and 100% oxygen on PaCO2 and
peak expiratory flow rate in acute asthma: a randomized trial. Chest. 2003; 124: 1312-7. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1081910
30. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the
management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic
Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
31. Sydney Children's Hospital. Oxygen therapy and delivery devices – SCH. Practice guideline. Guideline No: 0/C/13:701901:00. Sydney Children's Hospital Westmead, Sydney, 2013. Available from:
http://www.chw.edu.au/about/policies/alphabetical.htm
32. The Royal Children's Hospital of Melbourne, Oxygen Delivery. Clinical Guidelines (Nursing), The Royal Children's
Hospital 2013. Available from: http://www.rch.org.au/rchcpg/hospitalclinicalguidelineindex/Oxygendelivery/
33. Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of
respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2012; 12: CD004360.
Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004360.pub4/full
27
HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > SECONDARY ASSESSMENT
Completing secondary assessments and reassessing severity
Recommendations
When practical after starting treatment, complete clinical assessments and reassess severity.
Table. Secondary severity assessment of acute asthma in adults and children 6 years and over
Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/63
Table. Secondary severity assessment of acute asthma in children 0–5 years
Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/64
Table. Initial bronchodilator treatment in acute asthma (adults and children 6 years and over)
• Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.
• Do not give oral salbutamol.
• Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with
inhaled or IV salbutamol.
Mild/Moderate
Severe
Life-threatening
Give salbutamol† 4-12 puffs (100
Give salbutamol† 12 puffs (100
Give salbutamol 2 x 5 mg nebules
mcg/actuation) via pMDI and
mcg/actuation) via pMDI and
via continuous nebulisation
spacer
spacer
driven by oxygen‡
Repeat every 20-30 minutes for
If patient unable to breathe
Maintain oxygen saturations:
the first hour if required (sooner,
through a spacer, give 5 mg
Adults: 92% or higher
if needed to relieve
breathlessness)
‡
nebule via nebuliser
Children: 95% or higher
Start oxygen therapy if oxygen
Arrange immediate transfer to
saturation <95% and titrate to
higher-level care
target:
When dyspnoea improves,
Adults: 92–95%
consider changing to salbutamol
Children: 95% or higher
via pMDI plus spacer or
Repeat salbutamol as needed.
intermittent nebuliser‡ (doses as
Give at least every 20 minutes
for severe acute asthma)
for first hour (3 doses)
† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)
‡ See Table. Using nebulisers in acute asthma
Note: To deliver nebulised bronchodilators in a patient receiving oxygen therapy, use an air-driven compressor
nebuliser and administer oxygen by nasal cannulae.
Asset ID: 80
28
Table. Initial bronchodilator treatment in acute asthma (children 0–5 years)
• Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment.
• Do not give oral salbutamol.
• Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with
inhaled or IV salbutamol.
• Closely monitor level of consciousness, fatigue, oxygen saturation, respiratory rate and heart rate. If symptoms do
not respond, contact a paediatrician or senior clinician and reconsider the diagnosis. • In children under 12 months old, asthma is less likely to be the cause of wheezing than other conditions (e.g.
bronchiolitis, pneumonia).
Mild/Moderate
Severe
Life-threatening
Give salbutamol† 2-6 puffs (100
Give salbutamol† 6 puffs (100
Give salbutamol 2 x 2.5 mg
mcg/actuation) via pMDI and
mcg/actuation) via pMDI and
nebules via continuous
spacer plus mask
spacer plus mask
nebulisation driven by oxygen‡
Repeat every 20-30 minutes for
If patient unable to breathe
Maintain oxygen saturation at
the first hour if needed (sooner, if
through a spacer, give 2.5 mg
95% or higher
needed to relieve
breathlessness)
‡
nebule via nebuliser
Arrange immediate transfer to
Start supplementary oxygen if
higher-level care
oxygen saturation <95%
When dyspnoea improves,
Titrate to 95% or higher
consider changing to salbutamol
Repeat salbutamol as needed.
via pMDI plus spacer or
Give at least every 20 minutes
intermittent nebuliser‡ (doses as
for first hour (3 doses)
for severe acute asthma)
† Give one puff at a time followed by 4 breaths (See Table. Using pressurised metered-dose inhalers in acute asthma)
‡ See Table. Using nebulisers in acute asthma
Asset ID: 81
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Complete a brief history, including:
• reliever taken for this episode (dose, number of doses, time of last dose)
• current asthma medicines (regular and as-needed, including type of devices used)
• what triggered this episode, if known (e.g. allergies, immediate hypersensitivity, medicines, respiratory infections.
Note: acute asthma is rarely triggered by food allergies.)
• coexisting heart or lung disease, including chronic obstructive pulmonary disease.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
For adults and children, start titrated oxygen therapy if oxygen saturation <95% (measured by pulse oximetry).
Maintain oxygen saturation of 92–95% for adults and at least 95% for children.
29
• Excessive oxygen administration can lead to hypercapnoea in people with asthma or worsen hypercapnoea in people
with COPD
s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• British Thoracic Society and Scottish Intercollegiate Guidelines Network, 20081
• Global Initiative for Asthma, 20122
• Abramson et al. 20123
• O'Driscoll et al. 20084
Arrange chest X-ray if pneumonia, atelectasis, pneumothorax or pneumomediastinum is suspected.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
More information
Assessment of oxygen status in acute asthma
Hypoxia is the main cause of death that is due to acute asthma.5
Routine objective assessment of oxygen saturation at initial assessment of acute asthma is needed because clinical signs
may not correlate with hypoxaemia.
Pulse oximetry is the internationally accepted method for routine assessment of oxygen status in patients with acute
asthma.2
The risk of hypercapnoea increases when oxygen saturation falls below 92%.6
Pulse oximetry does not detect hypercapnoea, so blood gas analysis is necessary if hypercapnoea is suspected in patients
with severe or life-threatening acute asthma.
Oxygen therapy in acute asthma
Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been shown to improve the sensation of
breathlessness in non-hypoxaemic patients.4 When oxygen supplementation is used, pulse oximetry is necessary to
monitor oxygen status and titrate to target.
The aim of titrated oxygen therapy in acute care is to achieve normal or near-normal oxygen saturation, except in patients
who are at risk of hypercapnoeic respiratory failure,4 such as patients with overlapping asthma and COPD.
Adults
In adults with acute asthma, titrated oxygen therapy using pulse oximetry to maintain oxygen saturation at 93–95% while
avoiding hyperoxaemia achieves better physiological outcomes than 100% oxygen at high flow rate (8 L/min).7 Highconcentration and high-flow oxygen therapy cause a clinically significant increase in blood CO2 concentration in adults
with acute asthma.7, 8
National guidelines for the management of acute exacerbations of COPD recommend that hypoxic patients should be
given controlled oxygen therapy via nasal prongs at 0.5–2.0 L/minute or a venturi mask at 24% or 28%, with target oxygen
saturation of over 90% (PaO2 >50 mmHg, or 6.7 kPa).3 Excessive oxygen administration should be avoided because it can
worsen hypercapnoea.3
Go to: The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary
Disease
30
Children
Drying of the upper airway is a potential complication of oxygen therapy in children,9, 10 which might contribute to
bronchoconstriction.10 Humidified oxygen can be considered if necessary. Humidification is usually not needed for low
flow oxygen (<4 L/minute in children or 2 L/minute in infants) for short term. Humidification may be considered if the
oxygen is required for longer than 48 hours or if the nasal passages are becoming uncomfortable or dry.9
Guidance on oxygen delivery techniques and practical issues is available from Sydney Children's Hospital Network and
The Royal Children's Hospital Melbourne.
Go to: Sydney Children's Hospitals Network resource on oxygen therapy and delivery devices
Go to: The Royal Children's Hospital Melbourne guideline on Oxygen delivery Spirometry in acute asthma
Utility
Assessment of response to treatment should include spirometry considered alongside clinical assessment. Clinical
assessment alone may underestimate the severity of airflow limitation.11
On its own, FEV1 (measured by spirometry) at 1 hour after admission to the emergency department does not closely
correlate with the need for hospital admission in adults with acute asthma as assessed clinically.11
Feasibility and technique
Most adults with acute asthma can perform spirometry within the first hour of admission to the emergency department.12
(Hospital staff and primary care health professionals may need specific training in spirometry technique to be able to
obtain acceptable spirometry in patients with acute asthma.12)
Younger children (most children under 6 years) are unlikely to be able to perform spirometry.
It may not be feasible to apply standard spirometry technique and manoeuvre acceptability criteria in patients with acute
asthma:12
• 80% of patients older than 12 years with acute asthma can perform an FEV1 manoeuvre. A forced exhalation from
total lung capacity for 2 seconds is sufficient and provides useful information about the severity of airflow
obstruction12
• two attempts may suffice if patients are unable to make three attempts12
• variability between manoeuvres of < 10% should be considered acceptable12
• patients may not be able to tolerate nose clips12
• patients are unlikely to be able to exhale for long enough to demonstrate the time-volume plateau. Although patients
should aim for forced exhalation of at least 6 seconds, 2 seconds is acceptable for measuring FEV1 in clinical
assessment during acute asthma.12 A spirometry manoeuvre might be considered acceptable if back-extrapolated
volume is either < 5% of FVC or 0.15 L (whichever is greater), or a time to peak flow < 120 ms.12
Table. Tips for performing spirometry in patients with acute asthma
• Ask the patient to sit straight upright, either in a chair or on a stretcher with their legs over the side.
• Make sure the person forms a tight seal around the mouthpiece.
• Tell the patient to take as deep a breath as possible, then blast out air as fast and hard as they can, then keep
blowing until asked to stop. Aim for exhalation of maximal force for at least 2 seconds (6 seconds if FVC is
measured).
• You may need to give the patient lots of coaching, repeat instructions, and give immediate feedback on
technique.
Asset ID: 66
Peak expiratory flow in acute asthma
Peak expiratory flow rate obtained using a peak flow meter underestimates the severity of airflow limitation in patients
with acute asthma, compared with FEV1 obtained by spirometry.13
31
Peak expiratory flow is not a sensitive measure of small clinical improvements as perceived by the patient.14
References
1. British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. Quick Reference Guide. Revised May 2011. BTS, SIGN, Edinburgh, 2008.
2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available
from: http://www.ginasthma.org
3. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the
management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic
Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
4. O’Driscoll BR, Howard LS, Davison AG, British Thoracic Society (BTS) Emergency Oxygen Guideline Development
Group. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008; 63 (Suppl 6): vi1-vi68. Available from:
http://thorax.bmj.com/content/63/Suppl_6/vi1.full
5. Hodder R, Lougheed MD, Rowe BH, et al. Management of acute asthma in adults in the emergency department:
nonventilatory management. CMAJ. 2010; 182: E55-67. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2817338/
6. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.britthoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
7. Perrin K, Wijesinghe M, Healy B, et al. Randomised controlled trial of high concentration versus titrated oxygen
therapy in severe exacerbations of asthma. Thorax. 2011; 66: 937-41. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21597111
8. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C. Effects of short-term 28% and 100% oxygen on PaCO2 and
peak expiratory flow rate in acute asthma: a randomized trial. Chest. 2003; 124: 1312-7. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1081910
9. Sydney Children's Hospital. Oxygen therapy and delivery devices – SCH. Practice guideline. Guideline No: 0/C/13:701901:00. Sydney Children's Hospital Westmead, Sydney, 2013. Available from:
http://www.chw.edu.au/about/policies/alphabetical.htm
10. The Royal Children's Hospital of Melbourne, Oxygen Delivery. Clinical Guidelines (Nursing), The Royal Children's
Hospital 2013. Available from: http://www.rch.org.au/rchcpg/hospitalclinicalguidelineindex/Oxygendelivery/
11. Wilson MM, Irwin RS, Connolly AE, et al. A prospective evaluation of the 1-hour decision point for admission versus
discharge in acute asthma. J Intensive Care Med. 2003; 18: 275-285. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/15035763
12. Silverman RA, Flaster E, Enright PL, Simonson SG. FEV1 performance among patients with acute asthma: results from
a multicenter clinical trial. Chest. 2007; 131: 164-171. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1084897
13. Choi IS, Koh YI, Lim H. Peak expiratory flow rate underestimates severity of airflow obstruction in acute asthma.
Korean J Intern Med. 2002; 17: 174-179. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12298428
14. Karras DJ, Sammon ME, Terregino CA, et al. Clinically meaningful changes in quantitative measures of asthma
severity. Acad Emerg Med. 2000; 7: 327-334. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.15532712.2000.tb02231.x/abstract
32
HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > CORTICOSTEROIDS
Starting systemic corticosteroid treatment
Recommendations
For adults, start systemic corticosteroids within 1 hour of presentation (unless contraindicated), regardless of severity
at initial assessment.
Give starting dose of prednisolone 37.5–50 mg, then repeat each morning on second and subsequent days (total 5–10
days).
It is usually not necessary to taper the dose unless the duration of treatment exceeds 2 weeks.
Note: Pregnancy is not a contraindication for systemic corticosteroids. Oral prednisone or prednisolone is rated Category A for
pregnancy.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Cydulka and Emerman, 19981
• Dembla et al. 20112
• Hasegawa et al. 20003
• Hatton et al. 20054
• Jones et al. 20025
• Karan et al. 20026
• Kravitz et al. 20117
• Manser et al. 20018
• O'Driscoll et al.19939
• Rowe et al. 200110
• Rowe et al. 200711
For children aged 6 years and over (and children aged 0–5 if acute wheezing is severe), start systemic corticosteroids
within 1 hour of presentation (unless contraindicated).
Give prednisolone as a single starting dose of 2 mg/kg (maximum 50 mg) orally, then 1 mg/kg each morning for 2 days
(total 3 days). A longer course (e.g. 5 days) may be needed for severe cases.
It is usually not necessary to taper the dose unless the duration of treatment exceeds 2 weeks.
• For children aged 0–5 years, systemic corticosteroids should generally be limited to those with severe acute
wheezing to avoid over-use (particularly for those with intermittent viral-induced wheezing).
s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• Van Asperen et al. 201012
For adults, if corticosteroids cannot be given orally, give intravenously.
Give up to 100 mg hydrocortisone IV every 6 hours.
33
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Chan et al. 200113
• Clark et al. 200514
• Cunnington et al. 200515
• Dembla et al. 20112
• Kravitz et al. 20117
• Lahn et al. 200416
• Razi and Moosavi, 200617
For children, if corticosteroids cannot be given orally, give intravenously.
Give either of the following:
• hydrocortisone IV initial dose 8–10 mg/kg (maximum 300 mg), and then 4–5 mg/kg (maximum 300 mg) every 6 hours
on day 1, every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5
• methylprednisolone IV initial dose 2 mg/kg (maximum 60 mg), and then 1 mg/kg (maximum 60 mg) every 6 hours on
day 1, every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5.
s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• Van Asperen et al. 201012
Do not use inhaled corticosteroids as a substitute for systemic corticosteroids.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Edmonds et al. 201218
• Upham et al. 201119
More information
Systemic corticosteroids in acute asthma
Systemic corticosteroids given within 1 hour of presentation to an emergency department reduce the need for hospital
admission in patients with acute asthma, particularly if they have severe asthma or are not already taking systemic
corticosteroids.10
Oral prednisolone is as effective as intravenous or intramuscular corticosteroids during acute asthma in adults.14, 15, 17
Doses of up to 80 mg/day methylprednisolone (or up to 400 mg/day hydrocortisone) are adequate. Higher doses do not
appear to be more effective in adults with acute asthma.8
After an acute asthma episode, a short course of systemic corticosteroids reduces the risk of relapse, hospitalisations, and
use of short-acting beta2-agonist, and appears to be well tolerated.11 Oral and intramuscular corticosteroids are both
effective.11
34
A course of 5–10 days is sufficient.1, 3, 5, 9 In adults, a 5-day course of prednisolone 40 mg per day may be as effective as a
10-day course.5 In children, a 3-day course is generally effective, but 5 days may be needed for children with severe or lifethreatening acute asthma.12 The majority of studies have used 2mg/kg of oral prednisolone (maximum 60 mg) given
initially then 1mg/kg per day.
Abruptly ceasing a short (less than 2 weeks) course of oral prednisolone appears to be equally effective as tapering the
dose, and does not suppress adrenal function.1, 9
Note: The recommendation in this Handbook for a maximum prednisolone dose of 50 mg for children is based on practical
considerations, taking into account commercially available doses and strengths and consistency with the dose recommended for adults.
Systemic corticosteroids in acute asthma: adverse effects
Short-term use of oral corticosteroids is unlikely to cause harm – the majority of adverse effects are due to long-term
high-dose use.20 Adverse effects associated with prednisone or prednisolone use include headache, nausea, vomiting,
increased appetite, diarrhoea or constipation, vertigo, restlessness, insomnia and increased activity, salt and water
retention, and increased blood pressure. High doses can be associated with behavioural changes, facial plethora, bruising
and increased sweating.20
In people with diabetes or impaired glucose tolerance, corticosteroids increase blood glucose levels. Impaired glucose
tolerance is common among people aged over 65 years. In patients with diabetes or impaired glucose tolerance, blood
glucose monitoring (e.g. morning and evening samples) may be indicated during treatment with oral corticosteroids.
Long-term use of oral corticosteroids increases the risk of cataracts and osteoporosis in older patients,18 and may
increase body weight.
Inhaled corticosteroids in acute asthma
Inhaled corticosteroid treatment in acute care
Clinical trial evidence does not support the use of inhaled corticosteroids in place of systemic corticosteroid treatment in
the treatment of acute asthma.18
Some randomised clinical trials suggest that inhaled corticosteroid treatment may reduce hospital admission rates when
given in addition to systemic corticosteroids, but the evidence is conflicting.18 Overall, evidence from randomised clinical
trials does not show that inhaled corticosteroid therapy achieves clinically important improvement in lung function or
clinical scores when used in acute asthma in addition to systemic corticosteroids.18
Inhaled corticosteroid treatment in post-acute care
Current standard follow-up treatment after acute asthma includes a course of systemic corticosteroids, and continuation
of inhaled corticosteroids for patients already taking this treatment.
Overall, evidence from randomised clinical trials suggests that inhaled corticosteroid treatment, given at discharge from
the emergency department after acute asthma, does not provide additional short-term benefit in patients who are also
receiving oral corticosteroids.21
Some randomised clinical trials suggest that high-dose inhaled corticosteroid treatment at discharge from the emergency
department may be as effective as oral corticosteroids in patients with mild acute asthma, but overall evidence does not
support replacing oral corticosteroids with inhaled corticosteroids.21
These clinical trials were designed to assess effects of inhaled corticosteroid in managing the current acute asthma
episode. This evidence does not suggest that inhaled corticosteroids should be stopped after or during an acute asthma
episode.21 Regular inhaled corticosteroid treatment is effective for preventing future flare-ups.22
References
1. Cydulka RK, Emerman CL. A pilot study of steroid therapy after emergency department treatment of acute asthma: is
a taper needed?. J Emerg Med. 1998; 16: 15-19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9472754
2. Dembla G, Mundle RP, Salkar HR, Doifoide DV. Oral versus intravenous steroids in acute exacerbation of asthma-randomized controlled study. J Assoc Physicians India. 2011; 59: 621-623. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22479740
3. Hasegawa T, Ishihara K, Takakura S, et al. Duration of systemic corticosteroids in the treatment of asthma
exacerbation; a randomized study. Intern Med. 2000; 39: 794-797. Available from:
https://www.jstage.jst.go.jp/article/internalmedicine1992/39/10/3910794/_article
35
4. Hatton MQ, Vathenen AS, Allen MJ, et al. A comparison of 'abruptly stopping' with 'tailing off' oral corticosteroids in
acute asthma. Respir Med. 1995; 89: 101-104. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7708993
5. Jones AM, Munavvar M, Vail A, et al. Prospective, placebo-controlled trial of 5 vs 10 days of oral prednisolone in
acute adult asthma. Respir Med. 2002; 96: 950-954. Available from: http://www.resmedjournal.com/article/S09546111(02)91369-7/abstract
6. Karan RS, Pandhi P, Behera D, et al. A comparison of non-tapering vs. tapering prednisolone in acute exacerbation of
asthma involving use of the low-dose ACTH test. Int J Clin Pharmacol Ther. 2002; 40: 256-262. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12078939
7. Kravitz J, Dominici P, Ufberg J, et al. Two days of dexamethasone versus 5 days of prednisone in the treatment of
acute asthma: a randomized controlled trial. Ann Emerg Med. 2011; 58: 200-204. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21334098
8. Manser R, Reid D, Abramson MJ. Corticosteroids for acute severe asthma in hospitalised patients. Cochrane Database
Syst Rev. 2001; Issue 1: CD001740. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001740/full
9. O'Driscoll BR, Kalra S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993; 341: 324327. Available from: http://www.sciencedirect.com/science/article/pii/0140673693901343
10. Rowe BH, Spooner C, Ducharme F, et al. Early emergency department treatment of acute asthma with systemic
corticosteroids. Cochrane Database Syst Rev. 2001; Issue 1: CD002178. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002178/full
11. Rowe BH, Spooner C, Ducharme F, et al. Corticosteroids for preventing relapse following acute exacerbations of
asthma. Cochrane Database Syst Rev. 2007; Issue 3: CD000195. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000195.pub2/full
12. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The
Thoracic Society of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinicaldocuments/area?command=record&id=14
13. Chan JS, Cowie RL, Lazarenko GC, et al. Comparison of intramuscular betamethasone and oral prednisone in the
prevention of relapse of acute asthma. Can Respir J. 2001; 8: 147-152. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/11420590
14. Clark S, Costantino T, Rudnitsky G, Camargo CA. Observational study of intravenous versus oral corticosteroids for
acute asthma: an example of confounding by severity. Acad Emerg Med. 2005; 12: 439-435. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/15860696
15. Cunnington D, Smith N, Steed K, et al. Oral versus intravenous corticosteroids in adults hospitalised with acute
asthma. Pulm Pharmacol Ther. 2005; 18: 207-12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15707855
16. Lahn M, Bijur P, Gallagher EJ. Randomized clinical trial of intramuscular vs oral methylprednisolone in the treatment
of asthma exacerbations following discharge from an emergency department. Chest. 2004; 126: 362-368. Available
from: http://journal.publications.chestnet.org/article.aspx?articleid=1082734
17. Razi E, Moosavi GA. A comparative efficacy of oral prednisone with intramuscular triamcinolone in acute
exacerbation of asthma. Iran J Allergy Asthma Immunol. 2006; 5: 17-22. Available from:
http://ijaai.tums.ac.ir/index.php/ijaai/article/view/127
18. Edmonds ML, Milan SJ, Camargo CA, et al. Early use of inhaled corticosteroids in the emergency department
treatment of acute asthma. Cochrane Database Syst Rev. 2012; 12: CD002308. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002308.pub2/full
19. Upham BD, Mollen CJ, Scarfone RJ, et al. Nebulized budesonide added to standard pediatric emergency department
treatment of acute asthma: a randomized, double-blind trial. Acad Emerg Med. 2011; 18: 665-673. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21762229
20. Aspen Pharmacare Australia Pty Ltd. Product information: Panafcort (prednisone) and Panafcortelone (prednisolone).
Therapeutic Goods Administration, Canberra, 2010. Available from: https://www.ebs.tga.gov.au
21. Edmonds ML, Milan SJ, Brenner BE, et al. Inhaled steroids for acute asthma following emergency department
discharge. Cochrane Database Syst Rev. 2012; 12: CD002316. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002316.pub2/full
22. Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a
randomised, double-blind trial. Lancet. 2003; 361: 1071-1076. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12672309
36
HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > RESPONSE
Assessing response to treatment
Recommendations
Assess clinical response to each dose of bronchodilator:
• If dyspnoea is partially relieved within first 5 minutes, reassess at 15 minutes.
• If dyspnoea is not relieved, repeat bronchodilator dose and consider add-on options.
• If condition deteriorates at any time, consider add-on treatment options.
Table. Add-on treatment options for acute asthma
Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/61
• Reduced wheezing alone is an unreliable indicator of improvement, as it may indicate deterioration
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Review treatment response again 10–20 minutes after third dose (approximately 1 hour after first dose). If dyspnoea
persists, continue giving salbutamol every 20 minutes and consider add-on treatment options.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Camargo et al. 20031
• Chandra et al. 20052
• Karpel et al. 19973
• Rodrigo and Rodrigo, 20024
• Shrestha et al. 19965
Perform baseline spirometry and record FEV1 approximately 1 hour after giving initial bronchodilator treatment, if
feasible.
Table. Tips for performing spirometry in patients with acute asthma
• Ask the patient to sit straight upright, either in a chair or on a stretcher with their legs over the side.
• Make sure the person forms a tight seal around the mouthpiece.
• Tell the patient to take as deep a breath as possible, then blast out air as fast and hard as they can, then keep
blowing until asked to stop. Aim for exhalation of maximal force for at least 2 seconds (6 seconds if FVC is
measured).
• You may need to give the patient lots of coaching, repeat instructions, and give immediate feedback on
technique.
Asset ID: 66
37
• Patients with severe acute asthma are unlikely to be able to perform spirometry
• Do not continue attempting to obtain a spirometry reading if the patient is distressed
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Arnold et al. 20126
• Emerman and Cydulka, 19957
• Karras et al. 20008
• Langhan and Spiro, 20099
• Schneider et al. 201110
• Silverman et al. 200711
• Wilson et al. 200312
If spirometry is not available, a peak expiratory flow meter can be used to assess initial response.
Note: PEF is not as accurate as spirometry for measuring lung function.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Abisheganaden et al. 199813
• Geelhoed et al. 199014
• Henderson et al. 201015
• Ribeiro de Andrade et al. 200716
Obtain blood gas analysis in adults with features of life-threatening acute asthma (any of):
•
•
•
•
•
•
•
unable to speak due to dyspnoea
reduced consciousness or collapse
exhaustion
cyanosis
oxygen saturation <92%
poor respiratory effort
cardiac arrhythmia.
s
How this recommendation was developed
Adapted from existing guidance
Based on reliable clinical practice guideline(s) or position statement(s):
• British Thoracic Society and Scottish Intercollegiate Guidelines Network, 200817
• Global Initiative for Asthma, 201218
Monitor for signs of salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis).
• Salbutamol toxicity may occur with inhaled or IV salbutamol
s
How this recommendation was developed
Based on selected evidence
38
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Salmeron et al. 199419
• Travers et al. 201220
Admit patient to hospital if (any of):
• FEV1 <60% predicted at 1-hour check
• unable to lie flat without dyspnoea
• dyspnoea unresolved within 1–2 hours.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Wilson et al. 200312
More information
Salbutamol in acute asthma: dosing regimens
One placebo-controlled study showed that, for patients who showed clear improvement after the first dose of salbutamol
via pressurised metered-dose inhaler and spacer, there was no advantage in repeating the dose more often than every 60
minutes until full recovery (extra doses can be given as needed).3
However, in patients who did not show a clear response to the first salbutamol dose, repeating the dose at intervals of 30
minutes or less was more effective than every 60 minutes.3
Salbutamol in acute asthma: route of administration
Inhaler plus spacer, or nebuliser
Salbutamol delivered via a pressurised metered-dose inhaler with spacer is at least as effective as salbutamol delivered
via nebuliser in patients with moderate-to-severe acute asthma who do not require ventilation.21, 22, 24 The use of
nebulisers increases the risk of transmitting respiratory infections to staff and other patients.
Intravenous salbutamol
Overall, intravenous short-acting beta2 agonists do not appear to be superior to inhaled short-acting beta2 agonist.20
Benefits have not been demonstrated in adults.20 Very limited evidence from one study suggested that the addition of IV
salbutamol to inhaled salbutamol reduced recovery time in children with severe acute asthma in the emergency
department.20
However, there is a lack of consensus on the appropriate dose of IV salbutamol for children.25 Recommendations differ
between guidelines in Australia26 and elsewhere.25 Doses have not been calculated based on age-specific
pharmacokinetic and pharmacodynamic data. The doses recommended in guidelines are generally relatively higher than
for adults on a micrograms per kilogram body weight basis.
Compared with inhaled salbutamol, intravenous salbutamol is associated with increased risk of adverse effects including
tremor and hypokalaemia.20, 25 Concomitant use of the inhalation and IV routes may increase the risk of salbutamol
toxicity.27
Note: Salbutamol concentrate for infusion is available in 5 mL ampoules containing salbutamol sulfate equivalent to 5 mg (1 mg/mL)
salbutamol in a sterile isotonic solution (Ventolin obstetric injection). Salbutamol for injection is also available in ampoules of salbutamol
sulphate equivalent to 500 mcg salbutamol in 1 mL sterile isotonic solution (Ventolin injection).
Assessment of oxygen status in acute asthma
39
Hypoxia is the main cause of death that is due to acute asthma.28
Routine objective assessment of oxygen saturation at initial assessment of acute asthma is needed because clinical signs
may not correlate with hypoxaemia.
Pulse oximetry is the internationally accepted method for routine assessment of oxygen status in patients with acute
asthma.18
The risk of hypercapnoea increases when oxygen saturation falls below 92%.29
Pulse oximetry does not detect hypercapnoea, so blood gas analysis is necessary if hypercapnoea is suspected in patients
with severe or life-threatening acute asthma.
Oxygen therapy in acute asthma
Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been shown to improve the sensation of
breathlessness in non-hypoxaemic patients.30 When oxygen supplementation is used, pulse oximetry is necessary to
monitor oxygen status and titrate to target.
The aim of titrated oxygen therapy in acute care is to achieve normal or near-normal oxygen saturation, except in patients
who are at risk of hypercapnoeic respiratory failure,30 such as patients with overlapping asthma and COPD.
Adults
In adults with acute asthma, titrated oxygen therapy using pulse oximetry to maintain oxygen saturation at 93–95% while
avoiding hyperoxaemia achieves better physiological outcomes than 100% oxygen at high flow rate (8 L/min).31 Highconcentration and high-flow oxygen therapy cause a clinically significant increase in blood CO2 concentration in adults
31, 32
with acute asthma.
National guidelines for the management of acute exacerbations of COPD recommend that hypoxic patients should be
given controlled oxygen therapy via nasal prongs at 0.5–2.0 L/minute or a venturi mask at 24% or 28%, with target oxygen
saturation of over 90% (PaO2 >50 mmHg, or 6.7 kPa).33 Excessive oxygen administration should be avoided because it can
worsen hypercapnoea.33
Go to: The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary
Disease
Children
Drying of the upper airway is a potential complication of oxygen therapy in children,34, 35 which might contribute to
bronchoconstriction.35 Humidified oxygen can be considered if necessary. Humidification is usually not needed for low
flow oxygen (<4 L/minute in children or 2 L/minute in infants) for short term. Humidification may be considered if the
oxygen is required for longer than 48 hours or if the nasal passages are becoming uncomfortable or dry.34
Guidance on oxygen delivery techniques and practical issues is available from Sydney Children's Hospital Network and
The Royal Children's Hospital Melbourne.
Go to: Sydney Children's Hospitals Network resource on oxygen therapy and delivery devices
Go to: The Royal Children's Hospital Melbourne guideline on Oxygen delivery Spirometry in acute asthma
Utility
Assessment of response to treatment should include spirometry considered alongside clinical assessment. Clinical
assessment alone may underestimate the severity of airflow limitation.12
On its own, FEV1 (measured by spirometry) at 1 hour after admission to the emergency department does not closely
correlate with the need for hospital admission in adults with acute asthma as assessed clinically.12
Feasibility and technique
Most adults with acute asthma can perform spirometry within the first hour of admission to the emergency department.11
(Hospital staff and primary care health professionals may need specific training in spirometry technique to be able to
obtain acceptable spirometry in patients with acute asthma.11)
Younger children (most children under 6 years) are unlikely to be able to perform spirometry.
40
It may not be feasible to apply standard spirometry technique and manoeuvre acceptability criteria in patients with acute
asthma:11
• 80% of patients older than 12 years with acute asthma can perform an FEV1 manoeuvre. A forced exhalation from
total lung capacity for 2 seconds is sufficient and provides useful information about the severity of airflow
obstruction11
• two attempts may suffice if patients are unable to make three attempts11
• variability between manoeuvres of < 10% should be considered acceptable11
• patients may not be able to tolerate nose clips11
• patients are unlikely to be able to exhale for long enough to demonstrate the time-volume plateau. Although patients
should aim for forced exhalation of at least 6 seconds, 2 seconds is acceptable for measuring FEV1 in clinical
assessment during acute asthma.11 A spirometry manoeuvre might be considered acceptable if back-extrapolated
volume is either < 5% of FVC or 0.15 L (whichever is greater), or a time to peak flow < 120 ms.11
Table. Tips for performing spirometry in patients with acute asthma
• Ask the patient to sit straight upright, either in a chair or on a stretcher with their legs over the side.
• Make sure the person forms a tight seal around the mouthpiece.
• Tell the patient to take as deep a breath as possible, then blast out air as fast and hard as they can, then keep
blowing until asked to stop. Aim for exhalation of maximal force for at least 2 seconds (6 seconds if FVC is
measured).
• You may need to give the patient lots of coaching, repeat instructions, and give immediate feedback on
technique.
Asset ID: 66
Peak expiratory flow in acute asthma
Peak expiratory flow rate obtained using a peak flow meter underestimates the severity of airflow limitation in patients
with acute asthma, compared with FEV1 obtained by spirometry.36
Peak expiratory flow is not a sensitive measure of small clinical improvements as perceived by the patient.8
Heliox in acute asthma
When giving nebulised bronchodilators in acute asthma, the use of helium-oxygen mixtures (heliox) to drive the nebuliser
may be more effective than oxygen for improving lung function and reducing hospital admission rates, based on a metaanalysis of clinical trials in adults and children.37 However, the application of this finding to routine management of acute
asthma is limited, because nebulisation is not routinely recommended in Australia the use of oxygen to drive nebulisers is
not routinely recommended for adults who need nebulisation, and many patients do not require oxygen.
Ipratropium in acute asthma
Ipratropium bromide alone is less effective than salbutamol alone in acute asthma.38
Early administration of ipratropium bromide in addition to beta2 agonists may reduce admission rates and improve lung
function in children and adults with acute asthma, based on the findings of a systematic review of 32 randomised
controlled trials.39
However, ipratropium bromide does not appear to benefit patients with less severe acute asthma (patients with acute
asthma assessed as ‘mild’ in randomised controlled trials, e.g. FEV1 >70% predicted).39
Ipratropium bromide may be effective in patients with tolerance to the bronchodilator effect of short-acting betaagonists caused by beta-receptor down-regulation.40
It is well tolerated in children with acute asthma.38
Theophyllines in acute asthma
41
Aminophylline versus short-acting beta2 agonist
Intravenous aminophylline may be as effective as intravenous short-acting beta2 agonist in the management of acute
asthma in adults and children, but is associated with a higher rate of adverse effects including giddiness, nausea and
vomiting.41
Aminophylline plus beta2 agonist (adults)
Overall, evidence from randomised clinical trials in adults with acute asthma treated in emergency departments suggests
that intravenous aminophylline given in addition to inhaled beta2 agonists does not achieve greater bronchodilation or
reduce hospital admissions, compared with inhaled beta2 agonists alone.42 No sub-groups that benefit from intravenous
aminophylline have been clearly identified.42 Aminophylline is associated with vomiting and cardiac arrhythmias.42
Theophylline is metabolised mainly by the liver and commonly interacts with other medicines. Its concentration in plasma
should be monitored closely in older people or those with comorbid conditions.43
• Avoid short-acting theophylline for a patient who is already using long-acting theophylline.
Aminophylline plus beta2 agonist (children)
Overall, evidence from randomised clinical trials in children with acute asthma requiring hospital admission suggests that
the addition of intravenous aminophylline to beta2-agonists and corticosteroids (with or without anticholinergic agents)
improves lung function within 6 hours of treatment, but does not appear to improve symptoms or shorten hospital stay.44
Aminophylline is associated with a significant increased risk of vomiting in children.44
Magnesium sulfate in acute asthma
MgSO4 versus beta2 agonists
Clinical trial evidence does not support the use of magnesium sulfate as a substitute for inhaled beta2 agonists.45
Intravenous MgSO4 plus beta2 agonist
In patients with life-threatening acute asthma (FEV1 25–30% predicted) or patients with a poor response to initial
bronchodilator treatment, intravenous magnesium sulfate (2 g given as single infusion over 20 minutes) can reduce
18
hospital admission rates. However, it may only be effective in patients with more severe acute asthma. In a recent large,
well-conducted randomised controlled trial in adults with moderate-to-severe acute asthma treated in an emergency
department (excluding those with life-threatening asthma), intravenous magnesium sulfate improved dyspnoea scores
but did not reduce hospital admission rates.46
In children, intravenous magnesium sulfate improves lung function and reduces the need for hospital admission.47 Fewer
studies have been conducted in children under 6 years.
Intravenous magnesium sulfate is inexpensive and generally well tolerated.18, 46
Inhaled MgSO4 plus beta2 agonist
Overall, evidence from randomised controlled clinical trials suggests that nebulised magnesium sulfate in addition to
beta2 agonist (with or without ipratropium bromide) does not reduce hospital admissions or improve lung function in
adults or children, compared with beta2 agonist alone.45, 46
However, the results of some clinical trials suggest that the addition of nebulised magnesium sulfate improves lung
function in patients with severe acute asthma (FEV1 <50% predicted).45 In a recent large randomised controlled clinical
trial in children, nebulised magnesium sulfate was associated with a small improvement in asthma symptom scores at 60
minutes. The effect was greatest in the subgroups of children with more severe acute asthma, and those with a shorter
duration of symptoms.48
A recent study showed no benefit in adults for hospitalisation or dyspnoea with add-on nebulised magnesium compared
with standard therapy alone, but this study excluded patients with life-threatening acute asthma as defined in this
handbook.46
Fewer studies have been conducted in children than in adults.45
Ketamine in acute asthma
There is insufficient evidence from randomised clinical trials to assess the benefits of ketamine in the management of
acute asthma. Available evidence does not demonstrate benefits in non-intubated children with acute asthma.49
42
Ketamine has been suggested as a suitable option for pre-intubation sedation in patients with respiratory failure caused
by acute asthma (where not contraindicated) because it stimulates the release of catecholamines and may contribute to
bronchodilation through direct relaxation effect on bronchial smooth muscle.50 Adverse effects associated with ketamine
include hypersecretion, hypotension and hypertension, arrhythmias, and hallucinations.50
Oral montelukast in acute asthma
Evidence from randomised controlled clinical trials does not support routine use of oral leukotriene receptor agonists in
acute asthma in adults or children.51
In children with acute asthma, the addition of oral montelukast to usual care does not reduce hospital admission rates,
based on the findings of a systematic review and meta-analysis.51
In adults with acute asthma, the addition of oral montelukast to usual care may slightly reduce beta2 agonist
requirement.51 The addition of oral zafirlukast was associated with improvement in lung function, compared with usual
care.51
Antibiotics in acute asthma
Antibiotics are not used routinely in the management of acute asthma but should be used if they would otherwise be
indicated, e.g. for specific comorbidities or when there is evidence of an infective exacerbation or previous positive
microbiology.
The role of atypical bacterial infections (e.g. Chlamydophyla pneumonia, Mycoplasma pneumonae) in asthma is under
investigation. Atypical bacterial infections may make acute asthma more severe, especially in patients with poorly
controlled asthma. Macrolide antibiotics and telithromycin (a ketolide antibiotic not registered in Australia) are active
against atypical bacteria and have anti-inflammatory activity.52
Overall, evidence from randomised clinical trials does not support the routine use of antibiotics in managing acute asthma.
Evidence from one clinical trial suggested that telithromycin might help improve asthma symptoms when given after
acute asthma, but it was associated with nausea.53, 54
The ‘lie flat’ test (adults)
In adults, at 1 hour after initial treatment, the ability to lie flat without dyspnoea is a useful indicator of adequate recovery
without the need for hospital admission, particularly when combined with adequate improvement in FEV1 measured by
spirometry.12
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37. Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven beta2-agonists nebulization for children and adults with acute
asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2014; 112: 29-34. Available from:
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38. Teoh L, Cates CJ, Hurwitz M, et al. Anticholinergic therapy for acute asthma in children. Cochrane Database Syst Rev.
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39. Rodrigo J, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute asthma: a
systematic review with meta-analysis. Thorax. 2005; 60: 740-746. Available from:
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40. Haney S, Hancox RJ. Overcoming beta-agonist tolerance: high dose salbutamol and ipratropium bromide. Two
randomised controlled trials. Respir Res. 2007; 8: 19. Available from: http://respiratory-research.com/content/8/1/19
41. Travers AH, Jones AP, Camargo CA, et al. Intravenous beta(2)-agonists versus intravenous aminophylline for acute
asthma. Cochrane Database Syst Rev. 2012; 12: CD010256. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010256/full
42. Nair P, Milan SJ, Rowe BH. Addition of intravenous aminophylline to inhaled beta(2)-agonists in adults with acute
asthma. Cochrane Database Syst Rev. 2012; 12: CD002742. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002742.pub2/full
43. Gupta P, O'Mahony MS. Potential adverse effects of bronchodilators in the treatment of airways obstruction in older
people: recommendations for prescribing. Drugs Aging. 2008; 25: 415-43. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18447405
44. Mitra AA, Bassler D, Watts K, et al. Intravenous aminophylline for acute severe asthma in children over two years
receiving inhaled bronchodilators. Cochrane Database Syst Rev. 2005; Issue 2: CD001276. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001276.pub2/full
45. Powell C, Dwan K, Milan SJ, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst
Rev. 2012; 12: CD003898. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002308.pub2/full
46. Goodacre S, Cohen J, Bradburn M, et al. Intravenous or nebulised magnesium sulphate versus standard therapy for
severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med. 2013; 1: 293-300.
Available from: http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(13)70070-5/fulltext
47. Mohammed S, Goodacre S. Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and
meta-analysis. Emerg Med J. 2007; 24: 823-830. Available from: http://emj.bmj.com/content/24/12/823.long
48. Powell C, Kolamunnage-Dona R, Lowe J, et al. MAGNEsium Trial In Children (MAGNETIC): a randomised, placebocontrolled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children. Health
Technol Assess. 2013; 17: 1-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24144222
49. Jat KR, Chawla D. Ketamine for management of acute exacerbations of asthma in children. Cochrane Database Syst
Rev. 2012; 11: CD009293. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009293.pub2/full
50. Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure.
Proc Am Thorac Soc. 2009; 6: 371-379. Available from: http://www.atsjournals.org/doi/full/10.1513/pats.P09ST4
51. Watts K, Chavasse RJ. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and
children. Cochrane Database Syst Rev. 2012; Issue 5: CD006100. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22592708
52. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available
from: http://www.jacionline.org/article/S0091-6749(06)00741-X/fulltext
53. Black PN. Antibiotics for the treatment of asthma. Curr Opin Pharmacol. 2007; 7: 266-71. Available from:
http://www.sciencedirect.com/science/article/pii/S1471489207000616
54. Johnston SL, Blasi F, Black PN, et al. The Effect of Telithromycin in Acute Exacerbations of Asthma. N Engl J Med.
2006; 354: 1589-1600. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa044080#t=article
45
HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > ADD-ON TREATMENT
Continuing treatment and considering additional treatment
Recommendations
Consider add-on treatments based on response to initial doses of salbutamol.
Table. Add-on treatment options for acute asthma
Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/61
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
If response to initial inhaled salbutamol is incomplete or poor, add inhaled ipratropium bromide and continue
salbutamol as needed.
Adults: Give ipratropium bromide 8 puffs (21 mcg/actuation) via pressurised metered-dose inhaler and spacer every 20
minutes for first hour. Repeat 4–6 hourly for 24 hours.
If a nebuliser is being used to deliver salbutamol, 500 mcg ipratropium bromide can be added to the nebulised solution
every 20 minutes for first hour. Repeat 4–6 hourly.
Children 6–12 years: Give ipratropium bromide 8 puffs (21 mcg/actuation) via pressurised metered-dose inhaler and
spacer every 20 minutes for first hour. Repeat 4–6 hourly for 24 hours.
If a nebuliser is being used to deliver salbutamol, 500 mcg ipratropium bromide can be added to the nebulised
solution every 20 minutes for first hour. Repeat 4–6 hourly.
Children 0–5 years: Give ipratropium bromide 4 puffs (21 mcg/actuation) via pressurised metered-dose inhaler and
spacer (+ mask if needed) every 20 minutes for first hour. Repeat 4–6 hourly for 24 hours.
If a nebuliser is being used to deliver salbutamol, 250 mcg ipratropium bromide can be added to the nebulised solution
every 20 minutes for first hour. Repeat 4–6 hourly.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
1
• Iramain et al. 2011
• Rodrigo and Castro-Rodriguez, 20052
• Teoh et al. 20123
Montelukast is not recommended for the management of acute asthma in adults or children in acute care settings.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Adachi et al. 20124
• Watts and Chavasse, 20125
46
For adults with severe or life-threatening acute asthma, or with poor response to repeated maximal doses of other
bronchodilators, consider intravenous magnesium sulfate.
Give magnesium sulfate 10 mmol diluted in a compatible solution as a single infusion over 20 minutes.
• Intravenous magnesium sulfate may be associated with hypotension
Table. How to administer intravenous magnesium sulfate
Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/95
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Global Initiative for Asthma, 20126
• Mohammed and Goodacre, 20077
• Powell et al. 20128
• Song and Chang, 20129
For children 2 years and older with poor response to initial bronchodilator therapy, consider intravenous magnesium
sulfate.
Give magnesium sulfate 0.1–0.2 mmol/kg (maximum 10 mmol) diluted in a compatible solution as a single infusion over
20 minutes.
Do not use intravenous magnesium sulfate in children younger than 2 years.
• Intravenous magnesium sulfate may be associated with hypotension
Table. How to administer intravenous magnesium sulfate
Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/95
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Global Initiative for Asthma, 20126
• Mohammed and Goodacre, 20077
• Powell et al. 20128
In critical care units (e.g. emergency department, intensive care unit, high-dependency unit), IV salbutamol can be
considered for patients with life-threatening acute asthma that has not responded to continuous nebulised salbutamol,
after considering other add-on treatment options.
• Salbutamol toxicity may occur with either the inhaled or IV route of administration. Risk may be increased when the
inhaled and IV routes are used concomitantly.
Table. Add-on treatment options for acute asthma Please view and print this figure separately:
http://www.asthmahandbook.org.au/table/show/61
×
47
Table. Add-on treatment options for acute asthma
Add-on treatment options for acute asthma
Agent
Recommended use in
Administration and dosage
Notes
acute asthma
Inhaled
Second-line
Via pMDI
Adults and
Use spacer (plus
ipratropium
bronchodilator if
21 mcg/actuation
children 6 years
mask, if patient
bromide
inadequate response to
every 20 minutes
and over:
cannot use
salbutamol
for first hour
8 puffs
mouthpiece)
Repeat every 4
Children 0–5
–6 hours for
years:
24 hours
4 puffs
Via nebuliser
Adults and
If salbutamol is
every 20 minutes
children 6 years
delivered by
for first hour
and over:
nebuliser, add to
Repeat every 4
500 mcg nebule
nebuliser solution
–6 hours
Children 0–5
years:
250 mcg nebule
IV magnesium
Second-line
IV infusion over
sulfate
bronchodilator in severe
20 minutes
or life-threatening acute
Adults: 10 mmol
Children 2 years
and over: 0.1
asthma, or when poor
–0.2 mmol/kg
response to repeated
maximal doses of other
Avoid magnesium
sulfate in children
younger than
2 years
(maximum
Dilute in
10 mmol)
compatible
bronchodilators
solution
IV salbutamol
Third-line
Follow hospital/organisation’s
Use only in
(only in ICU)
bronchodilator in life-
protocol critical care units
threatening acute
(e.g. emergency
asthma that has not
department,
responded to continuous
intensive care
nebulised salbutamol
unit/high-
after considering other
dependency unit)
add-on treatment
Monitor blood
options
electrolytes,
heart rate and
acid/base balance
(blood lactate)
48
Agent
Recommended use in
Administration and dosage
Notes
acute asthma
Reduce initial
dose for older
adults. Consider
dose reduction
for those with
impaired renal
function.
Impaired liver
function may
result in
accumulation of
unmetabolised
salbutamol
Non-invasive
Consider if starting to
Do not sedate
positive pressure
tire or signs of
patient
ventilation respiratory failure
If no
improvement,
intubate and start
mechanical
ventilation
Back to top
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
10
• Travers et al. 2012
• Travers et al. 201211
• Abramson et al. 200112
If using IV salbutamol to manage acute asthma, follow your hospital/organisation’s protocol for dosage and delivery.
If no local protocol is available, use the following as a guide:
Using a 1 mg/mL (1000 mcg/mL) salbutamol concentrate for infusion, prepare a solution of 5 mg in 50 mL normal saline.
Deliver by continuous infusion or bolus.
Children 2–12 years:
Loading dose of 5 mcg/kg/minute (maximum 200 mcg/minute) for 1 hour and then infusion of 1–2 mcg/kg/minute
(maximum 80 mcg/minute).
Adults and children older than 12 years:
As continuous infusion: initial loading dose of 200 mcg over 1 minute and then start infusion at 5 mcg/minute (can
increase to 10 mcg/minute, then up to 20 mcg/minute every 15–30 minutes according to response)
As bolus: 250 mcg over 5 minutes.
49
• The initial dose should be reduced for older adults. Dose reduction may be needed for people with impaired renal
function. Impaired liver function may result in accumulation of unmetabolised salbutamol. Refer to TGA-approved
product information.
Monitor blood electrolytes, heart rate and acid/base balance (blood lactate).
• Salbutamol toxicity can occur with either the inhaled or IV route of administration. Risk may be increased when the
inhaled and IV routes are used concomitantly.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• GlaxoSmithKline Australia Pty Ltd 200813
If the patient is starting to tire, or shows signs of respiratory failure, consider noninvasive positive pressure ventilation.
For patients with respiratory arrest, acute respiratory failure that does not respond to treatment, severe exhaustion
suggesting impending respiratory arrest, or failure of noninvasive positive pressure ventilation, start mechanical
ventilation.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Brandao et al. 200914
• Gupta et al. 201015
• Lim et al. 201216
• Soroksky et al. 201017
• Soma et al. 200818
• Williams et al. 2011
19
If intubation is needed, ketamine can be considered.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Jat and Chawla, 201220
If dyspnoea does not respond to treatment, consider transfer to an intensive care unit.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Admit patient to hospital if (any of):
• FEV1 <60% predicted at 1-hour check
• unable to lie flat without dyspnoea
• dyspnoea unresolved within 1–2 hours.
50
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Wilson et al. 200321
More information
Ipratropium in acute asthma
Ipratropium bromide alone is less effective than salbutamol alone in acute asthma.3
Early administration of ipratropium bromide in addition to beta2 agonists may reduce admission rates and improve lung
function in children and adults with acute asthma, based on the findings of a systematic review of 32 randomised
controlled trials.2
However, ipratropium bromide does not appear to benefit patients with less severe acute asthma (patients with acute
asthma assessed as ‘mild’ in randomised controlled trials, e.g. FEV1 >70% predicted).2
Ipratropium bromide may be effective in patients with tolerance to the bronchodilator effect of short-acting betaagonists caused by beta-receptor down-regulation.22
It is well tolerated in children with acute asthma.3
Magnesium sulfate in acute asthma
MgSO4 versus beta2 agonists
Clinical trial evidence does not support the use of magnesium sulfate as a substitute for inhaled beta2 agonists.8
Intravenous MgSO4 plus beta2 agonist
In patients with life-threatening acute asthma (FEV1 25–30% predicted) or patients with a poor response to initial
bronchodilator treatment, intravenous magnesium sulfate (2 g given as single infusion over 20 minutes) can reduce
hospital admission rates.6 However, it may only be effective in patients with more severe acute asthma. In a recent large,
well-conducted randomised controlled trial in adults with moderate-to-severe acute asthma treated in an emergency
department (excluding those with life-threatening asthma), intravenous magnesium sulfate improved dyspnoea scores
but did not reduce hospital admission rates.23
In children, intravenous magnesium sulfate improves lung function and reduces the need for hospital admission.7 Fewer
studies have been conducted in children under 6 years.
Intravenous magnesium sulfate is inexpensive and generally well tolerated.6, 23
Inhaled MgSO4 plus beta2 agonist
Overall, evidence from randomised controlled clinical trials suggests that nebulised magnesium sulfate in addition to
beta2 agonist (with or without ipratropium bromide) does not reduce hospital admissions or improve lung function in
adults or children, compared with beta2 agonist alone.8, 23
However, the results of some clinical trials suggest that the addition of nebulised magnesium sulfate improves lung
function in patients with severe acute asthma (FEV1 <50% predicted).8 In a recent large randomised controlled clinical
trial in children, nebulised magnesium sulfate was associated with a small improvement in asthma symptom scores at 60
minutes. The effect was greatest in the subgroups of children with more severe acute asthma, and those with a shorter
duration of symptoms.24
A recent study showed no benefit in adults for hospitalisation or dyspnoea with add-on nebulised magnesium compared
with standard therapy alone, but this study excluded patients with life-threatening acute asthma as defined in this
handbook.23
Fewer studies have been conducted in children than in adults.8
51
Salbutamol in acute asthma: route of administration
Inhaler plus spacer, or nebuliser
Salbutamol delivered via a pressurised metered-dose inhaler with spacer is at least as effective as salbutamol delivered
via nebuliser in patients with moderate-to-severe acute asthma who do not require ventilation.25, 26, 28 The use of
nebulisers increases the risk of transmitting respiratory infections to staff and other patients.
Intravenous salbutamol
Overall, intravenous short-acting beta2 agonists do not appear to be superior to inhaled short-acting beta2 agonist.10
Benefits have not been demonstrated in adults.10 Very limited evidence from one study suggested that the addition of IV
salbutamol to inhaled salbutamol reduced recovery time in children with severe acute asthma in the emergency
department.10
However, there is a lack of consensus on the appropriate dose of IV salbutamol for children.29 Recommendations differ
between guidelines in Australia30 and elsewhere.29 Doses have not been calculated based on age-specific
pharmacokinetic and pharmacodynamic data. The doses recommended in guidelines are generally relatively higher than
for adults on a micrograms per kilogram body weight basis.
Compared with inhaled salbutamol, intravenous salbutamol is associated with increased risk of adverse effects including
tremor and hypokalaemia.10, 29 Concomitant use of the inhalation and IV routes may increase the risk of salbutamol
toxicity.12
Note: Salbutamol concentrate for infusion is available in 5 mL ampoules containing salbutamol sulfate equivalent to 5 mg (1 mg/mL)
salbutamol in a sterile isotonic solution (Ventolin obstetric injection). Salbutamol for injection is also available in ampoules of salbutamol
sulphate equivalent to 500 mcg salbutamol in 1 mL sterile isotonic solution (Ventolin injection).
Adrenaline in acute asthma
Systemic adrenaline (intravenous in clinical settings with appropriately trained staff, or intramuscular) is indicated for
patients with anaphylaxis and angioedema,6, 31 but current evidence does not support its routine use in the management
of acute asthma in the absence of anaphylaxis.6
Nebulised adrenaline does not have a significant benefit over salbutamol or terbutaline in the management of moderateto-severe acute asthma in adults and children.32
Go to: Australasian Society of Clinical Immunology and Allergy (ASCIA)’s Acute management of anaphylaxis guidelines
Theophyllines in acute asthma
Aminophylline versus short-acting beta2 agonist
Intravenous aminophylline may be as effective as intravenous short-acting beta2 agonist in the management of acute
asthma in adults and children, but is associated with a higher rate of adverse effects including giddiness, nausea and
vomiting.11
Aminophylline plus beta2 agonist (adults)
Overall, evidence from randomised clinical trials in adults with acute asthma treated in emergency departments suggests
that intravenous aminophylline given in addition to inhaled beta2 agonists does not achieve greater bronchodilation or
33
reduce hospital admissions, compared with inhaled beta2 agonists alone. No sub-groups that benefit from intravenous
aminophylline have been clearly identified.33 Aminophylline is associated with vomiting and cardiac arrhythmias.33
Theophylline is metabolised mainly by the liver and commonly interacts with other medicines. Its concentration in plasma
should be monitored closely in older people or those with comorbid conditions.34
• Avoid short-acting theophylline for a patient who is already using long-acting theophylline.
Aminophylline plus beta2 agonist (children)
Overall, evidence from randomised clinical trials in children with acute asthma requiring hospital admission suggests that
the addition of intravenous aminophylline to beta2-agonists and corticosteroids (with or without anticholinergic agents)
improves lung function within 6 hours of treatment, but does not appear to improve symptoms or shorten hospital stay.35
Aminophylline is associated with a significant increased risk of vomiting in children.35
52
Heliox in acute asthma
When giving nebulised bronchodilators in acute asthma, the use of helium-oxygen mixtures (heliox) to drive the nebuliser
may be more effective than oxygen for improving lung function and reducing hospital admission rates, based on a metaanalysis of clinical trials in adults and children.36 However, the application of this finding to routine management of acute
asthma is limited, because nebulisation is not routinely recommended in Australia the use of oxygen to drive nebulisers is
not routinely recommended for adults who need nebulisation, and many patients do not require oxygen.
Ketamine in acute asthma
There is insufficient evidence from randomised clinical trials to assess the benefits of ketamine in the management of
acute asthma. Available evidence does not demonstrate benefits in non-intubated children with acute asthma.20
Ketamine has been suggested as a suitable option for pre-intubation sedation in patients with respiratory failure caused
by acute asthma (where not contraindicated) because it stimulates the release of catecholamines and may contribute to
bronchodilation through direct relaxation effect on bronchial smooth muscle.37 Adverse effects associated with ketamine
include hypersecretion, hypotension and hypertension, arrhythmias, and hallucinations.37
Oral montelukast in acute asthma
Evidence from randomised controlled clinical trials does not support routine use of oral leukotriene receptor agonists in
acute asthma in adults or children.5
In children with acute asthma, the addition of oral montelukast to usual care does not reduce hospital admission rates,
based on the findings of a systematic review and meta-analysis.5
In adults with acute asthma, the addition of oral montelukast to usual care may slightly reduce beta2 agonist
requirement.5 The addition of oral zafirlukast was associated with improvement in lung function, compared with usual
care.5
Antibiotics in acute asthma
Antibiotics are not used routinely in the management of acute asthma but should be used if they would otherwise be
indicated, e.g. for specific comorbidities or when there is evidence of an infective exacerbation or previous positive
microbiology.
The role of atypical bacterial infections (e.g. Chlamydophyla pneumonia, Mycoplasma pneumonae) in asthma is under
investigation. Atypical bacterial infections may make acute asthma more severe, especially in patients with poorly
controlled asthma. Macrolide antibiotics and telithromycin (a ketolide antibiotic not registered in Australia) are active
against atypical bacteria and have anti-inflammatory activity.38
Overall, evidence from randomised clinical trials does not support the routine use of antibiotics in managing acute asthma.
Evidence from one clinical trial suggested that telithromycin might help improve asthma symptoms when given after
acute asthma, but it was associated with nausea.39, 40
Non-invasive positive pressure ventilation in acute asthma
Efficacy
Few randomised clinical trials have evaluated non-invasive positive pressure ventilation (biphasic positive airway
pressure or continuous positive airway pressure) for adults with severe acute asthma.16 This technique has not been
shown to reduce risk of death or the need for intubation, but may reduce hospital admissions, length of hospital stay and
length of ICU stay.16 It may also improve lung function, but evidence is inconsistent.16
Delivering bronchodilators in patients undergoing noninvasive positive-pressure ventilation
When delivering nebulised salbutamol while using noninvasive positive-pressure ventilation set at pressures commonly
used in clinical practice, the amount of salbutamol inhaled is likely to be significantly higher than with a nebuliser alone
(based on a bench model of a spontaneously breathing adult). This increase may be because the ventilator tubing acts as a
spacer.41
The position of the nebuliser in the ventilator circuit significantly affects the total dose of salbutamol inhaled. Salbutamol
is delivered most effectively when the nebuliser is positioned immediately after the expiration port (i.e. starting from the
facemask, the expiration port is positioned before the nebuliser).41
53
The ‘lie flat’ test (adults)
In adults, at 1 hour after initial treatment, the ability to lie flat without dyspnoea is a useful indicator of adequate recovery
without the need for hospital admission, particularly when combined with adequate improvement in FEV1 measured by
spirometry.21
References
1. Iramain R, Lopez-Herce J, Coronel J, et al. Inhaled salbutamol plus ipratropium in moderate and severe asthma crises
in children. J Asthma. 2011; 48: 298-303. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21332430
2. Rodrigo J, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute asthma: a
systematic review with meta-analysis. Thorax. 2005; 60: 740-746. Available from:
http://thorax.bmj.com/content/60/9/740.full
3. Teoh L, Cates CJ, Hurwitz M, et al. Anticholinergic therapy for acute asthma in children. Cochrane Database Syst Rev.
2012; 4: CD003797. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003797.pub2/full
4. Adachi M, Taniguchi H, Tohda Y, et al. The efficacy and tolerability of intravenous montelukast in acute asthma
exacerbations in Japanese patients. J Asthma. 2012; 49: 649-656. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22742205
5. Watts K, Chavasse RJ. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and
children. Cochrane Database Syst Rev. 2012; Issue 5: CD006100. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22592708
6. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available
from: http://www.ginasthma.org
7. Mohammed S, Goodacre S. Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and
meta-analysis. Emerg Med J. 2007; 24: 823-830. Available from: http://emj.bmj.com/content/24/12/823.long
8. Powell C, Dwan K, Milan SJ, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst
Rev. 2012; 12: CD003898. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002308.pub2/full
9. Song WJ, Chang YS. Magnesium sulfate for acute asthma in adults: a systematic literature review. Asia Pac Allergy.
2012; 2: 76-85. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3269605/
10. Travers AH, Milan SJ, Jones AP, et al. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute
asthma. Cochrane Database Syst Rev. 2012; 12: CD010179. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010179/full
11. Travers AH, Jones AP, Camargo CA, et al. Intravenous beta(2)-agonists versus intravenous aminophylline for acute
asthma. Cochrane Database Syst Rev. 2012; 12: CD010256. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010256/full
12. Abramson MJ, Bailey MJ, Couper FJ, et al. Are asthma medications and management related to deaths from asthma?.
Am J Respir Crit Care Med. 2001; 163: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11208619
13. GlaxoSmithKline Australia Pty Ltd. Product information: Ventolin Sugar Free Syrup and Injection (salbutamol).
Therapeutic Goods Administration, Canberra, 2008. Available from: https://www.ebs.tga.gov.au
14. Brandao DC, Lima VM, Filho VG, et al. Reversal of bronchial obstruction with bi-level positive airway pressure and
nebulization in patients with acute asthma. J Asthma. 2009; 46: 356-61. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19484669
15. Gupta D, Nath A, Agarwal R, Behera, D.. A prospective randomized controlled trial on the efficacy of noninvasive
ventilation in severe acute asthma. Respir Care. 2010; 55: 536-43. Available from:
http://rc.rcjournal.com/content/55/5/536.short
16. Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of
respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2012; 12: CD004360.
Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004360.pub4/full
17. Soroksky A, Klinowski E, Ilgyev E, et al. Noninvasive positive pressure ventilation in acute asthmatic attack. Eur Respir
Rev. 2010; 19: 39-45. Available from: http://err.ersjournals.com/content/19/115/39.long
18. Soma T, Hino M, Kida K, Kudoh, S.. A prospective and randomized study for improvement of acute asthma by noninvasive positive pressure ventilation (NPPV). Intern Med. 2008; 47: 493-501. Available from:
https://www.jstage.jst.go.jp/article/internalmedicine/47/6/476493/_article
19. Williams AM, Abramo TJ, Shah MV, et al. Safety and clinical findings of BiPAP utilization in children 20 kg or less for
asthma exacerbations. Intensive Care Med. 2011; 37: 1338-43. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21567114
20. Jat KR, Chawla D. Ketamine for management of acute exacerbations of asthma in children. Cochrane Database Syst
Rev. 2012; 11: CD009293. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009293.pub2/full
21. Wilson MM, Irwin RS, Connolly AE, et al. A prospective evaluation of the 1-hour decision point for admission versus
discharge in acute asthma. J Intensive Care Med. 2003; 18: 275-285. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/15035763
54
22. Haney S, Hancox RJ. Overcoming beta-agonist tolerance: high dose salbutamol and ipratropium bromide. Two
randomised controlled trials. Respir Res. 2007; 8: 19. Available from: http://respiratory-research.com/content/8/1/19
23. Goodacre S, Cohen J, Bradburn M, et al. Intravenous or nebulised magnesium sulphate versus standard therapy for
severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med. 2013; 1: 293-300.
Available from: http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(13)70070-5/fulltext
24. Powell C, Kolamunnage-Dona R, Lowe J, et al. MAGNEsium Trial In Children (MAGNETIC): a randomised, placebocontrolled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children. Health
Technol Assess. 2013; 17: 1-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24144222
25. Dhuper S, Chandra A, Ahmed A, et al. Efficacy and cost comparisons of bronchodilatator administration between
metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011; 40:
247-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19081697
26. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute
asthma. Cochrane Database Syst Rev. 2013; 9: Cd000052. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/24037768
27. Cates CJ, Bestall J, Adams N. Holding chambers versus nebulisers for inhaled steroids in chronic asthma. Cochrane
Database Syst Rev. 2006; Issue 1: CD001491. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001491.pub2/full
28. Ferguson C, Gidwani S. Delivery of bronchodilators in acute asthma in children. Emerg Med J. 2006; 23: 471-472.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564350/
29. Starkey ES, Mulla H, Sammons HM, Pandya HC. Intravenous salbutamol for childhood asthma: evidence-based
medicine?. Arch Dis Child. 2014; 99: 873-877. Available from: http://adc.bmj.com/content/99/9/873.abstract
30. Babl FE, Sheriff N, Borland M, et al. Paediatric acute asthma management in Australia and New Zealand: practice
patterns in the context of clinical practice guidelines. Arch Dis Child. 2008; 93: 307-312. Available from:
http://adc.bmj.com/content/93/4/307.abstract
31. Australasian Society of Clinical Immunology and Allergy (ASCIA). Acute management of anaphylaxis guidelines. ASCIA,
Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/acute-management-ofanaphylaxis-guidelines
32. Rodrigo GJ, Nannini LJ. Comparison between nebulized adrenaline and beta2 agonists for the treatment of acute
asthma. A meta-analysis of randomized trials. Am J Emerg Med. 2006; 24: 217-22. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16490653
33. Nair P, Milan SJ, Rowe BH. Addition of intravenous aminophylline to inhaled beta(2)-agonists in adults with acute
asthma. Cochrane Database Syst Rev. 2012; 12: CD002742. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002742.pub2/full
34. Gupta P, O'Mahony MS. Potential adverse effects of bronchodilators in the treatment of airways obstruction in older
people: recommendations for prescribing. Drugs Aging. 2008; 25: 415-43. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18447405
35. Mitra AA, Bassler D, Watts K, et al. Intravenous aminophylline for acute severe asthma in children over two years
receiving inhaled bronchodilators. Cochrane Database Syst Rev. 2005; Issue 2: CD001276. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001276.pub2/full
36. Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven beta2-agonists nebulization for children and adults with acute
asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2014; 112: 29-34. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/24331390
37. Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure.
Proc Am Thorac Soc. 2009; 6: 371-379. Available from: http://www.atsjournals.org/doi/full/10.1513/pats.P09ST4
38. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available
from: http://www.jacionline.org/article/S0091-6749(06)00741-X/fulltext
39. Black PN. Antibiotics for the treatment of asthma. Curr Opin Pharmacol. 2007; 7: 266-71. Available from:
http://www.sciencedirect.com/science/article/pii/S1471489207000616
40. Johnston SL, Blasi F, Black PN, et al. The Effect of Telithromycin in Acute Exacerbations of Asthma. N Engl J Med.
2006; 354: 1589-1600. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa044080#t=article
41. Calvert LD, Jackson JM, White JA, et al. Enhanced delivery of nebulised salbutamol during non-invasive ventilation. J
Pharm Pharmacol. 2006; 58: 1553-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17132219
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HOME > ACUTE ASTHMA > CLINICAL MANAGEMENT > POST-ACUTE CARE
Providing post-acute care
Recommendations
After dyspnoea or difficulty breathing has resolved and symptoms have stabilised, observe the patient for at least 1
hour.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
If the patient is already using (or has been prescribed) inhaled corticosteroids, check adherence and inhaler technique,
and instruct them to continue their inhaled corticosteroid.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Edmonds et al. 20121
For adults who have not been prescribed inhaled corticosteroids, prescribe inhaled corticosteroid and arrange
comprehensive assessment in 2–4 weeks to review the treatment regimen (e.g. refer to person’s GP or arrange specialist
assessment).
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Edmonds et al. 20121
For children not currently taking a preventer, consider whether preventer treatment is indicated. Arrange a follow-up
appointment in 2–4 weeks to review the treatment regimen (e.g. refer to child’s GP or arrange specialist assessment).
Note: The need for preventer in children should be assessed based on the pattern of symptoms between flare-ups, not on the severity
of symptoms seen during a flare-up.
s
How this recommendation was developed
Based on selected evidence
Based on a limited structured literature review or published systematic review, which identified the following
relevant evidence:
• Edmonds et al. 20121
For patients treated in acute care services, complete all of the following:
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•
•
•
•
•
Ensure that the patient (or carer) is able to to monitor and manage asthma at home.
Check the patient has a reliever medicine and assess their inhaler technique.
Provide a spacer, if needed.
Advise patient (or carer) to make an appointment with their usual GP within 2–4 weeks (or earlier if necessary).
For patients with severe acute asthma or a previous presentation, consider arranging referral to a
consultant/respiratory physician.
• Provide an interim asthma action plan and explain that the person needs their own written asthma action plan
prepared by their usual doctor (e.g. GP or respiratory physician).
• Provide a copy of the discharge summary to the patient’s usual GP.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
At the follow-up review, the patient’s usual doctor (e.g. GP) should:
•
•
•
•
try to identify trigger factors associated with the acute asthma episode
review the written asthma action plan
review the person’s regular medicines regimen
offer specialist review if the person has had more than one emergency visit to health services for acute asthma
within the previous 12 months or repeated corticosteroid treatments.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
Routine treatment with antibiotics is not recommended after acute asthma.
s
How this recommendation was developed
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference
to the following source(s):
• Black, 20072
• Fonseca-Aten et al. 20063
• Graham et al. 20014
• Johnston, 20065
• Johnston et al. 20066
• Koutsoubari et al. 20127
More information
Interim asthma action plans
The purpose of the interim action plan is to provide written instructions until the person returns to their usual doctor for
review of their written asthma action plan.
The interim action plan should include (all of):
• the patient’s name
• instructions for oral corticosteroid course (dose, duration, when to take)
• instructions for reliever dose in immediate post-acute period (dose, how to take including use of spacer, duration of
this dose)
• instructions for when to go back to usual as-needed reliever regimen
• what to do if symptoms getting worse or recur within hours of taking reliever
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• instruction to make appointment with usual doctor e.g. GP.
Antibiotics in acute asthma
Antibiotics are not used routinely in the management of acute asthma but should be used if they would otherwise be
indicated, e.g. for specific comorbidities or when there is evidence of an infective exacerbation or previous positive
microbiology.
The role of atypical bacterial infections (e.g. Chlamydophyla pneumonia, Mycoplasma pneumonae) in asthma is under
investigation. Atypical bacterial infections may make acute asthma more severe, especially in patients with poorly
controlled asthma. Macrolide antibiotics and telithromycin (a ketolide antibiotic not registered in Australia) are active
against atypical bacteria and have anti-inflammatory activity.5
Overall, evidence from randomised clinical trials does not support the routine use of antibiotics in managing acute asthma.
Evidence from one clinical trial suggested that telithromycin might help improve asthma symptoms when given after
acute asthma, but it was associated with nausea.2, 6
References
1. Edmonds ML, Milan SJ, Brenner BE, et al. Inhaled steroids for acute asthma following emergency department
discharge. Cochrane Database Syst Rev. 2012; 12: CD002316. Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002316.pub2/full
2. Black PN. Antibiotics for the treatment of asthma. Curr Opin Pharmacol. 2007; 7: 266-71. Available from:
http://www.sciencedirect.com/science/article/pii/S1471489207000616
3. Fonseca-Aten M, Okada PJ, Bowlware KL, et al. Effect of clarithromycin on cytokines and chemokines in children with
an acute exacerbation of recurrent wheezing: a double-blind, randomized, placebo-controlled trial. Ann Allergy
Asthma Immunol. 2006; 97: 457-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17069099
4. Graham V, Lasserson TJ, Rowe BH. Antibiotics for acute asthma. Cochrane Database Syst Rev. 2001; Issue 2:
CD002741. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002741/full
5. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available
from: http://www.jacionline.org/article/S0091-6749(06)00741-X/fulltext
6. Johnston SL, Blasi F, Black PN, et al. The Effect of Telithromycin in Acute Exacerbations of Asthma. N Engl J Med.
2006; 354: 1589-1600. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa044080#t=article
7. Koutsoubari I, Papaevangelou V, Konstantinou GN, et al. Effect of clarithromycin on acute asthma exacerbations in
children: an open randomized study. Pediatr Allergy Immunol. 2012; 23: 385-90. Available from:
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-3038.2012.01280.x/full
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