Asthma emergency management: Difference between revisions
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{{Asthma}} | {{Asthma}} | ||
{{CMG}}; [[Philip Marcus, M.D., M.P.H.]] [mailto:pmarcus192@aol.com]; {{AE}} | |||
==Overview== | ==Overview== | ||
Inhaled [[SABA|β2 agonist]] such as [[albuterol]], is the | Inhaled [[SABA|β2 agonist]], such as [[albuterol]], is the drug of choice for acute severe exacerbation of asthma. In cases of [[Mild persistent asthma|mild]] to [[Moderate persistent asthma|moderate]] exacerbations, metered-dose inhalation (MDI) of a [[SABA|β2 agonist]] in conjunction with a [[asthma spacer|spacer]] may be used. In more severe exacerbations, nebulized [[SABA|β2 agonist]] has been demonstrated to be most effective. In case of severe exacerbation with non- reponsiveness to [[SABA|β2 agonist]] inhalation/[[Asthma anticholinergic therapy|anticholinergic]] therapy, parenteral [[SABA|β2 agonist]] such as [[terbutaline]] may be administered. [[Ipratropium]] may also be utilized in cases of severe exacerbation.<ref name="pmid18240881">Urbano FL (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18240881 Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines.] ''J Manag Care Pharm'' 14 (1):41-9. PMID: [http://pubmed.gov/18240881 18240881]</ref> [[Steroids|Steroid therapy]] remains the mainstay of therapy in the treatment of acute and sub-acute phases of exacerbation. Steroids speed in the resolution of airway obstruction and prevent a late-phase response; hence, shown to provide highly beneficial outcomes to patients with acute exacerbation presenting to the emergency department.<ref name="pmid1535500">Rowe BH, Keller JL, Oxman AD (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1535500 Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis.] ''Am J Emerg Med'' 10 (4):301-10. PMID: [http://pubmed.gov/1535500 1535500]</ref><ref name="pmid15072167">Rowe BH, Edmonds ML, Spooner CH, Diner B, Camargo CA (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15072167 Corticosteroid therapy for acute asthma.] ''Respir Med'' 98 (4):275-84. PMID: [http://pubmed.gov/15072167 15072167]</ref> | ||
==Emergency Management== | ==Emergency Management== | ||
When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital: | When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital. These include:<ref name=rodrigo>Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults: a review. ''Chest''. 2004;125(3):1081-102. PMID 15006973</ref> | ||
*[[Oxygen]] to alleviate the [[hypoxia]] (but not the asthma ''per se'') that results from extreme asthma attacks. | |||
*[[Oxygen]] to alleviate the [[hypoxia]] (but not the asthma ''per se'') that results from extreme asthma attacks | *Nebulized [[salbutamol]] or [[terbutaline]] ([[SABA|short-acting beta-2-agonists]]), often combined with [[ipratropium]] (an [[Asthma anticholinergic therapy|anticholinergic]]). | ||
*Nebulized [[salbutamol]] or [[terbutaline]] ([[SABA|short-acting beta-2-agonists]]), often combined with [[ipratropium]] (an [[Asthma anticholinergic therapy|anticholinergic]]) | |||
*Systemic [[steroids]], oral or intravenous ([[prednisone]], [[prednisolone]], [[methylprednisolone]], [[dexamethasone]], or hydrocortisone). Some research has looked into an alternative inhaled route.<ref name="pmid15764724">Rodrigo GJ (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15764724 Comparison of inhaled fluticasone with intravenous hydrocortisone in the treatment of adult acute asthma.] ''Am J Respir Crit Care Med'' 171 (11):1231-6. [http://dx.doi.org/10.1164/rccm.200410-1415OC DOI:10.1164/rccm.200410-1415OC] PMID: [http://pubmed.gov/15764724 15764724]</ref> | *Systemic [[steroids]], oral or intravenous ([[prednisone]], [[prednisolone]], [[methylprednisolone]], [[dexamethasone]], or hydrocortisone). Some research has looked into an alternative inhaled route.<ref name="pmid15764724">Rodrigo GJ (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15764724 Comparison of inhaled fluticasone with intravenous hydrocortisone in the treatment of adult acute asthma.] ''Am J Respir Crit Care Med'' 171 (11):1231-6. [http://dx.doi.org/10.1164/rccm.200410-1415OC DOI:10.1164/rccm.200410-1415OC] PMID: [http://pubmed.gov/15764724 15764724]</ref> | ||
*Other [[bronchodilators]] that are occasionally effective in cases of non-responsiveness to initial drugs include: | *Other [[bronchodilators]] that are occasionally effective in cases of non-responsiveness to initial drugs include: | ||
:*Intravenous [[salbutamol]] | :*Intravenous [[salbutamol]]. | ||
:*Nonspecific beta-agonists, injected or inhaled ([[epinephrine]], isoetharine, [[isoproterenol]], [[metaproterenol]]) | :*Nonspecific beta- agonists, injected or inhaled ([[epinephrine]], isoetharine, [[isoproterenol]], [[metaproterenol]]). | ||
:* Anticholinergics, IV or nebulized, with systemic effects ([[glycopyrrolate]], [[atropine]], [[ipratropium]]) | :* Anticholinergics, IV or nebulized, with systemic effects ([[glycopyrrolate]], [[atropine]], [[ipratropium]]). | ||
:*[[Bronchodilator#Theophylline|Methylxanthines]] ([[theophylline]], [[aminophylline]]) | :*[[Bronchodilator#Theophylline|Methylxanthines]] ([[theophylline]], [[aminophylline]]). | ||
:*Inhalation anesthetics that have a bronchodilatory effect ([[isoflurane]], [[halothane]], [[enflurane]]) | :*Inhalation anesthetics that have a bronchodilatory effect ([[isoflurane]], [[halothane]], [[enflurane]]). | ||
:*The dissociative | :*The dissociative anesthetic [[ketamine]], often used in [[endotracheal tube]] induction. | ||
:*[[Magnesium sulfate]], intravenous | :*[[Magnesium sulfate]], intravenous. | ||
*[[Intubation]] and [[mechanical ventilation]], for patients in or approaching [[respiratory arrest]]. | *[[Intubation]] and [[mechanical ventilation]], for patients in or approaching [[respiratory arrest]]. | ||
*[[Heliox]], a mixture of helium and oxygen, may be used in a hospital setting. It has a more laminar flow than ambient air and moves more easily through constricted airways. | *[[Heliox]], a mixture of helium and oxygen, may be used in a hospital setting. It has a more laminar flow than ambient air and moves more easily through constricted airways. | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Pulmonology]] | [[Category:Pulmonology]] | ||
[[Category:Immunology]] | |||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category: | [[Category:Mature chapter]] | ||
Latest revision as of 20:30, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Philip Marcus, M.D., M.P.H. [2]; Associate Editor(s)-in-Chief:
Overview
Inhaled β2 agonist, such as albuterol, is the drug of choice for acute severe exacerbation of asthma. In cases of mild to moderate exacerbations, metered-dose inhalation (MDI) of a β2 agonist in conjunction with a spacer may be used. In more severe exacerbations, nebulized β2 agonist has been demonstrated to be most effective. In case of severe exacerbation with non- reponsiveness to β2 agonist inhalation/anticholinergic therapy, parenteral β2 agonist such as terbutaline may be administered. Ipratropium may also be utilized in cases of severe exacerbation.[1] Steroid therapy remains the mainstay of therapy in the treatment of acute and sub-acute phases of exacerbation. Steroids speed in the resolution of airway obstruction and prevent a late-phase response; hence, shown to provide highly beneficial outcomes to patients with acute exacerbation presenting to the emergency department.[2][3]
Emergency Management
When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital. These include:[4]
- Oxygen to alleviate the hypoxia (but not the asthma per se) that results from extreme asthma attacks.
- Nebulized salbutamol or terbutaline (short-acting beta-2-agonists), often combined with ipratropium (an anticholinergic).
- Systemic steroids, oral or intravenous (prednisone, prednisolone, methylprednisolone, dexamethasone, or hydrocortisone). Some research has looked into an alternative inhaled route.[5]
- Other bronchodilators that are occasionally effective in cases of non-responsiveness to initial drugs include:
- Intravenous salbutamol.
- Nonspecific beta- agonists, injected or inhaled (epinephrine, isoetharine, isoproterenol, metaproterenol).
- Anticholinergics, IV or nebulized, with systemic effects (glycopyrrolate, atropine, ipratropium).
- Methylxanthines (theophylline, aminophylline).
- Inhalation anesthetics that have a bronchodilatory effect (isoflurane, halothane, enflurane).
- The dissociative anesthetic ketamine, often used in endotracheal tube induction.
- Magnesium sulfate, intravenous.
- Intubation and mechanical ventilation, for patients in or approaching respiratory arrest.
- Heliox, a mixture of helium and oxygen, may be used in a hospital setting. It has a more laminar flow than ambient air and moves more easily through constricted airways.
References
- ↑ Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm 14 (1):41-9. PMID: 18240881
- ↑ Rowe BH, Keller JL, Oxman AD (1992) Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med 10 (4):301-10. PMID: 1535500
- ↑ Rowe BH, Edmonds ML, Spooner CH, Diner B, Camargo CA (2004) Corticosteroid therapy for acute asthma. Respir Med 98 (4):275-84. PMID: 15072167
- ↑ Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults: a review. Chest. 2004;125(3):1081-102. PMID 15006973
- ↑ Rodrigo GJ (2005) Comparison of inhaled fluticasone with intravenous hydrocortisone in the treatment of adult acute asthma. Am J Respir Crit Care Med 171 (11):1231-6. DOI:10.1164/rccm.200410-1415OC PMID: 15764724