You are unlikely to be expected to make decisions about long term asthma management, therefore focus your efforts on learning how to deal with acute exacerbations.
If a patient reports having a diagnosis of asthma, it is worth asking a few questions to clarify the accuracy of the statement. It isn’t uncommon for patients to use asthma & COPD interchangeably.
- When the diagnosis was made (COPD is unlikely in younger patients)
- How the diagnosis was made (spirometry, PEFR diary, bronchial challenge test)
- Who made the diagnosis (GP v secondary care. If the latter you may have access to test results and clinic letters etc to assist)
- Smoking history (NOT all smokers get COPD but smoking makes asthma worse)
- Associated hayfever and/or eczema
- Family history of asthma, hayfever and eczema
- What treatment they are on (increasing overlap with COPD & asthma) and crucially if they are using it.
Once you have ascertained that the patient has asthma, remember to exclude other causes for the deterioration in their symptoms.
It isn’t unheard of for diagnoses such as heart attacks to be missed due to diagnostic bias. A quick systematic review is advisable.
Examination of your patient should focus on 3 elements:
- Features to confirm the diagnosis of an exacerbation of asthma
- Absence of features associated with your differentials
- Assessment of severity
Broadly speaking initial treatment includes the following:
- Steroids: oral prednisolone 40mg or 100mg hydrocortisone IV if too unwell.
- Beta-agonist: nebulised salbutamol 2.5mg repeated every 20-30 min if needed.
- Anti-muscarinic: nebulised ipratropium bromide 500micrograms (max 2mg/day)
The following therapies should only be prescribed after involving your seniors as their need suggests the patient is very unwell & at risk of deteriorating further.
Magnesium sulphate: 2g IV over 20 minutes
Aminophylline: Patients on oral theophylline SHOULD NOT be given an IV loading dose. Otherwise, patients require a loading dose followed by a continuous infusion. The dose is weight dependent and it is important to ensure drug levels are checked and the dose altered appropriately. Most hospitals will have a specific prescription chart to simplify the process.
Remember, severity increases if the patient meets any ONE criteria in that section. Asthma death reviews have identified clinicians being falsely reassured by how a patient looks as a contributing factor to poor outcomes.
Another common oversight is that a pCO2 within normal limits is a worrying sign in an acute asthma attack. A breathless patient should have a low carbon dioxide on their blood gas due to the high respiratory rate.
Most Trusts will have a pathway for the management of acute exacerbations that include a flow chart/checklist based on the BTS guidelines to help you correctly assess and treat the patient.
Don’t be afraid to ask for help (registrar, critical care outreach, intensive care or other). Make it clear what the severity of the attack is and which criteria are being met. In a life-threatening situation, it is not unreasonable to get help whilst carrying out your initial assessment and treatment. Be clear about why you are calling early, what you plan to do until they arrive and ascertain if anything further is required before assistance arrives.
When caring for patients on the ward who have been admitted with an exacerbation of asthma, your focus is now on ensuring that they are improving and identifying when they are safe for discharge. Key elements will include:
- What the patient tells you!
- Peak flow monitoring – crucial but often missed. You want this to be at least 75% of their best/predicted prior to discharge.
- If the patient requires therapy only available in hospital i.e.: are they stable without nebulisers? Routine practice is 24hrs neb free before discharge.
Asthma symptoms are worse overnight. Therefore, it is best practice to keep the patient in for monitoring to ensure they don’t deteriorate, so if you stop regular nebs on a morning ward round, prep for discharge the next day.
Check if your Trust has specialist asthma nurses. They are a fantastic source of help and will usually want to review all patients admitted with an exacerbation. They assist with:
- Inhaler technique
- Whether patients are on the appropriate level of therapy at home
- Recommending investigations into possible triggers (e.g.: Allergic Bronchopulmonary Aspergillosis)
- Providing patients with a written management plan
- Arrange appropriate follow-up
Asthma UK has an excellent online resource with short videos demonstrating the correct technique for each inhaler type.
Inhalers can be safely recycled to avoid entering a landfill. Encourage patients to locate the nearest pharmacy that provides this service.
By Dr Ruwani Rupesinghe (SpR)
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