Acute management

6.1 Lessons from studies of asthma deaths and near fatal asthma

Table 3: Patients at risk of developing near fatal or fatal asthma

A COMBINATION OF SEVERE ASTHMA recognised by one or more of:

AND ADVERSE BEHAVIOURAL OR PSYCHOSOCIAL FEATURES RECOGNISED BY ONE OR MORE OF:

Health care professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death.

Keep patients who have had near fatal asthma or brittle asthma under specialist supervision indefinitely.

6.1.5 PREDICTION AND PREVENTION OF A SEVERE ASTHMA ATTACK

A respiratory specialist should follow up patients admitted with severe asthma for at least one year after the admission.

6.7 Acute asthma in children aged over 2 years

6.7.1 INITIAL ASSESSMENT

Table 6 details criteria for assessment of severity of acute asthma attacks in children.

See also annexes 4,5,6.

Table 6: Clinical features for assessment of severity

Acute severe Life threatening

Can't complete sentences in one breath or too breathless to talk or feed

Pulse:

  • >120 in children aged >5 years
  • >130 in children aged 2-5 years

Respiration:

  • >30 breaths/min aged >5 years
  • >50 breaths/min aged 2-5 years
  • Silent chest
  • Cyanosis
  • Poor respiratory effort
  • Hypotension
  • Exhaustion
  • Confusion
  • Coma

Before children can receive appropriate treatment for acute asthma in any setting, it is essential to assess accurately the severity of their symptoms. The following clinical signs should be recorded:

Clinical signs correlate poorly with the severity of airways obstruction. Some children with acute severe asthma do not appear distressed. Evidence level 2++

Objective measurements of PEF and SpO2 are essential. Suitable equipment should be available for use by all health professionals assessing acute asthma in both primary and secondary care settings.

Low oxygen saturations after initial bronchodilator treatment selects a more severe group of patients. Evidence level 2++

Consider intensive inpatient treatment for children with SpO2 <92% on air after initial bronchodilator treatment.

Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatment.

A measurement of <50% predicted PEF or FEV1 with poor improvement after initial bronchodilator treatment is predictive of a more prolonged asthma attack.

Attempt to measure PEF or FEV1 in all children aged >5 years, taking the best of three measurements, ideally expressed as percentage of personal best for PEF (as detailed in a written action plan) or alternatively as percentage of predicted for PEF or FEV1.

Chest x-rays and ABG measurements rarely provide additional useful information and are not routinely indicated.