care, treatment and destination for asthma

what care should be delivered for an asthma attack?

• if clinically appropriate follow patients own individualised asthma treatment plan

• ensure pt is in calm, comfortable environment + gentle reassurance

• move pt away from any environmental triggers

what treatment should be delivered for a mild asthma pt?

• patients own inhaler using a spacer should be used as first line treatment (b2 agonist)

• short-acting b2 agonist such as salbutamol should be used by increasing dose by 2 puffs every 2 mins, up to 10 puffs according to response

• long-acting b2 agonist such as formoterol should be used 1 puff every minute up to 6 puffs

• if poor response, nebulise salbutamol + transfer to nearest ED

what should be done if mild asthma responds to treatment?

• consider discharge if pt stable however be cautious

• consider alternative pathways such as referral back to primary/urgent care (eg GP)

• worsening care advice

how should moderate asthma be treated?

• if pt does not respond to own medication consider supplementary oxygen being cautious to not over-ventilate

• administer salbutamol via oxygen driven nebuliser

• administer prednisolone

how should severe asthma be treated?

• supplementary oxygen

• continued nebulised salbutamol

• ipratropium bromide

• administer steroids - prednisolone/hydrocortisone

how should life threatening asthma be treated?

• early consideration for enhanced care support

• nebulised salbutamol if appropriate

• then ipratropium bromide (nebulised)

• single dose of magnesium (CCP only)

• adrenaline 1:1000

• prednisolone/hydrocortisone

• consider + treat bilateral tension pneumothorax

• pre-alert + transfer to nearest ED

how does salbutamol work?

• salbutamol is a beta2 adrenoreceptor stimulant drug

• works to relax small and medium airways, relaxing the smooth muscle

• administered by nebuliser additionally moistens the airway

• this treats bronchospasm, allowing normal breathing to resume

what are the indications for salbutamol?

• acute asthma attack where inhaler treatment has failed

• expiratory wheeze

what are the contraindications for salbutamol?

• none in an emergency setting

• use with care in pts with hypertension, angina, overactive thyroid, late pregnancy (may relax uterus), pts taking beta-blockers

what is the dose for salbutamol?

• aged 6+ - 5mg every 5 mins

• aged under 6 - 2.5mg every 5 mins

• no limit on dose

how does ipratropium bromide work?

• antimuscarinic bronchodialtor (block the actions of acetylcholine)

• provide short term relief in acute asthma

• (b2 agonists generally work quicker)

• considered to have greater benefit in children suffering from asthma

what are the indications for ipratropium bromide?

• acute/severe/life-threatening asthma

• acute asthma unresponsive to salbutamol

• expiratory wheeze

what are the contraindications for ipratropium bromide?

• none in emergency situation

• use with care in pregnancy and breastfeeding

what is the dosage for ipratropium bromide?

• adults

• 500 micrograms

• 250 micrograms in 1ml, in 2mls of fluid

• max dose 500 micrograms

• 18 months - 11 years

• 250 micrograms

• 250 micrograms in 1 ml

• max dose 250 micrograms

• 12 months and under

• 125-250 micrograms

• 250 micrograms in 0.5-1ml

• max dose 125-250 micrograms

no repeat dose!!

how does hydrocortisone work?

• reduces airway inflammation and swelling by suppressing immune response

what are the indications for hydrocortisone?

• severe or life threatening asthma

what are the contraindications for hydrocortisone?

• known allergy

what is the dosage of hydrocortisone?

• given IV over min of 2 mins, IO or IM

• adult

• 100mg

• 100mg in 1 ml

• max dose 100mg

• 5 years - 12 months

• 50mg

• 50mg in 0.5ml

• max dose 50mg

• 9 months - 1 month

• 25mg

• 25mg in 0.25ml

• max dose 25mg

• birth

• 10mg

• 10mg in 0.10ml

• max dose 10mg

no repeat dose!!

how does adrenaline 1:1000 work?

• relieves bronchospasm

• adrenaline stimulates b2 adrenergic receptors relaxing smooth muscle, causing airways to open

when is adrenaline 1:1000 indicated?

• anaphylaxis

• life-threatening asthma with failing ventilation + deterioration despite nebuliser therapy

what are the contraindications of adrenaline 1:1000?

none

what is the dose of adrenaline 1:1000?

• 12 years +

• 500 micrograms