A Brief Synopsis of AFP's "Management of Acute Asthma Exacerbations"

Management of Acute Asthma Exacerbations
SUSAN M. POLLART, MD, MS; REBEKAH M. COMPTON, MSN, FNP-C; and KURTIS S. ELWARD, MD, MPH, University of Virginia Health System, Charlottesville, Virginia
Am Fam Physician. 2011 Jul 1;84(1):40-47.
http://www.aafp.org/afp/2011/0701/p40.pdf

     According to this article, asthma can be classified into mild, moderate, severe, or life threatening (I'm not sure what happened to intermittent and the different levels of persistent, but let's go with it for now). The classes can be determined by lung function (PEF or FEV1). Mild asthma has symptoms of dyspnea with activity and a PEF of greater than 70% predicted (of their personal best peak expiratory flow). Moderate asthma is described as dyspnea affecting usual activity and a PEF between 40-69%. Severe asthma has dyspnea at rest and a PEF less than 40%. Life threatening asthma has a PEF of less than 25%. Signs of an exacerbation in a child include accessory muscle use, chest wall retractions, tachypnea, cyanosis, and wheezing.  Lab tests are generally not helpful.  ABGs or chest radiographs may be considered under certain circumstances.
     The most effective home treatment of acute asthma is a proper action plan (a personalized, written algorithm based on symptoms and PEF). Serious exacerbations (PEF less than 50%) may require an immediate physician visit. Otherwise, initial treatment should be short acting beta agonists (two treatments, 20 minutes apart). If the treatment stopped the wheezing (PEF greater than 80%) then the patient can continue the beta agonist for 1-2 days or add an oral corticosteroid. If the response is incomplete (PEF 50-70%) and the patient is having persistent wheezing, the patient should continue the beta agonist and add the oral steroids, as well as contact the primary care physician. A poor response (PEF < 50%) usually requires a trip to the ER in addition to the previous medications.
     treatment goals in the emergency room setting consist of fixing any hypoxia, reversing any airflow obstruction, and reducing the risk of relapse. The patient is given supplemental oxygen to maintain a saturation above 94%. inhaled short-acting beta agonists will be given, or continuous administration if the exacerbation is severe.  Anticholinergics can be added to nebulized beta agonists. IV magnesium may also have a role. Systemic corticosteroids (either oral or parenteral will decrease the need for hospitalization.
     On discharge, patients should be sent home with about a weeks worth of oral corticosteroids. If lon term oral steroids are not needed, then inhaled steroids may be used. They should also have a scheduled follow-up within a week of discharge. .