The bronchial asthma refers to the reversible airway obstruction which is caused by an inflammation of the airways. In susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night and early morning.
Acute bronchial asthma in adults
The application of the guidelines on the treatment of acute bronchial asthma assumes you have been diagnosed with asthma after excluding other differential diagnosis in pathological situations such as:
1. COPD exacerbation;
2. congestive heart failure;
3. pulmonary embolism;
4. mechanical obstruction of the airways;
5. laryngeal dysfunction.
The asthma exacerbations (acute asthma) are a marked, often progressive worsening of asthma symptoms and bronchial obstruction, which appear in the space of hours or even days and can last up to weeks. The goals of treatment of asthma attack are:
1. The answer to the bronchial asthma as soon as possible.
2. Plan for preventing future recurrences.
The severe asthma attack is a potentially fatal situation. Therefore, once diagnosed, treatment should be started as soon as possible. The therapy differs depending on the severity of the crisis and therefore it is necessary to advance a rapid assessment of severity, which is essential for detecting a range of symptoms and signs, and some objective parameters of respiratory function and oxygenation status of the patient. The assessment of respiratory function by measuring the PEF (peak expiratory flow) is easy to perform and can be made by the patient at home. The management of asthma attack should include:
1. Early intervention: It is important that the patient be educated to recognize the severity of asthma in early action at home and seek medical attention when necessary.
2. Appropriate drug treatment: The cornerstone of treatment of asthma attack are as follows:-
- Repeated administration of rapid acting beta2-agonists
- Early introduction of systemic corticosteroids
- Correction of hypoxemia
3. Monitoring the patient’s condition and response to treatment. Monitoring must be done through assessment of symptoms and objective parameters (repeated measurement of lung function).
Home treatment of asthma attack
The home treatment is possible for the less severe asthma attacks, defined by level of symptoms and possibly as a reduction of PEF below 20%, presence of nocturnal awakenings, and increased use of beta2-agonist bronchodilators in the short duration of action.
Each patient must have a written action plan based on symptoms and possibly also on the measurement of PEF, which determines how to recognize signs of deterioration and to assess the severity of the crisis, when to modify or improve the treatment and require specialist care when appropriate. This allows you to initiate appropriate treatment for early signs of deterioration with a greater chance of success.
The first use of drugs are fast acting beta2-agonists: salbutamol spray 2-4 puffs (200-400 mcg) every 20 minutes for the first time with a spacer (or salbutamol 100/150 micrograms / kg max 5 mg in 2 – 3 ml of saline via nebulizer). At constant dose, the use of a pressurized aerosol with spacer (if the patient is able to use it) is able to achieve the same improvement as with the nebulizer.
After the first hour, the dose of rapid-acting beta2-agonist depends on the severity of the crisis: 2-4 puffs every 3-4 hours for one or two days in severe asthma and in the most serious crises it can take 6-10 puffs every 1-2 hours.
If the patient improves rapidly and if the PEF values increased to above 80% predicted or personal best and improvement persists for at least 3-4 hours, no other therapy is needed. Otherwise, you may want to add oral corticosteroids for 4 to 5 days to expedite the resolution of the crisis. It is a careful patient monitoring and prompt delivery to the hospital in case of no response.
Directions for immediate hospitalization
The patient should be hospitalized if:
1. Patient is at high risk for fatal asthma.
2. The exacerbation is severe (the patient has significant symptoms, does not improve after the first dose of medication, PEF is below 60% predicted or personal best after treatment with beta2-agonists).
3. The response to beta2-agonists is not quick or sustained for at least 3 hours.
4. There is no improvement after 6 hours of treatment with systemic corticosteroids.
5. There is further deterioration.