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Respiratory disease
Published in Catherine Nelson-Piercy, Handbook of Obstetric Medicine, 2020
The features of acute severe asthma are: PEFR 33%–50% best/predictedRespiratory rate >25/minHeart rate >110/minInability to complete sentences in one breath
Disorders of the respiratory system
Published in Judy Bothamley, Maureen Boyle, Medical Conditions Affecting Pregnancy and Childbirth, 2020
An exacerbation (or acute severe asthma) is defined as symptoms severe enough to result in an admission to hospital (or attendance at A&E), or unscheduled attendance by a doctor, or additional oral corticosteroids to normal medication (Murphy, et al., 2005). Acute severe asthma is considered to be the triad of usual signs and symptoms of asthma but to a more serious degree: wheezing, breathlessness and a cough. Acute severe asthma may occur rapidly or gradually build up over days. These attacks can rapidly become life-threatening, so the prompt attention of the multidisciplinary team and medication are necessary.
Practice paper
Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Acute severe asthma is severe asthma that has not been controlled by the patient’s current medications. Common triggers are infections and known allergens. History should include asking about previous hospital admissions, ITU admissions and current drug history to gauge the severity of their asthma. Peak expiratory flow (PEF) is a simple way of measuring the severity of the current episode and forms part of the criteria to determine the severity of the attack. The criteria for diagnosing acute severe asthma have been listed above. Signs of life-threatening asthma include PEF <33% best/predicted, bradycardia, hypotension, exhaustion, confusion, cyanosis and a silent chest. Notify your senior team and ITU if a patient is exhibiting any of these signs. An arterial blood gas should be taken to ensure there is not severe hypoxaemia, type 2 respiratory failure or severe acidosis, and a chest X-ray should be arranged to rule out a pneumothorax. The majority of cases of acute severe asthma can be managed with oxygen and nebulised salbutamol and ipratropium bromide. If symptoms do not improve with these measures, oral B agonists, magnesium sulphate and/or aminophylline may be considered. Steroids are often given orally for minor attacks, but may be required intravenously if severe. Infections should be treated with appropriate antibiotics.
Attack, flare-up, or exacerbation? The terminology preferences of patients with severe asthma
Published in Journal of Asthma, 2021
Kimberley A. Jones, Peter G. Gibson, Janelle Yorke, Robert Niven, Amber Smith, Vanessa M. McDonald
The 2017 Lancet commission on asthma calls for zero tolerance of asthma attacks, and recommends the abandonment of the terms exacerbations and flare ups in an effort to highlight the importance of these events and reduce the current “weak responses” (2). This has been previously proposed in COPD (18), another obstructive airway disease in which exacerbations are common, important and have long term negative consequence (19). This approach has also been taken in other diseases including cardiovascular disease, where the term “heart-attack” activates a more aggressive response accompanied by routine risk stratification, implementation of care bundles and referral to well-funded cardiac rehabilitation programs (18). Similarly neurology has also reevaluated the nomenclature, referring to stoke as a “brain attack” in an effort to highlight the urgency of the event and prompt patients to take immediate action (20). On the other hand, flare ups are used in other conditions such as gout and fibromyalgia, these flare ups signify painful events that are temporary and not necessarily life threatening, as an acute myocardial infarct and stroke may be. Given the life-threatening nature of acute severe asthma events the use of the term attack seems fitting for this population in line with other disease areas.
Solving the problem of dose optimization of children’s medicines
Published in Expert Review of Clinical Pharmacology, 2018
Stephen J. McWilliam, Daniel B. Hawcutt
Intravenous salbutamol for acute severe asthma is a good example of how the dose of older medicines may be well established, but may not be optimal. Both the 2014 British Thoracic Society guidelines [9] and the British National Formulary for Children [10] recommend an initial loading dose of 15 µg/kg. At the Royal Melbourne children’s hospital in Australia, the loading dose is 0.3–0.6 mg/kg over an hour [11], while in Starship Children’s hospital New Zealand, the dose is 10 mg/kg over 2 min [12]. These doses appear to be derived from a single Australian randomized controlled trial conducted in 1997 [13]. This trial involved 29 children, only 14 of whom received the active drug. This regimen means that children aged 2 and above who weigh 20 kg or over will receive the same bolus dose as an adult [14]. Pharmacokinetic simulations predict that this dosing regimen puts children at significant risk of experiencing systemic salbutamol concentrations in the toxic range, and thus increases the risk of adverse effects [14].
High frequency percussive ventilation as a rescue mode for refractory status asthmaticus – a case study
Published in Journal of Asthma, 2021
David Albecker, T. Glen Bouder, B. Franklin Lewis
Acute exacerbation of asthma is a common reason for an Emergency Department visit. If symptoms worsen, despite conventional medical treatment in the hospital, the case is referred to as status asthmaticus which is a medical emergency that can be life threatening (1). If the patient’s arterial blood gas values deteriorate dangerously and this is accompanied by respiratory muscle fatigue, the patient will require mechanical ventilation. However, mechanical ventilation of the severe asthmatic presents difficult challenges. We report on High Frequency Percussive Ventilation used along with continuous inhaled albuterol, and neuromuscular blockade, as rescue therapy for a case of acute severe asthma that was refractory to conventional treatment and conventional mechanical ventilation.