Responding to acute severe asthma

• All exacerbations of asthma must be treated aggressively to prevent near-fatal asthma and cardiac arrest. Patients should be cared for in a critical care environment with full monitoring and observation.

• Oxygen - high-flow oxygen (10-15l/min) should be administered as soon as possible.

• First-line therapy - inhaled beta agonists are recommended. Nebulised salbutamol, 5 mg in 5 ml of normal saline, should be administered with oxygen or alternatively 4-6 puffs through a metered dose inhaler with a holding chamber (SIGN & BTS 2003).

• Corticosteroid therapy - either oral or intravenous cortico-steroids should be given in the first 30 minutes (SIGN & BTS 2003).

• Other therapies - inhaled anticholinergics, intravenous aminophylline, intravenous magnesium sulphate or Heliox may be used if patients fail to respond to other treatments (SIGN & BTS 2003).

• Fluid replacement - patients with severe acute asthma will often be dehydrated and benefit from intravenous fluid replacement.

• Basic and advanced life support - standard guidelines for basic and advanced life support should be followed.

• It may be difficult to ventilate the patient's lungs because of high airway resistance. Ventilation with a bag-valve-face-mask may predispose the patient to gastric inflation. Tracheal intubation should be performed as early as possible.

• The patient may have a hyperinflated chest, making chest compressions difficult or impossible. To overcome this, allow a prolonged expiratory time between breaths (AHA & ILCOR 2000).

• Any arrhythmias should be treated according to the current advanced life support (ALS) guidelines.

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