Acute asthma & COPD exacerbation management

Include in assessment

  • History: baseline and severity, exacerbation history, ICU admissions, normal PEFR (if asthmatic), infective symptoms, inhaler compliance, home oxygen/nebs
  • PEFR regularly (in asthma)
  • Investigations:
    • ABG (should suggest hyperventilation asthma; if hypoxaemic/hypercapnic, patient is tiring) 
    • CXR (exclude pneumothorax)
    • Bloods (including regular potassium monitoring)

Classifying asthma severity

  • Life-threatening (PEFR <33%): 33, 92 CHASE
    • 33: PEFR <33% predicted
    • 92: Sats <92%
    • Cyanosis
    • Hypotension
    • Arrhythmia
    • Silent chest
    • Exhaustion
  • Severe (PEFR <50%): cannot complete sentences, respiratory rate > 25, heart rate >110
  • Moderate (PEFR <75%)
  • Mild (PEFR >75%)

Treating asthma exacerbation: O SHIT ME!

Reference: BTS/SIGN ‘Guideline for the management of asthma’ 2019

Treating COPD exacerbation

  • O SHIT as in asthma but prednisolone dose is 30mg OD and give controlled oxygen, i.e. 24-28% (venturi mask), and do regular ABGs to determine further oxygen therapy (see prescribing notes on oxygen therapy)
  • Antibiotics: prescribe if any signs of infection as per local guidelines, e.g. doxycycline
  • Chest physiotherapy
  • Consider BiPAP in hypercapnic respiratory acidosis not responding to medical management (or if you achieve oxygen sats of 88-92%/PaO2 ≥8 without a hypercapnic respiratory acidosis despite medical management)

If hypoxaemia/hypercapnia is worsening despite maximal therapy, involve senior/anaesthetist with a view to intubation and ventilation.

Intensive care indications

  • Requiring ventilator support
  • Worsening hypoxaemia / hypercapnia / acidosis
  • Exhaustion
  • Drowsiness / confusion

Try some questions

What is procalcitonin and how could this help in management?

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How are nebulisers best administered?

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What are the adverse effects of back-to-back salbutamol nebulisers?

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Here’s some OSCE stations

  1. Acute assessment – shortness of breath II
  2. COPD data interpretation
  3. Asthma exacerbation prescribing
  4. COPD exacerbation prescribing
  5. Infective Exacerbation of COPD history
  6. Asthma exacerbation history
  7. Find more here

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