3.14 SFGH am report pearls: severe asthma exacerbation management

Highlights from the guidelines for management of asthma from the Expert Panel Report 3 of the NIH guidelines

  • Short acting beta agonist (SABA) to relieve obstruction, with addition of inhaled ipratropium bromide in severe exacerbations (Category A evidence)
    • The addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized
  • Systemic steroids in moderate or severe exacerbations or if incomplete response to SABA (category A)
  • Consider IV magnesium sulfate or heliox, in severe exacerbations unresponsive to the above treatments (Category B)
    • heliox: decreases airway resistance by reducing airflow turbulence in the bronchial passages – mixed results in small studies
  • IV beta2-agonists (epinephrine or terbutaline) have no proven advantage over aerosol therapy
  • intubation/mechanical ventilation: (all Category D expert opinion)
    • consider a trial of NPPV before intubation in select patients who can tolerate and cooperate with therapy (and who can be closely monitored) (Category B)
    • intubate if severe hypoxia, failure to reverse severe respiratory acidosis despite intensive therapy, pH<7.2, pCO2 increasing by > 5 mm Hg/h or to >55-70
    • ketamine and propofol may be preferred over other sedative agents
      • ketamine: (limited data) – stimulates the release of catecholamines and may have a direct relaxation effect on bronchial smooth muscle, leading to bronchodilation
      • propofol: has bronchodilatory effects

Category A: RCTs, rich body of data

Category B: RCTs, limited body of data

Category C: nonrandomized trials and observational studies

Category D: expert opinion based on clinical experience and nonsystematic clinical observation


US Department of Health and Human Services, National Institute of Health, National Heart, Lung, and Blood Institute. Expert Panel Report 3: guidelines for the diagnosis and management of asthma [Accessed April 8, 2008]. Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.


Evernote link: http://www.evernote.com/l/AoM054FSkBhFqb_GgkuFCuoTXTdA7rpno2Y/


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