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Overview
There is no cure for asthma. The aim of treatment is to manage symptoms and prevent asthma exacerbations (Eggert and Majumdar, 2022).
Deaths from asthma exacerbations are on the rise, having increased by more than 33% between 2009 and 2019 (Asthma and Lung UK, 2019).
A national review of asthma deaths between 2012 and 2013 found that 46% of asthma deaths were avoidable. Failings in routine management of asthma and lack of provision of personal asthma action plans were shown in 77% of deaths resulting from asthma (Royal College of Physicians, 2014).
Although the goal of asthma management is prevention of exacerbations, in the UK, there are around 75 000 hospital admissions as a result of asthma exacerbations per year (Asthma and Lung UK, 2022).
Therefore, recognition of signs and symptoms of exacerbation and an understanding of the acute management is vital. This article focuses on recognition, initial assessment and management
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Symptoms
Patients may experience the following during an asthma exacerbation:
- shortness of breath
- cough – often dry and non-productive
- wheeze – may be audible or heard of chest auscultation
- chest tightness
- sleep disturbance
- exercise limitation (Asthma and Lung UK, 2022; National Institute for Health and Care Excellence (NICE), 2022a).
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Aetiology
Asthma is a condition caused by chronic inflammation of the airways resulting in airway obstruction and hyper-reactivity (Eggert and Majumdar, 2022).
Exacerbations may be triggered by the following:
- viral infections
- allergies – such as dust mites, pollen, perfumes, cleaning products or animal fur
- pollution
- medications – including anti-inflammatory medications or beta blockers
- strong emotions
- change in weather – particularly cold weather
- exercise
- occupational exposure to triggers (British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN), 2019).
Exposure to allergens and triggers is therefore a risk factor for asthma exacerbation. Trigger avoidance should be discussed with patients.
Other risk factors for asthma exacerbation include:
- uncontrolled asthma symptoms* defined by NICE (2017) as:
- three or more days a week with symptoms or
- three or more days a week with required use of a short-acting beta-agonist (e.g. salbutamol) for symptomatic relief or
- one or more nights a week with awakening due to asthma.
* validated
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Diagnosis
Diagnosis of an asthma exacerbation involves the following:
- history
- examination
- peak expiratory flow rate
- pulse oximetry (NICE, 2022).
History
The clinical history should consider symptoms, history and severity of previous asthma exacerbations and identification of triggers and risk factors. Consideration should also be given to medication compliance (Eggert and Majumdar, 2022).
Examination
Respiratory rate, pulse, blood pressure and chest auscultation should be performed.
Patients may have the following signs on examination:
- raised respiratory rate
- signs of respiratory distress
- audible wheeze
- raised pulse
- silent chest
- use of accessory muscles
- altered consciousness
- cyanosis
- hypotension
- collapse (BTS/SIGN, 2019; Eggert and Majumdar, 2022).
Peak expiratory flow rate
Peak expiratory flow rate uses a handheld device to assess how quickly air can be blown out of the lungs. The patient’s score is compared to average for age, height and sex. Patients should have their normal peak expiratory flow rate
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Management
The management of an exacerbation of asthma differs depending on its severity (Table 1).
| Table 1. Severity of asthma exacerbation | |||
| Moderate | Acute severe | Life-threatening | |
| Peak expiratory flow rate | more than 50-75% of best or predicted | 33-50% best or predicted | <33% best or predicted |
| Respiratory rate |
≥ 25/min (aged >12 years) ≥ 30/min (aged 5-12 years) ≥ 40/min (aged 2-5 years) |
||
| Pulse |
≥ 110 bpm (aged >12 years) ≥ 125 bpm (aged 5-12 years) ≥ 140 bpm (aged 2-5 years) |
||
| Oxygen saturations | ≥92% | <92% | |
| Other |
Normal speech No features of acute severe or life-threatening asthma. |
|
|
| From: BTS/SIGN (2019) | |||
All patients with life-threatening asthma should be admitted to hospital for treatment.
Patients with acute severe asthma should be admitted to
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Treatment
Initial therapy
All patients experiencing moderate asthma exacerbations should receive inhaled beta-2 agonists (i.e salbutamol) via a large volume spacer. 2–10 puffs should be administered every 10–20 minutes. If administration via spacer is not possible or where patients have life-threatening or severe asthma, patients should receive nebulised salbutamol (5mg to patients aged 5 years or more and 2.5mg to children aged 2–5 years).
For patients experiencing a moderate exacerbation and not requiring hospital admission, inhaled corticosteroid therapy should be quadrupled at the onset of the exacerbation and continued for 14 days. However, if hospital admission is required or there is better adherence to inhaler therapy oral prednisolone should be initiated. Oral prednisolone should be given as long as this can be swallowed. Parenteral hydrocortisone may be considered where oral treatment is not feasible. Oral corticosteroid should be continued for a minimum of 5 days.
Oxygen therapy should be administered if required and titrated
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Resources
Asthma and Lung UK. Asthma death toll in England and Wales. 2019. https://www.asthma.org.uk/about/media/news/press-release-asthma-death-toll-in-england-and-wales-is-the-highest-this-decade/#:~:text=2.-,Asthma%20UK%20analysed%20asthma%20deaths%20data%20from%20the%20Office%20for,us%20an%20increase%20of%207.7%25 (accessed 5 October 2022)
Asthma and Lung UK. Asthma data visualizations. 2022. https://www.asthma.org.uk/support-us/campaigns/data-visualisations/#:~:text=How%20many%20people%20go%20to,every%20year%20in%20the%20UK. (accessed 5 September 2022)
Bennett J, Russell R. BMJ Best Practice: Acute asthma exacerbation in adults. 2021.
https://bestpractice.bmj.com/topics/en-gb/3000085/history-exam (accessed 14 September 2022)
British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline for the management of asthma. 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ (accessed 1 December 2022)
Eggert L, Majumdar S. BMJ Best Practice: Asthma in adults. 2022. https://bestpractice.bmj.com/topics/en-gb/44?q=Asthma%20in%20adults&c=suggested (accessed 14 September 2022)
Global Initiative for Asthma. Global strategy for asthma management and prevention. 2021 https://ginasthma.org/gina-reports/ (accessed 3 December 2022)
Murphy VE, Clifton VL, Gibson PG. Asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes. Thorax. 2006;61(2):169-76. https://doi.org/10.1136/thx.2005.049718
National Institute for Health and Care Excellence. Asthma. 2013. https://www.nice.org.uk/guidance/qs25/chapter/quality-statement-4-follow-up-by-general-practice-after-emergency-care (accessed 6 October 2022)
National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. 2017.
https://www.nice.org.uk/guidance/ng80
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