NHS Kirklees and NHS Wakefield District
Guidelines for the management of acute asthma in general practice for adults • Failure by clinical staff to use objective Many asthma deaths measurement of severity are preventable. • Patients or relatives failing to appreciate severity Factors leading to poor • Under-use of corticosteroids outcome include:
Assess and record: • Peak Expiratory Flow Rate (PEFR) • Heart and respiratory rate
• Oxygen saturation*
PEFR >75 % previous best or predicted value NO features of acute severe asthma
PEFR 50 – 75% previous best or predicted value NO clinical features of acute severe asthma
PEFR ≤ 50% previous best or predicted value Can’t complete sentences, use of accessory muscles Respiratory rate ≥ 25/min Tachycardia ≥ 110, Previous ventilation Admit
• Air driven Nebulised Salbutamol 5mg or via spacer (salbutamol 100mcg 4-6 puffs given 1 at a time and inhaled separately)
Observe for 30 mins
Stable or improving PEFR > 75%
Not improving PEFR 50-75%
Improving and PEFR > 60%
Allow home • Prednisolone 40mg daily for 7 days • Review by GP/diploma-level practice nurse within 48 hrs • Supply relevant contact numbers
FOLLOW UP should include:• Review inhaler technique and understanding of medication • Provoking factors for uncontrolled asthma • Formulate or revise written selfmanagement plan with patient
• Prednisolone 40 mg orally Observe for 30 mins Reasons for admission: • Not improving or PEFR remains < 60% • Requires 2nd neb • Previous ventilation • Concern over social circumstances • Patient unable to assess / monitor own condition.
• Address potentially preventable contributors to admission • Issue patient education leaflet (such as Asthma UK’s ‘After Your Asthma Attack’)
Group responsible for development: NHS Kirklees in collaboration with NHS Wakefield District, Mid Yorkshire NHS Hospitals Trust and Calderdale and Huddersfield Hospital Foundation Trust (Kirklees Sector).
• Oxygen 10-15 L/min a.s.a.p (to maintain SpO2 94-98% - pulse oximeter should be available) • Nebulised Salbutamol 5 mg • Prednisolone 40mg orally or if shock or GI tract disturbance Hydrocortisone 100mg IV • IV access • If no nebuliser available salbutamol 100mcg 4-6 puffs via spacer given 1 at a time and inhaled separately Contact hospital for admission. Arrange ambulance.
LIFE THREATENING Any of the following: PEFR<33% previous best or predicted value Quiet chest, Cyanosis Bradycardia, Exhaustion, Confusion, Hypoxia O2 Sat < 92% • Dial 999 for ambulance • Oxygen 10-15 L/min a.s.a.p (to maintain SpO2 94-98% - pulse oximeter should be available) • Nebulised Salbutamol 5mg & Ipratropium 0.5mg ideally via oxygen driven nebuliser • Venous access if possible: • IV Hydrocortisone 100mg • IV Salbutamol 250 -500mcg • If no nebuliser available salbutamol 100mcg 4-6 puffs via spacer given 1 at a time and inhaled separately
If further nebulised Salbutamol 5mg needed add Ipratropium Bromide 0.5mg or via spacer
• GP review within 48hrs • Hospital specialist asthma nurse or respiratory consultant review about a month after admission
Discharge home from hospital
Inhaled Bronchodilator via spacer device
* If low (<92%) urgent admission is required, but do not be reassured by a normal reading if other parameters indicate a severe or life-threatening episode.
• Symptoms and response to self treatment
Life threatening features: • Features of acute severe present after initial treatment • Previous near fatal attack
Repeat nebulised Salbutamol 5mg and Ipratropium 0.5mg or via spacer
• Lower admission threshold if afternoon or evening attack, recent nocturnal symptoms or hospital admission, previous severe attack, patient unable to assess own condition or concern over social circumstances
Enquiries to: email@example.com, Anuj.Handa@GP-B85611.nhs.uk or Lisa.Chandler@wdpct.nhs.uk
References: SIGN guidance 2009
Ref: PH3536 Published: Aug 2010 Review due: Aug 2011 (unless clinical evidence base changes)