Asthma Exacerbation

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Asthma Exacerbation

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Asthma exacerbation
Acute respiratory distress 2/2 to asthma exacerbation
-DDx includes COPD exacerbation vs vocal cord dysfunction vs anxiety attack.
-Asthma exacerbation due to hx, excessive use of bronchodilators, night time awakenings and PEF <400.
-Likely precipitated by exercise vs stress vs pollen vs dust vs smoke vs detergent vs URI infection, vs GERD vs aspirin vs beta blockers.
-Obtain ABG & Peak expiratory flow (PEF): XXXX if <40%, and ABG shows a normal pCo2, this is severe and needs ICU admission. 
-Oxygen saturation: XX%.
-Obtain CXR, ABG, CBC and CMP to rule out infection. 
–Titrate Oxygen to keep SpO2 > 92% (or 95% if pregnant).
–Begin inhaled SABA Nebs or MDI. Albuterol 2.5 mg per 3mL by neb q 20 minutes x 3 doses, then 2.5 mg q1-4hrs prn OR Albuterol MDI with a spacer, 4 to 8 puffs q 20 minutes x 3 doses, then 4 to 8 puffs q1-4hrs prn. If decompensating or critically ill, will do continuous nebs giving 10 to 15 mg of albuterol over one hour. May use Levalbuterol (Xopenex) to mitigate tachycardia.
–Add Ipratropium Nebs or MDI. Duonebs or Xopenex-Ipratropium for patients w/ severe exacerbation. Ipratropium 0.5 mg per 2.5 mL by neb (or 4-8 puffs from MDI) q 20 minutes x 3 doses, then prn for up to 3 hours.
-Breathing tx above q1h as needed.
–Will add solumedrol 125mg q6 IV and when improving will taper. 
–Add Magnesium sulfate 2g IV infused over 20 minutes. 
-Reassess pt frequently.
-Low threshold for ICU admission; if tiring, pt will need rapid sequence intubation. If PEF<40% will go to ICU. 
-Consult critical care on-call for co-management. May need ECMO if not improving on mechanical ventilation and maximal therapy.
-At discharge, will provide pt education about meds, inhaler technique, Asthma Action Plan, and instructions for f/u with PCP.
-When ready for discharge, will review stepwise approach for chronic management of asthma and prescribe appropriate medications.