Literature Review: Asthma Exacerbation

Summary of the 2023 GINA Guidelines

Assessment

• A brief history and physical exam should be done concurrently with prompt treatment initiation. Important elements include timing, severity, risk factors for poor outcomes, current medications and response.
• Assess for signs of exacerbation severity, complications, and alternative causes of acute breathlessness.
• Objective measures like lung function and oxygen saturation should be obtained if possible before starting treatment. These help assess severity and monitor response.

Treatment

• Give oxygen to target saturation 93-95% in adults or 94-98% in children 6-11 years. Avoid excessive oxygen in adults.
• Give inhaled SABA as first line bronchodilator. Ipratropium bromide provides added benefit. Consider high dose ICS-formoterol as an alternative bronchodilator.
• Give systemic corticosteroids to all but mildest exacerbations. Use for 5-7 days in adults, 3-5 days in children. Oral and IV routes are equally effective.
• Add inhaled corticosteroids within the first hour if not on maintenance treatment. On discharge, prescribe maintenance ICS-containing treatment to reduce future risk.
• Other treatments like magnesium sulfate, leukotriene antagonists, aminophylline/theophylline, and antibiotics have little role unless specific indications. Avoid sedatives.
• Reassess after 1 hour of treatment. Patients with severe exacerbations not responding to treatment need ICU referral.

Hospitalization vs Discharge

• Factors favoring hospitalization include poor lung function after 1st hour of treatment, past history of severe exacerbations or intubations, and social factors impacting follow up.
• Discharge may be considered with post-treatment lung function 40-60% predicted and close follow up.
• Discharge is favored if post-treatment lung function is >60% predicted and risk factors/follow up are acceptable.

Discharge Planning

• Arrange early follow up visit. Provide oral corticosteroids, ICS-containing medications, and written asthma action plan.
• Review modifiable risk factors, inhaler technique, adherence, and patient responses during the exacerbation.
• For adults/adolescents, prescribe ICS-formoterol as the reliever to reduce future exacerbation risk.

Select Articles

Reviewing Cochrane Review Articles on Acute Asthma Treatment

1. Preparation:
   • Ensure you are in a conducive environment, free from distractions.
   • Have a computer or tablet with an active internet connection.
2. Access the Articles:
   • Click on the following links to access each article:
     1. Early emergency department treatment of acute asthma with systemic corticosteroids
     2. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department
3. Note Key Points:
   • As you read, make brief notes of critical findings or insights that you feel might be pertinent in your practice or that might come up in discussions with colleagues or physicians.
4. Review:
   • After reading both articles, revisit any highlighted or noted sections to reinforce your understanding and ensure you’ve grasped the core findings.