Treatment of Acute Severe Asthma

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The optimal treatment of acute severe asthma depends on the severity of the exacerbation. The patient's condition usually deteriorates over several hours, days, or weeks. Gradual deterioration may indicate failure of long-term controller therapy. However, rapid deterioration can occur in some patients; these patients usually respond well to bronchodilator therapy.41 Severity at the time of the evaluation can be estimated by signs and symptoms or presenting PEF or FEV1 but patient response 30 minutes after inhalation of a bronchodilator is the best predictor of outcome. 4

O In acute severe asthma, early and appropriate intensification of therapy is important to resolve the exacerbation, prevent relapse, and prevent severe airflow obstruction in the future. Starting therapy at home allows for rapid initiation and early assessment of response (see Fig. 14-3). Patients should follow their written action plan as symptoms intensify or lung function deteriorates. Based on the initial response to P2-agonist therapy, the severity of the exacerbation can be assessed, and treatment can be appropriately intensified.

In patients with a good response to therapy, doubling the dose of ICS is no longer recommended, and a short course of oral corticosteroids should be considered. All patients with an incomplete response or whose response to an inhaled SABA lasts less than 1 hour should receive a short course of systemic corticosteorids.1 Corticosteroid therapy should continue until PEF is at least 70% of predicted or personal best.1 The SABA therapy can be continued at two to four inhalations every 3 to 4 hours for 24 to 48 hours until symptoms resolve. Continued reliance on an SABA for prolonged periods indicates a need to seek medical care.

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■ Pal ¡eme al high risk fot a i a ta I attack require immediate medical attention after initial treatment

Symptoms and signs suggestive of a more serious exacerbation socti as marked breathlessness. Inability to sceat! moíe man sftort prirases, use of accessory muscles, or drowsiness should resu:t in initial ireaiment wttte immediately consulting wiin a clinician Less severe signs and symptoms can 6e treated initially wUh assessments response to therapy and further steps as listed below

IF avii'laHe, measure REf-waJues of 50-79% predicied or personal besi indicate (he reed lor quick-rei iel mediation, Depeding on the respo rise to treatment, contact with a ci in esan may also be indicated. Values betow indicate lhe need tor imrnediaie medcaf care

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FIGURE 14—3. Management of Asthma Exacerbations: Home Treatment. (ED, emergency department; MDI, metered-dose inhaler; PEF, peak expiratory flow; SABA, short-acting ß2-agonist.) (From Ref. 1.)

FIGURE 14—3. Management of Asthma Exacerbations: Home Treatment. (ED, emergency department; MDI, metered-dose inhaler; PEF, peak expiratory flow; SABA, short-acting ß2-agonist.) (From Ref. 1.)

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