Asthma in adults
  • Chronic, often allergic inflammation of airway walls causing
    • Narrowing of airways, bronchospasm (tightening of airway wall muscles)
    • Inflammatory oedema and increased mucus production 
  • Symptoms come and go

  • Not all wheeze or shortness of breath is asthma

Consider asthma if

  • Variable shortness of breath with exercise or physical activity
  • Cough or wheeze (whistling sound on breathing out) — usually with respiratory infection
  • Sensitive to irritants, allergic symptoms, eg sneezing, watery eyes

Diagnosis

  • Confirmed by history or presence of typical symptoms combined with reversible airflow obstruction on spirometry if  FEV1  and FEV/FVC are reduced on spirometry then improve by more than 12%  AND at least 200mL of FEV1 after 4 puffs of salbutamol (400microgram) via spacer
  • Normal spirometry does not exclude asthma

Managing an asthma attack

Do
  • Use Table 7.15 to assess severity (how bad it is)
    • Do not stop oxygen to do pulse oximetry 
    • If person is in more than one severity category record the higher (worse) category as overall level
    • If not sure if it is mild or moderate — treat as moderate

Table 7.15 Rapid assessment of severity

Severe and life-threatening asthma

Do first

  • Sit person up — use wheelchair to move them
  • Start oxygen if O2 sats less than 92% and titrate to target oxygen saturation of 93–95%
    • Do not over-oxygenate to avoid risk of hypercapnia (CO2 retention)
  • Give salbutamol nebulised as needed — 5mg AND ipratropium nebulised as needed — 500microgram — can mix with salbutamol
  • Nebulisers have high risk of transmitting infection. Wear full PPE
  • Urgent medical consult 
  • Give prednisolone oral — adult 50mg, single dose OR if oral route not possible give hydrocortisone IV — 100mg, every 6 hours
  • If poor response consider — magnesium sulfate IV diluted in a compatible solution as a single IV infusion — 10mmol (2.5g) over 20 minutes
  • If severe or unresponsive — give adrenaline (epinephrine) IM — adult 0.5mg
  • Check RR, O₂ sats, pulse every 15 minutes. If getting better — try using spacer or reduce nebuliser frequency to half hourly
    • AVPU, RR, O₂ sats, pulse, BP, Temp — work out REWS
    • Can give prednisolone oral — 50mg, once a day for 5 days

Moderate and mild asthma

Ask

  • Onset — how many days have they been sick
  • Wheeze or cough, what makes them worse — dust, smoke, pollen, grass, recent cold or flu
  • Symptoms of chest infections (URTI/LRTI)
  • Contacts who are sick 
  • Medicines they have already used to manage attack, do they use a spacer
  • Adherence to regular medications
  • Coexisting heart or lung disease
  • Smoking status and exposure to second hand smoke
  • Do they have an asthma action plan, have they followed it
  • Previous hospitalisations for asthma especially intensive care admissions

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Head-to-toe exam with attention to  
    • Breathing — rib recession, accessory muscle use. Listen to front and back of chest for wheeze, air entry 

Do

  • FEV1 or PEFR
  • Treat according to moderate or mild asthma
  • If temp more than 38.5°C — medical consult

Moderate asthma

  • Give reliever
    • Salbutamol puffer with spacer — 100microgram/dose (4–12 puffs) OR terbutaline inhaler — 500microgram/dose (6 puffs)
    • Repeat every 20 minutes for 1 hour (total of 3 doses) if needed
  • Check response 10–20 minutes after third dose
  • May need oxygen to target O2 sats 93–95% 
    • Nasal cannula 2–4L/min OR mask 5–10L/min
  • Medical consult
  • Give prednisolone oral — adult 50mg, single dose OR give hydrocortisone IV — adult 100mg — can repeat after 6 hours
  • If not better — may need to ADD magnesium sulfate IV diluted in a compatible solution as a single IV infusion — 10mmol (2.5g) over 20 minutes
  • If better — keep in clinic for 1 hour. When stable
    • Make management plan with doctor. Update asthma action plan and give copy to patient
    • Advise to use reliever — salbutamol puffer with spacer — 100microgram/dose (2–4 puffs) every 4 hours 
      OR terbutaline inhaler — 500microgram/dose (1–2 puffs) repeat every 4 hours
      OR usual reliever
    • Give prednisolone oral — adult 50mg, once a day for 4 more days
    • Send home then review every day
    • Medical follow-up next visit

Mild asthma

  • Give reliever
    • Salbutamol puffer with spacer — 100microgram/dose (4–12 puffs) OR terbutaline inhaler — 500microgram/dose (4 puffs)
  • If person has been sick for a few days or on regular preventer treatment — give prednisolone oral — adult 50mg, single dose
  • Check response to treatment after 20 minutes
  • If not better — treat as moderate asthma
  • If better — keep in clinic for 1 hour. When condition stable
    • Advise to use reliever every 4 hours — salbutamol puffer with spacer — 100microgram/dose (2 puffs)
      OR terbutaline inhaler — 500microgram/dose (1 puff) repeat every 4 hours
      OR usual reliever
    • Advise what to do if symptoms get worse
    • Record in asthma action plan and give copy to person
    • Send home then review next day
  • If more than 1 attack in last year — medical consult to check and revise asthma action plan

Managing ongoing asthma

Asthma management is adults in based on

  • Confirmation of diagnosis — symptoms, medicines used, spirometry
    • If diagnosis made elsewhere — get results
  • Education
    • Make sure person understands and can manage asthma, including how to use devices and make a bush spacer — See Spacer devices for respiratory medicines
    • Provide advice about smoking, healthy eating, physical activity, healthy weight and immunisation
  • Assessment of symptoms and control 
    • Reassessing asthma control regularly — increase or decrease preventive therapy based on this
  • Monitoring (PEFR or spirometry) — achieve and maintain best lung function
  • Triggers identified and avoided including fire, e-cigarettes and tobacco smoke
  • Managing comorbid conditions that affect asthma or contribute to respiratory symptoms
  • Asthma action plan developed and reviewed regularly

Table 7.16 Levels of asthma symptom control

* Not including reliever used for prevention before physical activity

Management — key points

  • Manage by level of symptom control — Table 7.16 and Table 7.17
  • Most important medicines for asthma control are relievers (eg salbutamol) and inhaled corticosteroids (ICS)
  • Regular follow up is important to assess control and adjust (increase or decrease) treatment
    • Effect of change in ICS dose usually reached in 4 weeks
    • If ICS started at high dose for acute attack with newly diagnosed asthma — reduce after 2 weeks if now good control
    • If partial or poor control — adjust ICS dose every 4 weeks until good control
  • If partial or poor control despite high dose ICS — may need Long Acting Bronchodilator (LABA), eg salmeterol
  • Do not use LABA without ICS — always use combination LABA/ICS device
  • Check inhaler technique regularly and when changing treatment 

Table 7.17 Management by level of control

Follow-up care

  • If good control — review once a year
  • If partial or poor control — review every 4 weeks
  • If frequent or persistent asthma — 3 monthly until symptoms well controlled
  • Medical follow-up after any hospital admission

Ask

  • How often do they get symptoms — cough, wheeze, waking at night
  • Does asthma stop them doing usual physical activities or work
  • How often do they use their reliever
  • Are there any problems with medicines
  • About causes, eg smoke exposure, dust, allergies

Check

Do

  • Assess level of control and adjust treatment if needed
  • Review and update asthma action plan
  • Give advice on avoiding triggers, eg avoid exposure to smoke

Asthma medicines

Table 7.18 Asthma medicines

Table 7.19 Total daily doses of inhaled corticosteroids (ICS) for adults

Inhaled therapy devices

  • All metered dose inhalers/MDIs (puffers) work best with a spacer — See Spacer devices for respiratory medicines
    • Have person show you their puffer and spacer techniques
    • Check they know how to make a bush spacer
  • Bronchodilators (relievers) work as well with puffer and spacer as with nebuliser — except in severe or life-threatening attacks
    • Salbutamol 100microgram/dose puffer 8–12 puffs = salbutamol 5mg nebulised
  • Other devices are available — find device person prefers or works best for them
  • Dry powder inhalers (DPIs), eg turbuhaler, accuhaler, Ellipta
    • Can get blocked in very humid climates
    • Need to be able to take a big enough breath to make work — Ellipta doesn't need as big a breath to activate as the others

Asthma action plan

Every person needs written asthma action plan — make sure they understand it

  • Keep copy at home and in file notes

Illustrated Aboriginal asthma action plans are available online — includes

  • What to do when
    • Person well
    • Asthma bit worse or they get a cold or chest infection
    • Asthma severe
  • How often they need regular reviews, medical follow-up, specialist reviews
  • When to collect medicines and have immunisations

Supporting resources