Emergency Department Management of Acute Asthma Exacerbations -

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Publication Date: February 2022 (Volume 24, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 02/01/2025.

Authors

Peer Reviewers

Abstract

Asthma is a disease of the airways characterized by inflammation, hyperresponsiveness, and bronchoconstriction. The diagnosis is primarily a clinical one, based on a focused history and physical examination, to differentiate from other entities such as heart failure, pneumonia, and pulmonary embolism. Radiographs, laboratory studies, and blood gases are not routinely recommended, except in atypical or refractory cases, or if there is diagnostic uncertainty. The cornerstone of acute asthma treatment includes short-acting beta agonists, anticholinergics, and systemic corticosteroids. This issue reviews the latest evidence in diagnostic and treatment strategies, including other pharmacologic treatments and newer management strategies to avoid intubation.

Case Presentations

A 43-year-old man with a history of frequent visits for asthma, including multiple admissions and intubations, is brought into the ED…

• The patient is anxious, tachypneic, using accessory muscles to breathe, and is in severe respiratory distress. On auscultation, air entry is significantly diminished, and he has faint expiratory wheezing.
• His blood pressure is 155/85 mm Hg; heart rate, 128 beats/min; respiratory rate, 30 breaths/min; temperature, 36.9°C; and oxygen saturation, 91% on 3 L nasal cannula.
• You place him on a cardiac monitor, begin treatment, and consider what other modalities can be used to avoid intubation…

A 22-year-old woman is brought in by EMS with complaints of difficulty breathing and dry cough. She is 20 weeks’ pregnant, with a history of several past hospital admissions for asthma…

• The patient says she discontinued her asthma medications because she said she did not want to harm the fetus.
• Her blood pressure is 120/75 mm Hg; heart rate, 115 beats/min; respiratory rate, 25 breaths/min; and room-air pulse oximeter reads 92%. You can hear audible wheezing and notice mild retractions. She is speaking in partial sentences.
• You consider what interventions for asthma are safe in pregnancy...

A 50-year-old man with a history of asthma is brought in by EMS after experiencing wheezing and shortness of breath all day…

• En route to the hospital, the paramedics have given him IV corticosteroids, nebulizer treatments, and magnesium sulfate, but he is not improving clinically.
• The patient's blood pressure is 180/110 mm Hg; heart rate, 125 beats/min; respiratory rate, 35 breaths/min; and oxygen saturation, 88% on 100% oxygen via aerosol mask. His arterial blood gas shows a PaO₂ of 68 mm Hg, PCO₂ of 110 mm Hg, and a pH of 7.1. He is using accessory muscles to breathe, and is clearly wearing down.
• You make the decision to intubate him before he decompensates further, and you consider the challenges of managing a critical asthmatic patient on mechanical ventilation…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.