Acute asthma can increase chest tightness, shortness of breath, cough, wheezing or any combination of these symptoms. It is the exacerbation of asthma that does not respond to conventional therapy is known as status asthmatics.
Management of an Acute Attack of Asthma
The following steps may be useful in planning the treatment protocol for a child with an acute attack of asthma.
- Assessment of severity of an attack.
- Initial bronchodilator therapy and treatment of hypoxia.
- Assessment of response to therapy and modification of therapy.
- Intensive care and ventilation in refractory cases
Assessment of Severity
The initial assessment is necessary to rapidly determine the degree of airway obstruction and hypoxia. One can immediately identify severe or life-threatening cases and gives these patients vigorous therapy even before going for detailed assessment. The features of a life-threatening attack are:
- Cyanosis, silent chest or feeble respiratory effort
- Fatigue or exhaustion
- Agitation or reduced level of consciousness.
Any child with features suggestive of a life-threatening attack should ideally be treated in a hospital where intensive care facilities are available. Enquiries should be made about the availability of a bed and child transferred as quickly as possible after initiation of oxygen and inhalational therapy with the help of nebulizer, the same being continued on the way.
- The goal is to rapidly reverse the acute airflow obstruction with consequent relief of respiratory distress. This is achieved by repeated use of inhaled beta-2 agonists.
- Hypoxia is treated by proper oxygenation of all acutely sick children.
- Corticosteroids are added early in an acute attack, particularly if the response to inhaled bronchodilators is not satisfactory.
- Repeated clinical and objective assessment is done to evaluate the response to the above and also to detect the impending respiratory failure at the earliest. Other drugs are added if necessary.
Assessment of Response to Initial Therapy
Close monitoring for detecting signs of improvement or deterioration is important. The patient should be assessed after initial therapy of 2-3 doses of bronchodilator along with oxygen over a period of one hour. The plan for further management will depend on whether the response to initial therapy has been good, partial or poor.
Intensive Care Management
The patient is observed on above therapy for next few hours and is monitored frequently. The decision to transfer to Intensive Care Unit (ICU) will depend upon the status of the child at the time of presentation and response to therapy. Any child with signs of life-threatening attack should immediately be transferred to the ICU.
If the child has been receiving therapy and has shown a poor response after being observed for a few hours or develops clinical signs of impending respiratory failure like persistent hypoxemia, exhaustion or change in the level of sensorium, he/she also warrants transfer to ICU. Continuous monitoring with the help of pulse oximetry or repeated ABG analysis is therefore mandatory since most of these patients may not be in a position to do PEFR.