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Acute asthma in primary care
Executive Editor, InnovAiT
E-mail: chantal.simon{at}oxfordjournals.org
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Abstract |
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 TOP Abstract The GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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Four people per day, or one person every 7 hours, die from asthma. In 2005, asthma caused the deaths of 1318 individuals in the UK and 27 of those deaths were children. Delay in appropriate management can be fatal. Factors leading to poor outcome include doctors failing to assess severity by objective measurement, patients or relatives failing to appreciate severity and underuse of corticosteroids. It is estimated that 75% of hospital admissions and 90% of asthma deaths are preventable. It is essential that GPs know how to manage acute asthma and regard each emergency asthma consultation as acute, severe asthma until proven otherwise.
Statement 7: Care of acutely ill people requires GPs in training to be able to recognize and evaluate acutely ill people and to be able to manage common medical emergencies, such as acute asthma. In particular, they must be able to decide when urgent action is necessary and demonstrate that they are aware of and can use national guidance on management. GPs in training should be competent to use a nebulizer. In relation to asthma care, Statement 15.8 of the GP curriculum, ‘Respiratory problems’, requires GPs in training to be able to manage primary contact with patients who have a respiratory problem. In particular, it requires GPs in training to be able to apply the guidelines for emergency admission of patients with an acute exacerbation of asthma, in order to help reduce preventable deaths.
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Risk factors for developing fatal or near-fatal asthma |
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TOPAbstractThe GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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Patients who have a combination of severe asthma (Box 1) and adverse behavioural or psychosocial factors (Box 2) are at particular risk of death from asthma.
| Box 1. Features of severe asthma Severe asthma can be recognized by the presence of any one, or a combination of, the following factors:
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Box 2. Adverse behavioural or psychosocial factors that predispose patients to severe asthma attacks include
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Assessment |
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TOPAbstractThe GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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It is important to note that patients with severe or life-threatening attacks may not be distressed or have all the characteristic abnormalities of severe asthma. The presence of any severe features should alert the doctor to the possibility of severe or life-threatening asthma.
In all cases, assess and record the patient's symptoms and response to self-treatment. Assess the patient's general condition including conscious level and degree of distress. Record if the patient is breathless and the respiratory rate. Note the use of accessory muscles and, particularly in children, the presence of recession. Check the pulse rate. Increase in heart rate generally reflects increased severity. Listen to the patient's chest for wheeze and to exclude other causes of breathlessness such as chest infection or pneumothorax. Check peak expiratory flow rate (PEF) and oxygen saturation with pulse oximetry if available.
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Classification of acute asthma exacerbations |
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TOPAbstractThe GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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Acute asthma attacks are classified into moderate asthma exacerbations, acute severe asthma attacks and life threatening asthma. If a patient has signs and symptoms across categories, always treat according to the most severe features. For the purpose of asthma treatment, children over 12 years of age are treated as adults.
Adults with moderate asthma exacerbations have increasing symptoms. Their PEF is less than 75% but greater than 50% of the patient's personal best or that predicted (Fig. 1), but there should be no features of acute severe asthma.
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Acute, severe asthma in adults is characterized by any one of:
- PEF of 33–50% of the patient's best or predicted peak flow (Fig. 1)
- Respiratory rate of 25 breaths per minute or more
- Heart rate of 110 beats per minute or more (though note that tachycardia can result from the use of beta agonists)
- Inability to complete sentences in a single breath
The attack is classified as life threatening if any one of the following features is present in a patient with severe asthma:
- PEF of less than a third of the patient's best or predicted peak flow (Fig. 1)
- Oxygen saturation of less than 92%
- Silent chest
- Cyanosis
- Feeble respiratory effort
- Bradycardia or dysrhythmia
- Hypotension
- Exhaustion, confusion or coma
Features of moderate exacerbations, acute severe asthma and life-threatening asthma in children of 2–5 years and 5–12 years are described in Figs. 2 and 3, respectively.
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Assessment of children who are wheezing under the age of 2 years can be difficult. Infants with moderate asthma have audible wheezing and may be using accessory muscles (and possibly also have subcostal or intercostal recession and/or tracheal tug), but have an oxygen saturation of 92% or more and are still feeding. Those who have severe asthma have an oxygen saturation of less than 92% and marked respiratory distress. They may be cyanosed and are too breathless to feed. If the child has episodes of apnoea, poor respiratory effort or is bradycardic, then classify the attack as life threatening.
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Management |
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TOPAbstractThe GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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Follow the treatment algorithms in Figs. 2
– 4 depending on the age of the patient. Remember that patients with severe or life-threatening attacks may not be distressed and may not have all the clinical symptoms and signs listed. The presence of any should alert the doctor. Admit the patient to hospital immediately if:- any life-threatening features are present
- there are features of acute severe asthma present after initial treatment or
- the patient has had a previous episode of near-fatal asthma
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Lower your threshold for admission if the patient:
- has an afternoon or evening attack
- has experienced recent nocturnal symptoms
- has had a recent hospital admission
- has had previous severe attacks
- is unable to assess their own condition or
- there is concern over the patient's social circumstances
If you are admitting the patient to hospital, stay with the patient until the ambulance arrives. Send written assessment and referral details to the hospital with the patient. Give a high dose beta-2 bronchodilator via an oxygen-driven nebulizer in the ambulance.
In children under the age of 2 years, intermittent wheezing attacks are usually in response to viral infection and response to bronchodilators is inconsistent. If the child has mild or moderate wheeze, consider a trial of bronchodilators if symptoms are of concern. Use a metered dose inhaler and spacer with a face mask or nebulizer. If there is no response to treatment, consider an alternative diagnosis such as aspiration pneumonitis, pneumonia, bronchiolitis or tracheomalacia and/or admit. If the child has severe wheezing, admit to hospital. Admit as a blue light emergency if there are any life-threatening features.
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Follow-up after treatment or discharge from hospital |
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TOPAbstractThe GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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Aim to review all patients within 2 days of treatment or discharge from hospital. Monitor symptoms and PEF. Check the patient's inhaler technique. Ensure the patient or parents have a written asthma plan. Modify treatment according to the guidelines for chronic persistent asthma. Address any potentially preventable contributors to admission.
Key points
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References |
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TOPAbstractThe GP curriculum and...Risk factors for developing...AssessmentClassification of acute asthma...ManagementFollow-up after treatment or...References |
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BTS/SIGN. British guideline on the management of asthma (2008) www.sign.ac.uk/pdf/sign101.pdf or www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/asthma_final2008.pdf [date last accessed 29.05.2008].
Lynch J, Simon C, Oxford GP Library: Respiratory problems (2007) Oxford: Oxford University Press. ISBN: 9780198571377.
RCGP. GP curriculum statement number 7: Care of Acutely ill patients. Accessed via www.rcgp-curriculum.org.uk/pdf/curr_7_Acutely_ill_people.pdf [date last accessed 29.05.2008].
RCGP. GP curriculum statement number 15.8: Respiratory problems. Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15_8_Respiratory_problems.pdf [date last accessed 29.05.2008].
Simon C, O'Reilly K, Proctor R, Buckmaster J. Emergencies in primary care (2007) Oxford: Oxford University Press. ISBN: 0198570686.
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