Neobook — clinical reference

J46/J45.0-1/J45.8-9

DESCRIPTION

This is an emergency situation recognised by various combinations of:

Wheeze
Tightness of the chest
Chest indrawing
Breathlessness
Respiratory distress
Cough

In adults, bronchospasm is usually associated with asthma (where the bronchospasm is usually completely reversible) or chronic obstructive pulmonary disease (COPD) (where the bronchospasm is partially reversible).

The clinical picture of pulmonary oedema due to left ventricular heart failure may be similar to that of asthma. If patients > 50 years of age present with asthma for the first time, consider pulmonary oedema due to left ventricular heart failure.

All PHC facilities must have peak expiratory flow rate (PEFR) meters, as asthma cannot be correctly managed without measuring PEFR.

Asthma

Recognition and assessment of severity of asthma attacks in adults

	Mild-Moderate	Severe	Life threatening
Oxygen saturation	>90%	<90%	<90%
Talks in	phrases	words	unable to speak
Alertness	normal	Usually agitated	agitated, drowsy or confused
Respiratory rate	20–30 breaths/minute	often >30 breaths/minute	often >30 breaths/minute OR feeble effort
Wheeze	present	present	absent
Heart rate	100–120 beats/minute	>120 beats/minute	bradycardia
PEFR	>60% of predicted	<60% of predicted	<33% of expected or unable to blow

Note:
PEFR is expressed as a percentage of the predicted normal value for the individual, or of the patient's personal best value obtained previously when on optimal treatment (see nomogram in Appendix I: Asthma monitoring, to predict PEFR).

COPD

Recognition and assessment of severity of COPD attacks in adults

	Moderate	Severe
Talks in	phrases	words
Alertness	usually agitated	agitated, drowsy or confused
Respiratory rate	20–30 breaths/minute	often >30 breaths/minute
Wheeze	loud	loud or absent
Heart rate	100–120 beats/minute	>120 beats/minute
PEFR after initial nebulisation	±50–75%	<50%; may be too short of breath to blow in PEF meter

MEDICINE TREATMENT

See Appendix II: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.

Mild to moderate attacks

Salbutamol 100 mcg metered-dose inhaler (MDI),
- Salbutamol inhaler 400–1000 mcg (4-10 puffs) using a spacer if required and available
- Shake the inhaler between each puff
- If no relief, repeat every 20–30 minutes in the first hour
- Thereafter, repeat every 2–4 hours if needed

LoE:IVb², LoE:IVb³

Note:
Administering salbutamol via a spacer is as effective as, and cheaper than, using a nebuliser.

Salbutamol 0.5% (5 mg/mL), solution,
- 1 mL (5 mg) salbutamol 0.5% solution made up to 4 mL with sodium chloride 0.9%, preferably delivered at a flow rate of 8 L/min with oxygen
- If no relief, repeat every 20–30 minutes in the first hour
- Thereafter, repeat every 2–4 hours if needed

LoE:IVb⁴

PLUS

Corticosteroids (intermediate-acting), e.g.:
- Prednisone, oral, 40 mg immediately if patient known to have asthma/COPD
- Follow with prednisone, oral, 40 mg daily for 7 days

LoE:IVb⁵

Severe attacks (while awaiting referral)

Oxygen to keep oxygen saturation 93-95%

Note:
For adults with COPD: Give oxygen with care (preferably by 24% or 28% facemask, if available). Observe patients closely, as a small number of patients’ condition may deteriorate.

AND

Salbutamol 0.5% (5 mg/mL) nebuliser solution,
- o 1 mL (5 mg) salbutamol 0.5% solution, made up to 4 mL with sodium chloride 0.9%, preferably delivered at a flow rate of 8 L/min with oxygen
- If no relief, repeat every 20–30 minutes until PEFR > 60% of predicted
- Once PEFR > 60% of predicted, repeat every 2–4 hours if needed

LoE:IVb⁶

Salbutamol, inhalation using a MDI,
- Salbutamol 400–1000 mcg (4–10 puffs), up to 20 puffs, using a spacer
- Inhale 1 puff at a time. Allow for 6 breaths through the spacer between puffs
- If no relief, repeat every 20–30 minutes until PEF > 60% of predicted
- Once PEF > 60% of predicted, repeat every 2–4 hours if needed

LoE:IVb⁶, LoE:IVb⁷

Note:
Administering salbutamol via a spacer is as effective as, and cheaper than, using a nebuliser.
LoE:IVb⁸

If poor response after first salbutamol nebulisation/inhalation

Continue salbutamol nebulisation as described in management above and

ADD

Ipratropium bromide 0.5 mg/2ml; nebuliser solution
- Ipratroprium bromide, 2 mL (0.5 mg) added to salbutamol 1 mL (5 mg) solution and made up to 4 mL with sodium chloride 0.9%
- Administer every 20–30 minutes up to a maximum of 3 doses depending on clinical response

LoE:IIb⁹

Ipratroprium bromide, MDI, 80–160 mcg (2–4 puffs), using a spacer every 20–30 minutes as needed for up to 3 hours

LoE:IIb¹⁰

AND

Corticosteroids (intermediate-acting), e.g.:
- Prednisone, oral, 40 mg immediately
- Follow with prednisone, oral, 40 mg daily for 7 days

LoE:IVb¹¹

If oral prednisone cannot be taken:

Hydrocortisone IM/slow IV, 100 mg as a single dose

Followed with:

Prednisone, oral, 40 mg daily for 7 days

LoE:IVb¹²

CAUTION
Avoid sedation of any kind.

Note:
If poor response to treatment, consider alternate diagnosis and refer urgently.

Life- threatening attacks

Oxygen, to keep oxygen saturation 93-95%.

Note:
For adults with COPD: Give oxygen with care (preferably by 24% or 28% facemask, if available). Observe patients closely, as a small number of patients’ condition may deteriorate.

AND

Salbutamol 0.5% (5 mg/mL) with ipratropium bromide 0.5 mg/2mL nebuliser solution
- Salbutamol 0.5%, 2 mL (10 mg) plus ipratroprium bromide, 2 mL (0.5 mg) every 20–30 minutes depending on clinical response for 4 doses over 2 hours
- Delivered at a flow rate of 8 L/min with oxygen
- If no relief, repeat every 20–30 minutes until asthma severity category moves from life-threatening to severe

AND

Parenteral corticosteroids (intermediate-acting) e.g.:
- Hydrocortisone IM/slow IV, 100 mg as a single dose
Followed with:
- Oral corticosteroids (intermediate-acting) e.g.:
  - Prednisone, oral, 40 mg daily for 7 days

LoE:IVb¹³

CAUTION
Avoid sedation of any kind.

Note:
If response to treatment is adequate and severity improves to become severe but not life threatening, treat as per severe asthma exacerbation above.

Assessment of response in adults

	Response	No response
PEFR (if possible)	improvement by >20%	improvement by <20%
Respiratory rate	<20 breaths/ minute	>20 breaths/ minute
Speech	normal	impaired

Patients responding to treatment

Routine prescription of antibiotics is not indicated for acute asthma
Review current treatment and possible factors causing acute attack, including poor adherence and poor inhaler technique
Advise patient/caregiver on further care at home, danger signs and that follow up is required
Caution patient on the high chance of further wheezing in the week following an acute attack
Patients with a first attack should be fully assessed for maintenance treatment
Ask about smoking: if yes, urge patient to stop

Note:
Patients needing repeated courses of oral corticosteroids (more than twice over 6 months) should be assessed by a doctor for maintenance therapy. (See Chronic asthma).

REFERRAL

Urgent (after commencing treatment)

All patients with severe attack
Poor response to initial treatment
PEFR < 75% of the predicted normal or of personal best value 15–30 minutes after nebulisation
A lower threshold for admission is appropriate in patients when:
- Seen in the afternoon or evening, rather than earlier in the day
- Recent onset of nocturnal symptoms or aggravation of symptoms
- Previous severe attacks, especially if the onset was rapid

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4-Version 1.0_16 September 2024

Chapter 17: Respiratory Conditions_17.1. Conditions with Predominant Wheeze_17.1.1. Acute Asthma & Acute Exacerbation of COPD, Adults

Acute Asthma & Acute Exacerbation of COPD, Adults

Drugs mentioned

ICD-10 codes