The assessment and management of patients with acute asthma

Acute asthma is a common medical emergency that is often poorly assessed and managed. Initial evaluation should include a review of historical factors for identifying high risk patients; appropriate evaluation of the current exacerbation, including an objective assessment of airflow obstruction; and, in parallel, initiation of therapy with controlled oxygen therapy, regular bronchodilator therapy and, in most cases, systemic corticosteroids. There is no benefit in using intravenous (IV) corticosteroids--a single 50 mg oral dose is appropriate. Although there is no significant additional bronchodilator effect with the use of ipratropium bromide or IV magnesium, both modalities have been shown to reduce hospitalisations for moderate to severe exacerbations. There is no role for the routine use of IV aminophylline or beta (beta) agonists in patients presenting with acute asthma. Patients who achieve 60% of their predicted peak expiratory flow (PEF) or 1 sec forced expiratory volume (FEV1) or best can usually be safely discharged. The exacerbation should be taken as an opportunity to review how a patient responded to the particular exacerbation. Were they on appropriate anti-inflammatory therapy? Did they modify the dose of therapy early in the exacerbation? Did they have an action plan? Such deficiencies can usually be managed by facilitated referral to a specialist clinic that ideally has an asthma education programme. The need for long-term anti-inflammatory therapy can be reviewed at this time as well as the potential incremental benefit of the addition of add-on therapy, most likely the use of a long-acting beta agonist.