[Management of acute asthma]

All patients with asthma are at risk of exacerbations. Mortality is often associated with failure to identify patients at risk and/or to appreciate the severity of acute episode, resulting in inadequate initial treatment, delay in referring to emergency care and inappropriate hospitalization rates, including delayed transfer to intensive care units. This review focuses on the management of acute severe and near fatal asthma.

Lung mechanics and cardiopulmonary interactions associated with airflow obstruction explain the physical presentation and severity criteria for exacerbations. The past and recent medical history, the initial evaluation of severity and the assessment of response to treatment direct the in-hospital management: emergency department visit, transfer to ward or intensive care unit. In any cases, the goals of therapy are summarized as oxygenation, repetitive inhalations of bronchodilators and early administration of systemic corticosteroids. Mechanical ventilation is required in a few patients with near fatal attacks resulting in asphyxia or progressive exhaustion despite maximal therapy. Controlled hypoventilation with permissive hypercapnia is the best strategy to avoid barotrauma. The role of adjunctive therapies, mainly halogenated agents and heliox, is discussed.

During the last decade, asthma related mortality has decreased in France (<1000/year). The majority of deaths occur at home or during transport to the hospital but some deaths occur suddenly. Most deaths could be preventable if one adopts the approach that every exacerbation is potentially fatal. This practice should be more vigorously included in patient and general practitioner educational programs.