Management of severe asthma exacerbation: French Guidelines
The French Emergency Medicine Society, the French Intensive Care Society and the Pediatric Intensive Care and Emergency Medicine French-Speaking Group have released guidelines on severe asthma exacerbation (SAE) in adult and pediatric patients. The Guidelines have been published in Annals of Intensive Care.
Following are the major recommendations:
For patients with asthma exacerbation, what severity criteria in medical history and at initial physical examination are associated with an increased risk of mortality and/or intensive care admission?
- adult—From first contact with patients with asthma exacerbation, the following severity criteria should be sought: history of hospital admission for asthma or need for mechanical ventilation, recent use of oral corticosteroids, considerable or increasing use of beta-2 adrenergic agonists, age > 70 years, difficulty speaking, altered consciousness, shock, respiratory rate > 30 breaths/min, arguments in favor of an underlying pneumonia.
- pediatric—From the first contact with children with asthma exacerbation, the following severity criteria should probably be sought: allergens polysensitization, insufficiently treated or poorly controlled asthma, history of hospitalization for asthma, exposure to passive smoking, and hypoxemia at initial management.
Should additional examinations be performed in patients with SAE in an emergency situation?
- adult—In SAE, chest radiography and blood gas measurements (venous or arterial) should probably be done if there is diagnostic doubt or non-response to treatment.
- pediatric—The experts suggest that additional examinations are not more effective at diagnosing SAE in children than physical examination alone.
What are the methods of administration of beta-2 adrenergic agonists in patients with SAE?
- Beta-2 adrenergic agonists should not be administered intravenously first line in adult or pediatric patients with SAE even in mechanically ventilated patients.
- Beta-2 adrenergic agonists should probably be administered by continuous rather than discontinuous nebulization during the first hour in adult and pediatric patients with SAE.
Should anticholinergic drugs be added to inhaled beta-2 adrenergic agonists in patients with SAE?
- Inhaled anticholinergic drugs should be combined with beta-2 adrenergic agonists in adult and pediatric patients with SAE.
- The experts suggest administering a 0.5-mg dose of ipratropium bromide every 8 h in adults and children over 6 years of age, and a 0.25-mg dose every 8 h in children under 6 years of age.
What are the methods of administration of corticosteroid therapy in patients with SAE?
- adult—Systemic corticosteroid therapy should be administered early intravenously or orally (1 mg/kg of methylprednisolone equivalent, maximum of 80 mg per day) to all adult patients with SAE.
- pediatric—Systemic corticosteroid therapy should probably be administered early intravenously or orally (2 mg/kg of methylprednisolone equivalent, maximum of 80 mg per day) to children with SAE.
Is magnesium sulfate indicated in patients with SAE?
- adult—Magnesium sulfate should probably not be administered routinely to adult patients with SAE.
- pediatric—Intravenous magnesium sulfate (dose ≥ 20 mg/kg) should be administered routinely to pediatric patients with SAE.
Should antibiotic therapy be administered to patients with SAE?
- Antibiotic therapy should probably not be administered routinely during SAE in adult and pediatric patients. Antibiotic therapy should probably be reserved for cases of suspected bacterial pneumonia, based on usual clinical, radiological, and laboratory signs.
What are the methods of oxygen administration to patients with SAE?
- Oxygen therapy titrated to a pulse oxygen saturation of 94%–98% should probably be administered to adult and pediatric patients with SAE.
Is there a role for non-invasive ventilation (NIV) or high-flow oxygen therapy in patients with hypoxemic SAE?
- adult—The experts were unable to recommend the use of NIV in SAE. High-flow nasal oxygen therapy has yet to be assessed in this setting.
- pediatric—The use of NIV in children with SAE should probably be considered when conventional treatments fail.
- pediatric—The experts are unable to recommend the use of high-flow nasal oxygen in children with SAE.
What are the indications for and methods of intubation in patients with SAE?
- The experts suggest resorting to intubation in adult and pediatric SAE patients if well-conducted medical treatment fails or if the inaugural clinical presentation is severe (altered consciousness, bradypnea). Intubation should be performed using the orotracheal route, after rapid sequence induction including ketamine in first line hypnotic agent and succinylcholine or rocuronium, by an experienced physician.
What are the methods of invasive ventilation in intubated patients with SAE?
- The experts suggest prevention of lung overdistension by reducing tidal volume, respiratory rate, and positive end-expiratory pressure (PEEP), and by increasing inspiratory flow, to limit plateau pressure in mechanically ventilated adult and pediatric patients with SAE.
What are the methods of sedation for mechanically ventilated patients with SAE? Do halogenated anesthetics have a part to play?
- adult—The experts suggest deep sedation—Richmond Agitation-Sedation Scale (RASS) of − 4 to − 5—at the initial phase of invasive mechanical ventilation, as well as neuromuscular blockers in the most severely ill patients. Their modalities are not specific to SAE. The experts are not able to recommend continuous administration of ketamine or halogenated agents.
- pediatric—Ketamine and halogenated gas should probably not be used for the sedation of mechanically ventilated children with SAE.
Does helium have a role as carrier gas for inhaled therapies in patients with SAE?
- Helium should probably not be used as carrier gas in nebulizers in adult and pediatric patients with SAE.
What are the methods of nebulization of therapeutic agents for patients with SAE?
- adult—The experts suggest that aerosols of salbutamol should be administered to spontaneously breathing patients with SAE using a nebulizer. The experts are unable to recommend a particular method of aerosol administration for patients with SAE receiving mechanical ventilation.
- pediatric—The experts suggest providing a sufficient flow of air or oxygen to ensure the nebulization of inhaled treatments in spontaneously breathing children with SAE. The experts suggest continuing nebulization using specific systems in children with SAE who are mechanically ventilated.
What is the role of extracorporeal membrane oxygenation (ECMO) in patients with SAE?
- In the absence of compelling data in adult and pediatric patients with SAE, the experts suggest discussing with an expert center the use of extracorporeal life support—venovenous ECMO or extracorporeal CO2 removal (ECCO2R)—in the case of respiratory acidosis and/or severe hypoxemia refractory to optimal medical treatment and to well-conducted mechanical ventilation.
What are the criteria allowing hospital discharge of patients with SAE?
- adult—The experts suggest that the decision to send patients with SAE home should be based on an assessment taking into account the patient’s characteristics, the frequency of exacerbations, the severity of the initial clinical presentation, the response to treatment, including the progression of PEF, and the patient’s ability to be managed at home (referral to the primary care physician).
- pediatric—The experts are unable to establish pediatric guidelines regarding the decision to send home children admitted for SAE.
For patients treated for SAE, what modalities of hospital discharge from the emergency room reduce the risk of a severe adverse event?
- adult—The experts suggest that the discharge prescription for patients treated for SAE in the ER should at least include a short-acting beta-2 adrenergic agonist, oral corticosteroid therapy for a short period, and inhaled corticosteroid therapy if it has not been prescribed before.
- pediatric—The experts are unable to draw up pediatric guidelines regarding the hospital discharge prescription of children admitted for SAE.
For patients with SAE, what criteria are used to indicate transfer from the emergency room to intensive care?
- The experts suggest that admission to intensive care of adult and pediatric patients with SAE should be discussed early, on a case-by-case basis, because there are no specific criteria on this subject.
For pregnant women with SAE, does specific management improve morbidity and mortality of mother and fetus compared with standard management?
- Pregnant women with SAE should probably be treated in the same way as the general population, by intensifying their controlling therapy upon admission to the emergency room if necessary.
For more details click on the link: https://doi.org/10.1186/s13613-019-0584-x