Acute exacerbation

• Severe features:

  • Peak flow 33-50% best or predicted
  • Oxygen saturations less than 92%
  • Raised respiratory rate (above 40 if 1-5 years, above 30 if over 5 years)
  • Raised heart rate (above 140 if 1-5 years, above 125 if over 5 years)
  • Unable to complete sentences
• Life-threatening features:

  • Peak flow less than 33%
  • Exhausted or drowsy
  • Confused
  • Cyanosis
  • Hypotension
  • Silent chest (the wheeze disappears when the airways are so tight that there is no air entry)
• Moderate exacerbations may be treated with:

  • Inhaled beta-2 agonists (e.g., salbutamol)
  • Consider steroids (e.g., oral prednisolone) for 3-5 days
• Salbutamol inhalers are given via a spacer. High doses are used initially and gradually stepped down as tolerated, reducing the dose and increasing the space between doses. One puff at a time, every 30-60 seconds. For example:

  • 10 puffs every 2 hours
  • 10 puffs every 4 hours
  • 6 puffs every 4 hours
  • 4 puffs every 6 hours
• Severe exacerbations may additionally be treated with:

  • Oxygen to maintain sats 94-98%
  • Nebulised beta-2 agonists (e.g., salbutamol)
  • Nebulised ipratropium bromide
• If not responding to treatment, additional options include:

  • IV magnesium sulphate
  • IV salbutamol
  • IV aminophylline