The video version of this podcast can be found here:

·      https://youtu.be/-fWEa4h6q64

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on initial assessment in adults.

 

In the next four episodes, I will cover:

·      Treatment of acute asthma in adults

·      Initial assessment of acute asthma in children

·      Treatment of acute asthma in children

·      And finally, lessons from asthma deaths and near-fatal asthma as well as reviewing the concept of difficult asthma

 

Just like the NICE guideline on the management of chronic asthma, which was updated in November 2024, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

 

There is a podcast version of this and other videos that you can access here:

 

Primary Care guidelines podcast:

 

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148


There is a YouTube version of this and other videos that you can access here: 

  • The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk


The link to the new NICE guideline on acute asthma can be found here:

·      https://www.nice.org.uk/guidance/ng244/chapter/Managing-acute-asthma

Based on recommendations on managing acute asthma in the BTS/SIGN British guideline on the management of asthma:

·      https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/managing-acute-asthma/

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on acute asthma, NG244, focusing on what is relevant in Primary Care only. Just like the NICE guideline on the management of chronic asthma, the NICE guideline on acute asthma is also a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

Given how extensive the guidance is, in this episode I will just focus on initial assessment in adults.

In the next four episodes, I will cover the assessment of children, treatment in adults and children and lessons from asthma deaths and the concept of difficult asthma. So, stay tuned for those!

Right, let’s jump into it.

When conducting the initial assessment of a patient with acute asthma, it helps to follow a systematic approach because using a structured recording process helps ensure consistency in order to determine:

  • Whether the patient is indeed having an acute attack,
  • The severity of the episode,
  • And the appropriate treatment required.

So let’s have a look at the different aspects of this Clinical Assessment and let’s start with clinical features.

Examination findings that can indicate severe asthma, are:

  • Severe breathlessness, including being too short of breath to complete full sentences,
  • Tachypnoea, with a high respiratory rate,
  • Tachycardia,
  • A silent chest, indicating minimal air entry,
  • Cyanosis,
  • The use of accessory muscles when breathing,
  • Or signs of altered consciousness or collapse.

However, we should note that while these signs are concerning, their absence does not exclude a severe attack.

We should also note that, although pulsus paradoxus is sometimes observed in severe asthma, it is not a reliable indicator of severity and should not be used in clinical decision-making. Pulsus paradoxus is an exaggerated drop in systolic blood pressure during inspiration and, in asthma, it occurs due to increased intrathoracic pressure, but, as we have said, its absence does not rule out a severe attack.

Let’s now look at some measurements, starting with PEF and FEV1 Measurements.

Both are valid indicators to assess the degree of airway obstruction, but PEF is more practical in acute settings.

For clinical accuracy:

  • We should express PEF as a percentage of the patient’s previous best value, when known, but
  • If the best value is unavailable, we will use the predicted peak flow value as a rough guide.
  • Keeping in mind that different peak-flow meters may give slightly different readings, so ideally, we should use the same or a similar device for consistency.

Let’s now look at assessing oxygen levels using Pulse Oximetry

The target of oxygen therapy is to maintain SpO2 between 94 and 98%.

If SpO2 drops below 92%, regardless of whether the patient is on air or oxygen, an arterial blood gas (ABG) measurement will be needed to evaluate for hypoxia and hypercapnia, which can indicate impending respiratory failure. So, in summary,  if the oxygen saturation is below 92%, the patient should be referred to the emergency department.

Looking at other investigations, a chest X-ray is not routinely required for asthma attacks.

However, it may be necessary in cases where we suspect:

  • Pneumothorax or consolidation, or in situations when there is
  • Life-threatening asthma,
  • Failure to respond to treatment,
  • Or a need for assisted ventilation.

Now, when assessing a patient with suspected acute asthma, we need to recognize the signs and determine the severity of the attack.

We classify acute asthma into different levels of severity, ranging from mild to life-threatening, based on symptoms and objective measures like peak flow readings. As we said earlier, if we don’t have the patient’s recent best peak flow reading, that is, within the past two years, then we will use the predicted peak flow value as a reference.

Let’s now look at the levels of Severity of Acute Asthma Attacks in Adults

And we will start with moderate acute asthma.

Patients in this category experience increasing symptoms, but their PEF remains between 50 and 75% of their best or predicted value. Importantly, there are no signs of severe asthma.

The next category is acute severe asthma and patients meet the criteria for this category if they exhibit any one of the following signs:

  • A PEF between 33 and 50% of their best or predicted value,
  • A respiratory rate of 25 breaths per minute or higher,
  • A heart rate of 110 beats per minute or more,
  • Or an inability to complete full sentences in one breath.

After this we come to the category of life-threatening asthma, which is basically patients who already have severe asthma, who also presents any one of the following features:

  • An altered conscious level,
  • PEF below 30% of best or predicted,
  • Signs of exhaustion,
  • Oxygen saturation (SpO2) dropping below 92%,
  • The development of an arrhythmia,
  • Hypotension,
  • Cyanosis,
  • A silent chest, indicating minimal air entry,
  • Or poor respiratory effort, which can suggest impending respiratory failure.

And finally, the last category is near-fatal asthma, which is the most critical stage.

It’s characterized by raised arterial CO2 levels, indicating respiratory failure, and often requires mechanical ventilation. Given that we do not have direct access to blood gases in Primary care, this category will only be accurately diagnosed in secondary care.

Let’s now look at the Criteria for hospital admission.

And, obviously, any patient showing any feature of a life-threatening or near-fatal asthma attack should be admitted urgently.

However, other factors may also warrant admission to hospital, including patients with severe asthma that does not fully resolve after initial treatment.

Additionally, even if symptoms improve and peak flow increases to over 75% of best or predicted one hour after treatment, hospital admission may still be appropriate if there are ongoing concerns. So, we should also consider admission if there are:

  • Persistent symptoms,
  • Concerns about medication adherence,
  • Psychological issues,
  • Other co-morbidities that could complicate the management
  • If there is a Physical or learning disability,
  • A previous history of near-fatal asthma,
  • An attack despite taking an adequate dose of oral corticosteroids prior to arrival,
  • A presentation at night, when follow-up may be limited,
  • If the patient lives alone or is socially isolated,
  • Or if the patient is pregnant.

And just before we finish, let’s just say that, in terms of prevention, the identification of these patients, who are at higher risk of asthma-related death is very important.

Therefore, in primary care we should maintain a register of these patients, ensuring that if they miss a follow-up appointment, they are proactively contacted. This helps prevent deterioration and reduces the risk of fatal outcomes.

And equally, patients with asthma, especially those with severe asthma, should have a written Personal Asthma Action Plan which outlines how to manage their condition day-to-day, when to adjust medication, and when to seek medical help.

Studies have shown that Personal Asthma Action Plans can significantly reduce both hospital admissions and asthma-related deaths.

So that is it, a review of the initial assessment and diagnosis of asthma.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

 

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