The video version of this podcast can be found here:

·      https://youtu.be/rmkFvK2O0KM

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 treatment of acute asthma in adults.

 

In the last episode I covered the initial assessment in adults and in the next episodes, I will cover:

·      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 collaboration between NICE, SIGN and the British Thoracic Society (BTS). It replaces previous guidance, and you can find a link to it in the episode description.

In this episode I will just focus on treatment of acute asthma in adults.

 

In the last episode we covered the initial assessment in adults and in the next three episodes, I will cover the assessment of children, treatment in children and lessons from asthma deaths. So, stay tuned for those!

Right, let’s jump into it.

When managing acute asthma in adults, our primary goal is to prevent poor outcomes> Many asthma-related deaths are due to clinical staff failing to assess severity with objective measurements, patients or their families underestimating the seriousness of the attack, and the underuse of corticosteroids.

The treatment of acute asthma depends on the severity of the attack, which can range from moderate to life-threatening. For a refresher on how to clinically differentiate between the various severity categories, you can refer to the previous episode on this channel.

But before looking at the specific treatment recommendations for each category, let’s look at some general treatment principles.

Many patients with acute severe asthma are hypoxaemic. We should give oxygen to those who are hypoxaemic. The flow rate needs to be adjusted as necessary to maintain Oxygen saturation between 94 and 98%, while being cautious to avoid overoxygenation, especially if there are concerns about hypercapnia

If pulse oximetry is unavailable, oxygen therapy should still be initiated without delay, and Oxygen saturation monitoring started as soon as possible. We should also monitor and record the patient’s heart rate regularly.

In most acute situations, high-dose inhaled β2 agonists act rapidly to relieve bronchospasm with minimal side effects so high-dose inhaled β2 agonists should be our first-line agents and given as early as possible, ideally nebulised with oxygen rather than air to prevent desaturation,  particularly in cases of acute-severe or life-threatening asthma.

When using oxygen cylinders, it’s important to fit a high-flow regulator and maintain a flow rate of at least 6 L/min to drive the nebuliser effectively. However, if oxygen is unavailable, this shouldn’t prevent us from administering nebulised therapy when clinically indicated.

PEF should also be recorded before and after administering β2 agonists.

For patients with severe asthma who respond poorly to initial β2 agonist therapy, we should repeat β2 agonist doses at 15–30-minute intervals or use continuous nebulisation of salbutamol at 5–10 mg/hour while arranging hospital admission. However, higher bolus doses, such as 10 mg of salbutamol, are unlikely to offer any additional benefit.

Also, all patients experiencing an acute asthma attack should receive adequate doses of oral steroids. Steroids significantly reduce mortality, relapse rates, hospital readmissions, and the need for further β2 agonist therapy. The earlier they are administered, the better the outcome.

Oral steroid tablets are as effective as injected steroids, as long as they can be swallowed and retained. Therefore, we would normally start and continue prednisolone (40–50 mg daily) until recovery, and for a minimum of five days.

While giving systemic corticosteroids, we will not discontinue inhaled corticosteroids.

After recovery, oral steroids can be stopped abruptly without tapering, provided the patient is on inhaled corticosteroids, except in cases of prolonged steroid use for three weeks or more or if maintenance oral steroid therapy is planned.

Nebulised Ipratropium Bromide at a dose 0.5 mg every 4–6 hours can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who respond poorly to initial β2 agonist therapy.

This is because combining nebulised ipratropium with β2 agonists provides greater bronchodilation, leading to faster recovery and shorter hospital stays.

However, in milder asthma attacks or after stabilisation, anticholinergic treatment is not necessary and offers limited benefit.

Intravenous Aminophylline should only be considered in secondary care because It carries a higher risk of side effects, including arrhythmias and vomiting.

Current evidence does not support the use of oral leukotriene receptor antagonists in acute asthma.

And equally, routine antibiotics are not recommended for acute asthma because most asthma exacerbations triggered by infection are viral rather than bacterial and we should therefore only consider antibiotics when there is clear evidence of bacterial infection, guided by objective clinical measures.

Right, let’s now look at the specific treatment recommendations for each category of severity of the asthma attack.

And let’s start with moderate asthma. Here:

  • We can Treat the patient either at home or in the practice and monitor their response.

·      For less severe asthma exacerbations, we can start by administering a β2 bronchodilator using a spacer, delivering one puff at a time with tidal breathing. According to their response, we can give another puff every 60 seconds, up to a maximum of 10 puffs.

·      If the patient doesn’t improve of if the exacerbation is more concerning, we will escalate to a nebuliser—preferably oxygen-driven—with salbutamol at a dose of 5 mg.

  • We will also give oral prednisolone 40–50 mg and then either
  • Continue or increase the patient’s usual asthma treatment.

If the patient responds well to the first round of treatment – meaning their symptoms improve, respiratory and pulse rate settle, and PEF rises above 50% – they can continue or increase their usual therapy along with daily prednisolone until recovery.

However, we will admit the patient to hospital if:

  • They show any life-threatening features.
  • They develop Symptoms of acute severe asthma despite initial treatment or if
  • They have a previous history of near-fatal asthma.

We should also consider a lower threshold for admission if:

  • The attack occurs in the afternoon or evening.
  • There are recent nocturnal symptoms or previous hospital admissions.
  • The patient has experienced severe asthma attacks in the past.
  • They are unable to assess their own condition or
  • There are concerns about their social circumstances.

Next is acute severe asthma. For them:

  • We will consider hospital admission.
  • We will start by administering oxygen to maintain Oxygen saturation between 94–98% and
  • We will use a β2 bronchodilator:
  • Via an oxygen-driven nebuliser with salbutamol 5 mg or
  • If a nebuliser is unavailable, we can use a spacer.
  • And we will give prednisolone 40–50 mg or, if available, IV hydrocortisone 100 mg.
  • If the patient does not respond to this treatment: we will admit them urgently.

When referring a patient to hospital:

  • We will stay with them until the ambulance arrives.
  • Provide a written assessment and referral details and
  • Continue administering the β2 bronchodilator via an oxygen-driven nebuliser during transport.

For life-threatening asthma:

  • We will obviously arrange immediate admission and in the meantime we will
  • Give oxygen to maintain Oxygen saturation between 94–98%.
  • Administer nebulised therapy:
  • Via an oxygen-driven nebuliser with salbutamol 5 mg and ipratropium 0.5 mg.
  • If neither the nebuliser nor ipratropium is available, we will use a β2 bronchodilator via spacer.
  • And we will give prednisolone 40–50 mg or IV hydrocortisone 100 mg immediately.

As follow up after an acute asthma attack, we will:

  • Continue prednisolone until full recovery, for a minimum of 5 days.
  • Arrange a GP review within 2 working days.
  • Monitor symptoms and PEF regularly.
  • Check the patient’s inhaler technique.
  • Provide a written asthma action plan, remembering that they have been shown to reduce morbidity and relapse rates.
  • We will modify treatment according to guidelines for chronic asthma.
  • And finally address any potentially preventable factors and triggers that may have contributed to the asthma attack.

So that is it, a review of the treatment of acute asthma in adults.

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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