An asthma exacerbation is a flare in which the airways narrow and swell, causing more wheeze, cough and breathlessness than usual. Many mild to moderate flares can be treated in clinic, but the clinician must judge severity quickly and know when the patient needs emergency care.
Key symptoms
- Shortness of breath, wheeze and chest tightness
- Cough, often worse at night
- Needing the rescue inhaler more often
- Trigger such as a cold, allergens, smoke or stopping controller medicine
What you find on exam
- Ability to speak in full sentences, respiratory rate, heart rate
- Oxygen saturation
- Wheeze, prolonged expiration, use of accessory muscles
- A quiet chest in a distressed patient is a danger sign
Tests
- Peak expiratory flow compared with the personal best
- Pulse oximetry
- Chest X-ray only if pneumonia or pneumothorax is suspected
- Repeat peak flow and symptoms after treatment
Treatment basics
- Albuterol by inhaler with spacer or nebulizer, repeated every 20 minutes for 1 hour
- Add ipratropium in moderate to severe flares
- Oral steroid such as prednisone for 5 days
- Oxygen to keep saturation 93 to 95 percent
- Review inhaler technique, controller therapy and written action plan; follow up in days
Red flags
- Unable to speak, drowsy or confused
- Silent chest, oxygen below 90 percent or peak flow under 50 percent after treatment
- Prior intubation or ICU stay for asthma
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.