1) ACUTE ASTHMATICS: Differentiate between
a) occasional acute, uncomplicated episode of short duration; and2) EVALUATION: For all patients - Pertinent history and pertinent physical exam; Review of all medications taken regularly as well as occasionally, including “alternative “ medications; Peak expiratory flow (PEF) measurements upon arrival in the ER and before planned discharge; serum theophyllin level for all patients taking this medication; toxicology survey when this problem is suspected. For prolonged - chronic - patients, CBC/Diff, ESR, Chest x-rays, and also Arterial Blood Gas Analysis (ABG).
b) prolonged acute episode superimposed on long-standing substantial asthma, especially if steroid-dependent.
THESE CONDITIONS MUST BE TREATED DIFFERENTLY!
3) TREATMENT: Remember that excessive use of beta-agonist medications, whether used by the patient before the ER visit by means of oral inhalers or nebulizers, or in the emergency room, can contribute to worsening of acute asthma.
a) Determine whether there exists superimposed infection (?viral or bacterial), and treat if present. These are not normal patients, but asthmatics and chronic bronchitics; and antibiotic treatment is definitely indicated . Consider amoxycillin, augmentin, bactrim DS, Biaxin, or vibramycin. Note that Zithromax, a good antibiotic, is generally NOT USEFUL for these categories of respiratory disease patients.If not, start treatment with albuterol or Xopenex inhalation therapy. The question of the number of treatments, or whether the inhalation therapy should be continuous for an extended period or intermittent, is the subject of some controversy. But what is not in question is that this should not be the only treatment that the patient with acute asthma receives while in the ER.
b) Determine if there already exists abuse of beta-agonists by the patient (eg. albuterol). If so, start treatment with Atrovent ( in the absence of infection) and/or theophyllin IV. Later in the treatment, albuterol - or preferrably Xopenex (levalbuterol) - may be tried.
Please see also the other offerings on Bronchial Asthma on this web
Specifically, attention is referred to the following Abstracts also listed above: