What are the treatment guidelines for acute severe vs moderate asthma according to NICE (National Institute for Health and Care Excellence) guidelines?

NICE Guidelines for Acute Severe vs Moderate Asthma Management

According to NICE guidelines, acute severe asthma requires immediate intensive treatment with nebulized bronchodilators, systemic corticosteroids, and consideration for hospital admission, while moderate asthma can be managed with nebulized salbutamol and oral prednisolone with close monitoring at home. 1

Assessment and Classification

Moderate Asthma

• Clinical Features:
  • Speech normal
  • Pulse <110 beats/min
  • Respiration <25 breaths/min
  • PEF >50% predicted or best 2

Acute Severe Asthma

• Clinical Features:
  • Cannot complete sentences in one breath
  • Pulse >110 beats/min
  • Respiration >25 breaths/min
  • PEF <50% of predicted or best 2, 1

Life-Threatening Features (requiring immediate ICU consideration):

• Silent chest, cyanosis, feeble respiratory effort
• Bradycardia, confusion, exhaustion, or coma
• PEF <33% of predicted/best after initial treatment 2

Management Algorithm

Moderate Asthma Management

1. Initial Treatment:

   • Nebulized salbutamol 5 mg or terbutaline 10 mg 2, 1
   • If no nebulizer available: 2 puffs of β-agonist via large volume spacer, repeated 10-20 times 2

2. Monitor Response after 15-30 minutes:

   • If PEF 50-75% predicted/best: Give prednisolone 30-60 mg
   • If PEF >75% predicted/best: Step up usual treatment 2, 1

3. Follow-up:

   • Monitor symptoms and PEF on chart
   • Provide self-management plan
   • Surgery review within 48 hours
   • Modify treatment according to guidelines for chronic persistent asthma 2

Acute Severe Asthma Management

1. Initial Treatment:

   • Oxygen 40-60% if available
   • Nebulized salbutamol 5 mg or terbutaline 10 mg (oxygen-driven nebulizer if possible)
   • Prednisolone 30-60 mg orally or intravenous hydrocortisone 200 mg 2, 1
   • Consider nebulized or subcutaneous ipratropium 0.5 mg 1

2. Monitor Response after 15-30 minutes:

   • If signs of acute severe asthma persist:
     • Arrange hospital admission
     • Repeat nebulized bronchodilator
     • Add ipratropium 0.5 mg if not already given 2, 1

3. Hospital Management:

   • Continue oxygen therapy to maintain saturation >90%
   • Repeat nebulized bronchodilators every 15-30 minutes as needed
   • Consider IV magnesium sulfate 2g over 20 minutes for refractory cases 1
   • Monitor vital signs, PEF, and blood gases 3

4. ICU Transfer Criteria:

   • Deteriorating PEF
   • Worsening exhaustion
   • Persistent hypoxia or hypercapnia
   • Confusion, drowsiness, or coma 2

Hospital Admission Criteria

Admit to Hospital if:

• Any life-threatening features present
• Features of acute severe asthma persist after initial treatment
• PEF <33% of predicted/best after treatment 2

Lower Threshold for Admission if:

• Attack occurs in afternoon or evening
• Recent nocturnal symptoms
• Recent hospital admission or previous severe attacks
• Patient concern or inability to assess own condition
• Poor social circumstances 2

Discharge Criteria

Patients should only be discharged when:

• On discharge medication for 24 hours
• Inhaler technique checked and recorded
• PEF >75% of predicted/best with diurnal variability <25%
• Treatment includes steroid tablets and inhaled steroids
• Patient has own PEF meter and self-management plan
• GP follow-up arranged within 1 week
• Hospital follow-up within 4 weeks 2, 1

Common Pitfalls and Caveats

1. Underestimation of Severity:

   • Always regard each emergency consultation as potentially acute severe asthma until proven otherwise 2
   • Physicians' subjective assessments of airway obstruction are often inaccurate 4

2. Delayed Corticosteroid Administration:

   • Administer corticosteroids early as benefits may not occur for 6-12 hours 4
   • Underuse of corticosteroids is a common factor in asthma deaths 2

3. Inappropriate Discharge:

   • Ensure patients meet all discharge criteria before leaving hospital
   • Approximately 50% of acute episodes are attributable to upper respiratory infections; consider this in follow-up planning 4

4. Medication Dosing:

   • High-dose corticosteroids (>80 mg/day methylprednisolone) do not appear to offer therapeutic advantage over lower doses 5
   • Continuous or frequent nebulized SABA therapy is more effective than intermittent dosing for severe exacerbations 6

By following these guidelines, clinicians can appropriately differentiate between moderate and acute severe asthma and implement the correct management strategy to reduce morbidity and mortality.