Initial Management of Acute Asthma with Hyperglycemia
The initial management for a patient presenting with acute asthma and hyperglycemia should focus on treating the asthma with high-flow oxygen, nebulized beta-agonists, and systemic corticosteroids while monitoring blood glucose levels. 1, 2
Assessment of Asthma Severity
- Evaluate for features of severe asthma: inability to complete sentences in one breath, respiratory rate >25/min, pulse >110/min, and peak expiratory flow (PEF) <50% of predicted 1
- Look for life-threatening features: PEF <33% of predicted, silent chest, cyanosis, bradycardia, hypotension, exhaustion, confusion, or coma 1, 2
- Measure oxygen saturation via pulse oximetry to guide oxygen therapy 1
Initial Asthma Treatment
- Administer high-flow oxygen (40-60%) via face mask to maintain SaO₂ >92% 1, 2
- Give nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
- Administer systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg intravenously 1
- Consider adding ipratropium bromide 0.5 mg to the nebulizer for severe exacerbations 1, 2
Monitoring Response to Treatment
- Repeat PEF measurement 15-30 minutes after starting treatment 1
- Monitor oxygen saturation continuously to maintain SaO₂ >92% 1
- Chart PEF before and after administering nebulized beta-agonists 1
- If not improving after 15-30 minutes, give nebulized beta-agonists more frequently (every 15-30 minutes) 1
Managing Hyperglycemia
- Monitor blood glucose levels regularly during treatment 3, 4
- Be aware that both beta-agonists (salbutamol/terbutaline) and systemic corticosteroids can cause hyperglycemia, with beta-agonists having a more immediate effect 3, 5
- For patients with significant hyperglycemia (>8.4 mmol/L or >150 mg/dL), consider insulin therapy 4
- For severe hyperglycemia or known diabetics, intravenous insulin infusion may be required to maintain glucose between 4.5-7.2 mmol/L (81-130 mg/dL) 4
Important Considerations and Pitfalls
- Do not delay asthma treatment due to hyperglycemia; treat the acute respiratory condition first 1, 2
- Avoid sedatives of any kind in patients with acute asthma 1
- Consider chest radiography to exclude pneumothorax or other complications 1
- Be aware that hyperglycemia during asthma exacerbation is associated with longer hospital stays and may require specific management 4, 6
- For patients with severe or life-threatening features not responding to initial treatment, prepare for possible ICU transfer 1
Follow-up Management
- Continue monitoring both respiratory status and blood glucose levels 1, 4
- If the patient is improving, continue oxygen, prednisolone 30-60 mg daily, and nebulized beta-agonist every 4-6 hours 1
- For persistent hyperglycemia, adjust insulin therapy based on regular glucose monitoring 4
- Be aware that hyperglycemia typically resolves as the acute asthma exacerbation improves and medication doses are reduced 3