Status
asthmaticus is a medical emergency in which asthma symptoms are refractory to
initial bronchodilator therapy.
• Patients report:
Rapidly progressive shortness of breath
Dry cough
Wheezing
• Typically patients present a few days after:
Following exposure to a potent allergen or irritant or
Exercise in a cold environment
• Frequently patients have underused or have been under prescribed anti-inflammatory
Causes of Status Asthmaticus
• In persons with acute asthma, bronchospasms occur as a result of one or more inciting
A viral upper or lower respiratory tract infection
Significant allergic response to an allergen such as
Pollen
Mold
Animal dang
House dust mites.
Exposure to an irritant or
Vigorous exercise in a cold environment
Infection
Poor adherence to the medical regimen
Rapid decrease in long-term oral steroid therapy
• Inflammation can be the result of:
Lymphocyte, mast cell, eosinophilic, and neutrophilic responses
Airway epithelial damage
Clinical Features of Status Asthmaticus
• History
days
Patients usually present with audible wheezing
Physical findings
• Patients are usually upon examination and, in early stages of status asthmaticus, may have
• Initially wheezing is heard only during expiration but later wheezing occurs during both
• The chest is hyper expanded and accessory muscles particularly the sternocleidomastoid,
• Later as bronchoconstriction worsens patients' wheezing may disappear which may
• Normally the pulsus paradoxus (i.e. the difference in systolic blood pressure between
• In patients with severe asthma a pulsus paradoxus of greater than 25 mm Hg usually
• Status asthmaticus is a medical emergency, if not managed initially can lead to the need
Differential Diagnoses, Investigations, Treatment, and Complications of
Status Asthmaticus
Differential Diagnoses
• Pulmonary hypertension
• Note: Investigations are available in equipped hospitals and therefore patients may be
be done are outlined below
• Pulse oximetry values should be used to monitor the progression of asthma
Pneumothorax
Congestive heart failure
Signs of chronic obstructive pulmonary disease
• These conditions may complicate patient's response to treatment
• Patients with status, asthmaticus need close monitoring as well as oxygen therapy and
• After confirming the diagnosis and assessing the severity of the asthma attack, direct
• Bronchodilator treatment with Beta-2 Agonists
(Salbutamol).
Handheld nebulizer treatments may be administered either continuously (10-15 mg/h)
or by frequent timing (e.g. q5-20min), depending on the severity of the
bronchospasm.
• Oxygen therapy
• Fluid replacement
sure the patients are not in congestive heart failure
• Antibiotics
Patients are administered antibiotics only when they show evidence of infection such
as pneumonia, sinusitis
• Aminophylline (theophylline)
to medical treatment with bronchodilators, oxygen, corticosteroids, and intravenous
fluids within 24 hours
The loading dose is usually 5-6 mg/kg followed by a continuous infusion of 0.5-0.9
mg/kg/h
Aminophylline has some significant side effects and need to monitor for therapeutic
range
Complications
• Pneumothorax may complicate acute asthma either because of increased airway pressure
• Superimposed infection can also occur in intubated patients.
Drugs for Treatment of Status Asthmaticus
Beta-Adrenergic Agonists Bronchodilators
• Act to decrease muscle tone in both small and large airways in the lungs, thereby increasing
• Relieve reversible bronchospasm by relaxing smooth muscles of the bronchi.
bronchospasm can give 4 puffs every 20 minutes x 3 doses then every 1-4 hours as
needed- need to monitor for tachycardia, hypertension, and agitation.
Nebulizer: Dilute 0.5 ml (2.5 mg) of 0.5% inhalation solution in 1-2.5 ml of NS;
administer 2.5-5 mg diluted in 2-5 ml sterile saline or water ( in the acute situation can
give every 20 minutes for 3 doses) then every 1-6has needed. There is a need to
monitor for side effects of medication as noted (for severe bronchospasm nebulizer
administration is the preferred method)
Pediatric/children dosing will be covered in the pediatric modules
Mast Cell Stabilizers
• These agents prevent histamine release from mast cells following stimuli by specific
• Inhibits degranulation of sensitized mast cells following their exposure to specific
Corticosteroids
• Maintenance medications that decrease inflammatory mediators to limit airway
• Must be taken regularly to be beneficial (for control of asthma). Inhaled steroids are the
bronchospasm.
• Glucocorticoids do not relieve acute bronchospasm and short-acting bronchodilators
• Multiple formulations are available that are not equivalent on a per-dose or per-mcg basis.
• These agents are proven to improve lung function (FEV1 and airway hyperactivity) and
Methylprednisolone (Solu-Medrol)
• Loading dose: 125-250 mg IV
dose quickly as the patient improves to avoid side effects of corticosteroids)
Theophylline (Aminophylline)
• 5mg/kg loading dose (based on aminophylline) IV over 20 min, followed by a maintenance
REFERENCES;
• Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed. Oxford: McGraw Hill
• Davidson, S (2006). Principles and practice of medicine 20th Ed. Churchill: Livingstone.
Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.
• Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold
• Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford
• Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.
• Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF
• Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby
initial bronchodilator therapy.
• Patients report:
Rapidly progressive shortness of breath
Dry cough
Wheezing
• Typically patients present a few days after:
Following exposure to a potent allergen or irritant or
Exercise in a cold environment
• Frequently patients have underused or have been under prescribed anti-inflammatory
Causes of Status Asthmaticus
• In persons with acute asthma, bronchospasms occur as a result of one or more inciting
A viral upper or lower respiratory tract infection
Significant allergic response to an allergen such as
Pollen
Mold
Animal dang
House dust mites.
Exposure to an irritant or
Vigorous exercise in a cold environment
Infection
Poor adherence to the medical regimen
Rapid decrease in long-term oral steroid therapy
• Inflammation can be the result of:
Lymphocyte, mast cell, eosinophilic, and neutrophilic responses
Airway epithelial damage
Clinical Features of Status Asthmaticus
• History
days
Patients usually present with audible wheezing
Physical findings
• Patients are usually upon examination and, in early stages of status asthmaticus, may have
• Initially wheezing is heard only during expiration but later wheezing occurs during both
• The chest is hyper expanded and accessory muscles particularly the sternocleidomastoid,
• Later as bronchoconstriction worsens patients' wheezing may disappear which may
• Normally the pulsus paradoxus (i.e. the difference in systolic blood pressure between
• In patients with severe asthma a pulsus paradoxus of greater than 25 mm Hg usually
• Status asthmaticus is a medical emergency, if not managed initially can lead to the need
Differential Diagnoses, Investigations, Treatment, and Complications of
Status Asthmaticus
Differential Diagnoses
• Pulmonary hypertension
• Note: Investigations are available in equipped hospitals and therefore patients may be
be done are outlined below
• Pulse oximetry values should be used to monitor the progression of asthma
Pneumothorax
Congestive heart failure
Signs of chronic obstructive pulmonary disease
• These conditions may complicate patient's response to treatment
• Patients with status, asthmaticus need close monitoring as well as oxygen therapy and
• After confirming the diagnosis and assessing the severity of the asthma attack, direct
• Bronchodilator treatment with Beta-2 Agonists
(Salbutamol).
Handheld nebulizer treatments may be administered either continuously (10-15 mg/h)
or by frequent timing (e.g. q5-20min), depending on the severity of the
bronchospasm.
• Oxygen therapy
• Fluid replacement
sure the patients are not in congestive heart failure
• Antibiotics
Patients are administered antibiotics only when they show evidence of infection such
as pneumonia, sinusitis
• Aminophylline (theophylline)
to medical treatment with bronchodilators, oxygen, corticosteroids, and intravenous
fluids within 24 hours
The loading dose is usually 5-6 mg/kg followed by a continuous infusion of 0.5-0.9
mg/kg/h
Aminophylline has some significant side effects and need to monitor for therapeutic
range
Complications
• Pneumothorax may complicate acute asthma either because of increased airway pressure
• Superimposed infection can also occur in intubated patients.
Drugs for Treatment of Status Asthmaticus
Beta-Adrenergic Agonists Bronchodilators
• Act to decrease muscle tone in both small and large airways in the lungs, thereby increasing
• Relieve reversible bronchospasm by relaxing smooth muscles of the bronchi.
bronchospasm can give 4 puffs every 20 minutes x 3 doses then every 1-4 hours as
needed- need to monitor for tachycardia, hypertension, and agitation.
Nebulizer: Dilute 0.5 ml (2.5 mg) of 0.5% inhalation solution in 1-2.5 ml of NS;
administer 2.5-5 mg diluted in 2-5 ml sterile saline or water ( in the acute situation can
give every 20 minutes for 3 doses) then every 1-6has needed. There is a need to
monitor for side effects of medication as noted (for severe bronchospasm nebulizer
administration is the preferred method)
Pediatric/children dosing will be covered in the pediatric modules
Mast Cell Stabilizers
• These agents prevent histamine release from mast cells following stimuli by specific
• Inhibits degranulation of sensitized mast cells following their exposure to specific
Corticosteroids
• Maintenance medications that decrease inflammatory mediators to limit airway
• Must be taken regularly to be beneficial (for control of asthma). Inhaled steroids are the
bronchospasm.
• Glucocorticoids do not relieve acute bronchospasm and short-acting bronchodilators
• Multiple formulations are available that are not equivalent on a per-dose or per-mcg basis.
• These agents are proven to improve lung function (FEV1 and airway hyperactivity) and
Methylprednisolone (Solu-Medrol)
• Loading dose: 125-250 mg IV
dose quickly as the patient improves to avoid side effects of corticosteroids)
Theophylline (Aminophylline)
• 5mg/kg loading dose (based on aminophylline) IV over 20 min, followed by a maintenance
REFERENCES;
• Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed. Oxford: McGraw Hill
• Davidson, S (2006). Principles and practice of medicine 20th Ed. Churchill: Livingstone.
Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.
• Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold
• Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford
• Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.
• Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF
• Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby
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