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1 CG02 VERSION 1.0 1/8 Guideline ID CG02 Version 1.0 Title Approved by Acute Exacerbation of Asthma: Discharging Patients On-scene Clinical Effectiveness Group Date Issued 01/01/2013 Review Date 31/12/2016 Directorate Authorised Staff Clinical First Responder Ambulance Care Assistant Student Paramedic Advanced Technician Paramedic (non-ecp) Nurse (non-ecp) ECP Doctor Clinical Publication Category Guidance (Green) - Deviation permissible; Apply clinical judgement 1. Scope 1.1 This guideline outlines the assessment and management of patients who are discharged on-scene following an acute exacerbation of asthma. 2. Background and Definitions Million people in the UK are affected by Asthma. Three people die every day and thousands more are hospitalised following an acute exacerbation. 1 However, many asthmatics know their condition well and can ly manage it without the need for routine admission. The guidance aligns Trust practice with the British Thoracic Society Asthma recommendations for the management of acute asthma. 2.2 Asthma is a respiratory disease characterised by significant variations in air flow resistance over short periods of time. Wheezing, breathlessness and a reduction in airflow occur due to episodes of reversible bronchospasm, increased mucous secretion and mucosal oedema The asthmatic response can be divided into an early phase which begins up to an hour after exposure to a trigger antigen, and a late phase which occurs approximately four to eight hours later. 4

2 CG02 VERSION 1.0 2/8 2.4 In the early phase, an antigen to which the bronchial mucosa has previously been sensitised contacts the mucosal surface, mast cells release antibody mediators which open mucosal intercellular junctions, allowing further penetration of the antigen. The parasympathetic nervous system is also involved in bronchoconstriction. Branches of the vagus nerve terminate in the bronchial walls, and release acetylcholine, causing smooth muscle contraction and mucosal hyper-secretion. 2.5 An array of other mediators are also released, causing the late inflammation phase. Leukotrienes promote prolonged bronchoconstriction and increase mucosal secretion. Prostaglandin causes bronchoconstriction and histamine is released. 3. Guidance 3.1 Assessment All asthmatic exacerbations must be assessed according to JRCALC guidance 5, with a prompt CABCD assessment to evaluate the severity of the episode. A comprehensive health history should be elicited; a comprehensive history is as important as physical findings. Consideration must be given to suitable patient positioning and preparation of a light, quiet, private environment for examination, wherever possible. The patient s chest will need to be sufficiently exposed to enable a correct diagnosis to be made The most common symptom is breathlessness, and there is more likely to be a sensation of difficulty in expiration than inspiration. Some patients are sensitive to physiological changes, whilst others have no appreciation, and will complain of few symptoms until they develop a severe attack. 3 Exacerbations of asthma are generally classified as either mild to moderate, severe or life-threatening (Table 1). 2,5 A patient is considered to fulfill a category if they have one or more of the signs/symptoms listed.

3 CG02 VERSION 1.0 3/ Table 1 - Asthma Severity: Mild to Moderate Severe Life Threatening Peak flow > 50-75% best or predicted Increasing symptoms No features of acute severe asthma PEF 33-50% best or predicted Respiratory rate >25/min (adult) Heart rate >110/min (adult) PEF <33% best or predicted Poor respiratory effort Arrhythmias SpO 2 <92% Cyanosis Inability to complete sentences in one breath Silent chest Hypotension Altered conscious level Exhaustion The respiratory assessment must include: Inspection - Comprehensive visual assessment; Palpation - Comprehensive assessment using touch; Percussion - Striking the chest to determine the state of underlying tissues; Auscultation - Listening to and interpreting sound transmission through the chest wall via a stethoscope; Peak expiratory flow rate (PEFR) where the patient is able to provide one; Pulseoximetery; Capnography (where available) The speed of onset of an acute attack varies; although severe episodes may develop over a period of minutes without warning, there is more often a background of deterioration over days or weeks. 4 Increasing use of bronchodilator inhalers or finding that they are less than normal are a good early guide to developing problems in older patients Differential Diagnosis The signs and symptoms of asthma are very similar to a variety of other medical conditions; not all that wheezes is asthma. Differential diagnoses include: Chronic obstructive pulmonary disease (COPD);

4 Pulmonary embolism; Heart failure; Airway obstruction; Respiratory Infection; Idiopathic hyperventilation syndrome; Laryngeal tracheal obstruction (e.g. croup). CG02 VERSION 1.0 4/ Check for the presence of the patient s asthma plan, as this may provide useful additional information. 3.3 Treatment The initial acute exacerbation of asthma must be managed according to JRCALC guidelines. The use of the T-piece should be considered for life-threatening asthma which meets the criteria detailed in Trust Clinical Guideline CG22 - T-Piece Nebulisation. Patients experiencing a life-threatening attack must be admitted to hospital Patients experiencing a mild to moderate or severe attack where signs and symptoms resolve following treatment with a nebuliser, may be safe to remain on-scene, provided that their final peak flow is greater than 75% of their best or predicted reading. The assessment algorithm is detailed in Appendix Confidential enquiries into over 200 asthma deaths in the UK concluded there are factors associated with the disease, the medical management and the patient s behaviour or psychosocial status which significantly increase the chance of dying following an exacerbation of asthma. The most important are detailed below, and considered as Asthma Red Flags : 2 Still have significant symptoms; Concerns about compliance (with treatment regime); Living alone or socially isolated; Psychological problems; Physical disability or learning difficulties; Previous near fatal or brittle asthma; Exacerbation despite adequate dose steroid tablets pre-presentation (current steroid use); Presentation at night; Pregnancy If no red flags are present the patient may be discharged on-scene. If any of the above red flags are present, advice regarding admission must be sought from an ECP or Doctor. If the consulted healthcare professional is in agreement with the ambulance clinician, the patient may be discharged on-scene. If advice cannot

5 be sought, the patient must be admitted. CG02 VERSION 1.0 5/ All patients who fulfill the requirements to be discharged on-scene detailed in the algorithm (Appendix 1) and also meet the criteria for its supply under the PGD must be supplied with oral prednisolone, unless they have already been prescribed the course Upper respiratory infections which affect the upper airways, are often caused by cold and flu viruses and are a common trigger of asthma. The patient should be referred to their GP or an ECP for consideration of antibiotic therapy where the acute exacerbation is thought to have an infective origin. 3.4 Prednisolone Referral packs containing a staff leaflet, patient information leaflet and a course of prednisolone must be made available on all ambulance vehicles When a course of the corticosteroid prednisolone is commenced following an exacerbation of asthma, it helps to reduce the inflammatory response, reducing oedema and secretion of mucus into the airway by blocking the action of prostaglandins and suppressing the immune system. 3 Use of corticosteroids within 1 hour of presentation significantly reduces: The need for hospital admission 7 ; The number of relapses to additional care 7 ; Beta-agonist use without increases in side effects 8, Studies have shown that patients who do not receive corticosteroids in the first instance of presenting with an acute exacerbation of asthma have: A much higher risk of relapse within the following 6hrs 7 ; An increased risk of re-occurrence up to 7-10 days later 10 ; An increased likelihood of a more severe attack Patients must be assessed against the Trusts PGD for prednisolone, with a course of prednisolone supplied where indicated. 4. Episode Closure 4.1 It is important to inform the patient and/or their carer to continue to take any medication provided by their GP practice. All patients must be supplied with the asthma patient leaflet, with patients supplied with prednisolone also receiving the prednisolone patient information leaflet. The patient must be left with a copy of the PCR.

6 CG02 VERSION 1.0 6/8 4.2 The patient s GP should be notified of the incident to inform future management. 5. Documentation 5.1 In line with Trust Policy, a Patient Clinical Record must be completed and annotated appropriately, with the supply of prednisolone recorded within the drugs section. Any deviation from this guideline must be recorded, with any potential or actual adverse event reported through the incident reporting system. 6. References 1. Asthma UK. [01/10/12]. 2. British Thoracic Society (2012) British Guideline on the Management of Asthma: A national clinical guideline. British Thoracic Society & Scottish Intercollegiate Guidelines Network. 3. Rees J. and Kanabar D. (2010) ABC of Asthma. 6th Ed. Blackwell Publishing. Oxford. 4. Lumb A. (2010) Nunn s applied Respiratory Physiology. 7th Ed. Butterworth Heinemann. Italy. 5. Joint Royal Colleges Ambulance Liaison Committee Pre-Hospital Guidelines. JRCALC. 6. Price P, Foster J, Scullion J. and Freeman D. (2004) Asthma and COPD. Churchill Livingstone. Edinburgh. 7. Rowe B.H, Spooner C.H, Ducharme F.M, Bretzlaff J.A and Bota G.W. (2004) Corticosteroids for preventing relapse following acute exacerbations of asthma (Cochrane Review), The Cochrane Library, Issue , Chichester, UK: John Wiley & Sons, Ltd. 8. Rowe B.H, Spooner C, Ducharme F.M, Bretzlaff J.A. and Bota G.W. (2004) Early emergency department treatment of acute asthma with systemic corticosteroids (Cochrane Review). The Cochrane Library, Issue 1, Chichester, UK: John Wiley & Sons, Ltd. 9. Edmonds M.L, Camargo C.A Jr, Pollack C.V Jr and Rowe B.H. (2004) Early use of inhaled corticosteroids in the emergency department treatment of acute asthma (Cochrane Review). The Cochrane Library, Issue 1, Chichester, UK: John Wiley & Sons, Ltd.

7 CG02 VERSION 1.0 7/8 10. Fiel S.B, Swartz M.A, Glanz K. and Francis M.E. (1983) Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma. American Journal of Medicine, 75. (2)

8 CG02 VERSION 1.0 8/8 Appendix 1 - Assessment Algorithm Presenting with Life threatening asthma? PEF < 33% YES Give oxygen and bronchodilator YES PEF >75%? NO NO PEF between 33-75% Treat according to JRCALC guidelines Noticeable improvement and PEF>75%? YES Still have concerns about patient? NO YES Transport to ED Follow JRCALC guidelines NO Treat and refer Supply prednisolone according to PGD Refer to GP Provide patient information leaflet/s Red Flag Concerns Include: Still have significant symptoms Concerns about compliance (with treatment regime) Living alone or socially isolated Psychological problems Physical disability or learning difficulties Previous near fatal or brittle asthma Exacerbation despite adequate dose steroid tablets pre-presentation (current steroid use) Presentation at night Pregnancy