1947 Title: Clinical Protocol for the initial emergency management of Asthma Document Owner: Deirdre Molloy Document Author: Deirdre Molloy Presented to: Care & Clinical Policies Date: August 2015 Ratified by: Care & Clinical Policies Date: August 2015 Review date: August 2017 Links to other policies: 1. Purpose of this document - This clinical protocol provides a clear framework for nurses employed by Torbay & Southern Devon Health & Care Trust when providing initial emergency management of Asthma in adults and children presenting to the Minor injury Units. 2. Scope of the Policy: This protocol is for the use by Minor Injury Unit staff employed by Torbay and Southern Devon Health Care Trust who has achieved the agreed Trust clinical competencies to work under this protocol 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Breathlessness, wheeze, cough, chest tightness, inability to complete sentences, cyanosis, use of accessory muscles, tracheal /deviation, arrhythmia, hypotension, exhaustion, confusion, altered conscious level. 3.2 History: refer to protocol for History taking and Clinical Documentation Specific History; Onset and duration of symptoms Personal/family history of Asthma. Worsening after use of Aspirin, Non- steroidal anti -inflammatory drugs, Beta Blockers. Recognised triggers/exposure pollen, dust, animal, exercise, viral infections, chemicals, irritants. Environmental changes e.g. cold or damp air. Near fatal asthma e.g. ventilation. Previous admissions in last year. Requiring 2 or more classes of asthma medication. Increases heavy use of inhalers. Repeat Emergency Department attendance in last year. Non- compliance with medication Past medical history. 4. Clinical Examination: Version 1.1 Page 1 of 8
4.1. Look/Inspect (expose chest and abdomen particularly in children whilst maintaining patient s dignity). General appearance pallor, malaise, breathlessness. Use of accessory muscle. Sternal recession, tracheal tug/deviation. Breathing difficulties/abnormalities. Auscultate: where competent Vesicular/bronchia breathing. Wheeze, crackles. 4.2. Clinical Observations 5. Treatment Pulse, respirations, blood pressure, oxygen saturations, peak flow, temperature. 5.1 Initial emergency management of acute severe asthma in adults (British Thoracic Guideline for Asthma 2014- management of acute severe asthma in adults in general practice) please refer to flow chart A 5.2 Initial Emergency management of acute severe asthma in children 2 5 years of age (British Thoracic Guideline for Asthma 2014- management of acute severe asthma in children in general practice) please refer to flow chart B 5.3 Initial Emergency management of acute severe asthma in children over 5 years of age (British Thoracic Guideline for Asthma 2014- management of acute severe asthma in children in general practice) please refer to flow chart C 5.4 Initial emergency management of acute severe asthma in Infants aged < 2 years of age in a hospital setting. (British Thoracic Guideline for Asthma 2014- management of acute severe asthma in infants aged < 2years) please refer to flow chart D Version 1.1 Page 2 of 8
Flow chart A MANAGEMENT OF ACUTE SEVER ASTHMA OF ADULTS IN GENERAL PRACTICE Moderate Asthma Acute Severe Asthma Life threatening Asthma Initial Assessment PEF > 50% -75% best or predicted PEF 33%-50% best or predicted PEF < 33% best or predicted Further Assessment SpO2 92% Speech normal Respirations<25 breaths/min Pulse< 110 beats/min SpO2 92% Can t complete sentences Respirations_> 25 breaths/min Pulse >110 beats /min Spo2 < 92% Silent chest, cyanosis, or poor Respiratory effort Arrhythmia or hypotension Exhaustion, altered consciousness Management Treat locally Assess response to treatment Consider admission Refer to duty GP or ED Arrange 999 Emergency admission Treatment B2 bronchodilator Via spacer (give 4 puffs initially and give a further 2 puffs every 2 minutes according to response up to a maximum of 10 puffs). If PEF > 50-75% predicted/best Nebuliser (oxygen driven) Salbutamol 5mg Give prednisolone 40mg Continue or step up usual treatment If good response to first aid treatment (symptoms improved, respirations and pulse settling and PRF > 50%) continue or step up usual treatment and continue prednisolone 40mg for 5 days Oxygen to maintain SpO2 94-98% B2 bronchodilator Nebuliser (oxygen driven) Salbutamol 5mg Or Via spacer (give 4 puffs initially and give a further 2 puffs every 2 minutes according to response up to a maximum of 10 puffs) Prednisolone 40-50mg or IV hydrocortisone 100mg (prescribed) If no response in acute severe asthma: Admit Repeat Salbutamol 5mg where awaiting transfer Oxygen to maintain Spo2 94-98% B2 Bronchodilator and ipratropium Nebulise (oxygen driven) salbutamol 5mg and ipratropium 0.5mg) Or Via spacer (give 4 puffs initially and give a further 2 puffs every 2 minutes according to response up to a maximum of 10 puffs) Prednisolone 40-50mg or IV hydrocortisone 100mg (prescribed) Refer to GP fro same day review if stable; otherwise Admit to hospital if any: Life threatening features. Features of acute severe asthma present after initial treatment. Previous near fatal asthmas. If admitting patient to hospital Stay with patient until ambulance arrives Repeat B2 Bronchodilator (salbutamol 5mg) via nebuliser (oxygen driven) for severe asthma. If condition deteriorates to life threatening treat accordingly Monitor patient until ambulance arrives. Repeat B2 Bronchodilator (salbutamol 5mg) via nebuliser (oxygen driven) Version 1.1 Page 3 of 8
Flow Chart B Management of acute asthma in children aged 2 5 years ASSESS ASTHMA SEVERITY Moderate asthma SpO2 > 92% Able to talk Heart rate 140/min Respiratory rate 40/min Severe exacerbation SpO2 < 92% Too breathless to talk Heart rate > 140/min Respiratory rate > 40/min Use of accessory neck muscles Life Threatening Asthma SpO2 < 92% plus any of: Silent chest Poor respiratory effort Agitation Altered conscious level Cyanosis Treatment & management *B2 agonist 2-10 puffs via space +/- facemask (given one puff at a time inhaled separately using tidal breathing) *Give one of B agonist every 30 60 seconds up to 10 puffs according to response *Consider soluble prednisolone 20mg *Oxygen via face mask 10 puffs of B2 agonist Or nebulised salbutamol 2.5mg *Soluble prednisolone 20mg Assess response to treatment 15 mins. after B2 agonist If poor response arrange 999 ambulance and repeat B2 agonist Arrange 999 ambulance Oxygen via facemask Nebulise - Salbutamol 2.5mg or + - Ipratropium 0.25mg Soluble prednisolone 20mg or IV hydrocortisone 50mg (prescribed) Repeat B2 agonist via oxygen driven nebuliser whilst waiting 999 transfer Refer to GP for immediate/urgent review or Emergency department for further management Good response: Refer to duty doctor/emergency department for further management Poor response: Transfer as 999 to Emergency department Transfer as 999 to Emergency department Version 1.1 Page 4 of 8
Flow Chart C MANAGEMENT OF ACUTE ASTHMA IN CHILDREN > 5YEARS ASSESS ASTHMA SEVERITY Moderate Exacerbation SpO2 92% PEF 50 % best or predicted Able to talk Hear rate 125/min Respiratory rate 30/min Severe exacerbation SpO2 < 92% PEF 33-50 % best or predicted To breathless to talk Heart rate 125/min Respiratory rate > 30/min Use of accessory neck muscles Life Threatening SpO2 < 92% PEF < 33% best or predicted Silent chest Poor respiratory effort Agitation Altered conscious level Cyanosis Treatment & management *B2 agonist 2-10puffs via spacer and mouthpiece(given one puff at a time inhaled separately using tidal breathing) *Give one puff of B2 agonist every 30 60 seconds up to 10 puffs according to response. Consider soluble prednisolone 30-40 mg *Oxygen via face mask *Give 10 puffs of B2 agonist or Nebulised salbutamol 5mg Soluble prednisolone 30-40 mg Assess response to treatment 15 minutes after B2 agonist If poor response arrange 999 ambulance and repeat B2 agonist nebulised, if poor response include 0.25mg nebulised ipratropium bromide Oxygen via face mask Nebulise - Salbutamol 5mg or + - Ipratropium 0.25mg Soluble prednisolone 3 0-40 mg or IV hydrocortisone 100mg (prescribed) Repeat B2 agonist via oxygen driven nebuliser whilst awaiting 999 transfer Refer to duty GP immediate/urgent review or Emergency department for further management Good response: Refer to duty GP/Emergency department for further management Poor response: Transfer as 999 to Emergency department Transfer as 999 to Emergency department Version 1.1 Page 5 of 8
Flow Chart D MANAGEMENT OF ACUTE ASTMA IN INFANTS < 2yrs of age ASSESS and REFER all children under the age of 2yrs to the duty GP where available or refer direct to the Emergency Department via 999 ambulance. Assess asthma severity Moderate Spo2 92% Audible wheezing Using accessory muscles Still feeding Severe Spo2 < 92% Cyanosis Marked respiratory distress Too breathless to feed Most infants are audibly wheezy with intercostal recession but not distressed. Life threatening features include apnoea, bradycardia and poor respiratory effort Initiate treatment whilst waiting for emergency Medical or 999 ambulance support Initial Treatment Oxygen via close fitting mask of nasal prongs to achieve normal saturations Give B2 agonist salbutamol up to 10 puffs via spacer or nebulised salbutamol 2.5 mg as per Patient Group Direction or nebulised Terbutaline 5mg as per Patient Group Direction. Continuous monitoring of: Heart rate Respiratory rate Pulse rate Oxygen saturation level Version 1.1 Page 6 of 8
6. Documentation 6.1. Clinical records must be written in accordance with Torbay and Southern Devon Health & Care Trust History Taking and Clinical Documentation protocol and the Nursing & Midwifery Council guidelines of records and record management (20010). 6.2. A summary letter of the MIU attendance and the care delivered must also be sent to the General practitioner and also the health visitor if less than 5yrs or school nurse if aged between 5yrs and 16yrs to ensure the central medical record of the patient is accurate. 6.3. For patients being transferred to the Emergency department, ensure notes are completed in a timely manner on shared Symphony IT system. A summary letter will be sent to the General Practitioner in the normal manner. 6.4. For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance record to take with them. A copy will be sent to the General Practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they Have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References Accident & Emergency, theory into practice. Dolan B, Holt L. 2000 Version 1.1 Page 7 of 8
11. Distribution Acute Medical Emergencies, a nursing guide. Harrison R, Daly L. 2000 British National Formulary March 2015 British National Formulary for Children 2015 British thoracic Society Asthma Guidance 2014 Clinical orthopaedic Examination. McRae R. 5 th edition 2004 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Guide to physical examination and History Taking. Bickley 2003 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S. 1999 NHS Devon Protocol for Asthma Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 Torbay Care Trust Protocol for Asthma South & West Devon Formulary www.patient.co.uk Amendment History Issue Status Date Reason for Change Authorised V1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for Asthma V 1.1 Review August 2015 Salbutamol inhaler technique/dose amended to meet BTS 2014 recommendations. Prednisolone 40mg for adults included as TTA D Molloy D Molloy Version 1.1 Page 8 of 8