The intensity of treatment corresponds to the severity of the attack (Fig. 4-9). Mild exacerbations of asthma are treated at home by temporarily increasing the frequency of use of short-acting bronchodilators with or without a course of oral steroids. In this case, a plan of action for asthma helps, and therefore there is no need to involve medical workers in treatment. On the contrary, life-threatening asthma is an emergency medical condition that urgently requires observation in a postoperative ward or ICU. UsingThe following forms of treatment are available. A high flow of O2 should be given immediately to patients: with PSV <50% of the best; with the inability to speak in whole sentences, with a breathing rate> 25 per minute; heart rate> 110 per minute. It is corrected later when the results of O2 saturation become available. Oxygen for exacerbations of asthma: • The therapy is guided by pulse oximetry, if necessary by blood gases (see. “Blood gas composition”). If it is unavailable and the patient has signs of severe asthma, hypoxemia is suggested and oxygen is supplied without waiting for oximetry. • Treatment should begin with high oxygen concentrations. Facial oxygen mask is used to supply oxygen at 40-60% concentration; a mask with an expendable bag is attached when the simple face mask is ineffective. • The goal is to achieve a SaO2 of 94-98%. The inability to reach the level of 92% in any patient indicates life-threatening asthma or the presence of a concomitant complicating pathology. b2-Agonists for exacerbations of asthma: • b2-Agonists, as a rule, quickly eliminate bronchospasm, although repeated doses are often required over a variable period of time. With mild asthma, the patient is treated at home independently. • Typically, b2-agonists are administered in the emergency room or in hospital with a nebulizer. However, it has been proven that in most cases, repeated use of a metered dose inhaler with a large volume spacer works better, with a low incidence of side effects. This is especially true for children, but also proven in adults. However, it should be noted that many of these studies exclude such patients with the most severe seizures and still prefer to use a nebulizer in these cases. The b2-agonist works better with the inhalation route of administration than with the intravenous route, and the use of a metered dose inhaler with a spacer is preferred to a nebulizer (except for life-threatening asthma). • If it is necessary to evaluate nebulized bronchodilators, continuous spraying should be considered. This method uses a nebulizer designed to deliver a uniform constant dose of a b2 agonist (salbutamol 5-10 mg / h). Studies show some advantages over traditional re-bolting. There are reports that “continuous” spraying is misinterpreted as consecutive spray cycles of bolus doses, one after the other without intervals; this is a misapplication of the principle and increases the risk of severe side effects. • Theoretically, it can be assumed that intravenous b2-agonists have advantages in such severe bronchospasm when the airways are completely obstructed, creating an obstacle for access to nebulized or inhaled drugs. In practice, most studies do not support any of the benefits of the intravenous route of administration in severe asthma. Ipratropium for exacerbations of asthma: • It was found that the addition of ipratropium to a b2-agonist via a nebulizer causes significantly greater bronchodilation than only one b2-agonist, and reduces the duration of hospitalization. In mild attacks, the b2-agonist itself causes bronchodilation close to the maximum possible, and the meaning of adding ipratropium is doubtful. Even with more severe seizures, it is unclear the addition of ipratropium is superior to a simple increase in the dose of a b-agonist; such a comparison is not made. A feasible strategy based on the available data is to add ipratropium in case of more severe seizures or with a poor response toinitial b2-agonist therapy. • Adding ipratropium to b2-agonists using a metered dose inhaler plus spacer is also being investigated and appears to be of value, but again no comparison with a higher dose of b-agonist is made. Glucocorticoids for exacerbations of asthma: • Glucocorticoids reduce mortality from acute attacks, accelerate recovery and reduce the risk of relapse. Although they are not necessary for mild exacerbations, the BTS / SIGN Recommendations suggest that they be used for PSV below 75% of what is due (or the best one registered for this patient). In some cases, they should be used as early as possible during an attack. • The effect of corticosteroids develops within a few hours, and the tablets are well absorbed. Therefore, there is no benefit to the intravenous route of administration unless the patient has a high risk of vomiting. • There is theoretical evidence to suggest that inhaled steroids are beneficial when added to oral steroids, but no practical effect of this combination based on the outcome of exacerbations has been found. However, it is good practice to continue using inhaled steroids during exacerbations to emphasize their importance in regular treatment. • The practice of treating mild exacerbations of asthma by temporarily doubling the dose of inhaled corticosteroids is not considered effective. Do not cancel inhaled glucocorticoids when the patient is taking a booster dose of prednisone. This gives the patient a false impression of the importance of inhaled glucocorticoids. Intravenous aminophylline or magnesia for exacerbations of asthma: • Aminophylline causes sharp bronchodilation through various mechanisms characteristic of b2-agonists, ipratropium, and random, clinically beneficial effects of aminophylline are observed in some patients, despite a poor response to inhaled drugs. However, it is difficult to demonstrate the effect of the addition of aminophylline in controlled studies, so such patients are rare. Side effects occur frequently, and therefore, the use of aminophylline is limited to patients with life-threatening asthma who do not respond to the initial treatment. • Potential indications for intravenous magnesia are the same as for aminophylline. Unlike aminophylline, magnesia intravenously in a single bolus dose has an effect in an asthmatic condition, and side effects rarely occur. The effect of magnesia is less pronounced in adults compared with children. In addition, some studies demonstrating the effect of magnesia are not high standard studies, and the effect is not observed in all studies. • Magnesia and aminophylline are not directly compared. Other drugs for asthma exacerbations: • Antibiotics are usually prescribed for patients with asthma exacerbation, who feel that the attack is caused by an infection that “penetrated my chest.” There is no doubt that infections occur in acute asthma, but are almost always viral, not bacterial. Therefore, the standard prescription of antibiotics is not shown, and their use should be the exception rather than the rule. • Heliox (a helium / oxygen mixture containing 70-80% helium) increases inspiratory flow, since reduced gas viscosity (compared to air) reduces turbulent flow. Therefore, Heliox relieves symptoms, although it does not necessarily accelerate the resolution of an asthma attack. To date, there is insufficient data to recommend the standard use of heliox. • Leukotriene receptor antagonists have a proven effect in the treatment of chronic asthma, and their intravenous preparations cause bronchodilation in acute asthma. The product is not licensed for use, and there is not enough data to recommend it.