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Therapeutic approach to bronchospasm and asthma 

Therapeutic approach to bronchospasm and asthma
Therapeutic approach to bronchospasm and asthma

Brett G. Sampson

and Andrew D. Bersten

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date: 23 February 2020

The optimal management of bronchospasm and acute asthma is reliant upon confirmation of the diagnosis of asthma, detection of life-threatening complications, recognition of β‎2 agonist toxicity, and exclusion of important asthma mimics (such as vocal cord dysfunction and left ventricular failure). β‎2 agonists, anticholinergics, and corticosteroids are the mainstay of treatment. β‎2 agonists should be preferentially administered by metered dose inhaler via a spacer, and corticosteroids by the oral route, reserving nebulized (and intravenous) salbutamol, as well as intravenous hydrocortisone, for situations when these routes are not possible. A single intravenous dose of magnesium may be of benefit in severe asthma, but repeat dosing is likely to cause serious side effects. Parenteral administration of adrenaline may prevent the need for intubation in the patient in extremis. Aminophylline has an unfavourable side effect profile and has not been shown to offer additional benefit in adults. However, it does have a role in paediatric asthma. Unproven medical therapies with potential benefit include ketamine, heliox, inhalational anaesthetics, and leukotriene antagonists. The need for ventilatory support is usually preceded by worsening dynamic hyperinflation, exhaustion, hypoxia, reduced conscious state, or a combination of these. While non-invasive ventilation may have a temporizing role to allow time for response to medical therapy, there is insufficient evidence for its use, and should not delay invasive ventilation. If invasive ventilation is indicated, a strategy of hypoventilation and permissive hypercapnoea, minimizes barotrauma and dynamic hyperinflation. Extracorporeal support may have a role as a rescue therapy.

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