Welcome back to emergency medicine video. In this section, we will discuss the treatment for asthma in the emergency department. We should avoid hypoxia in asthma patients. We need to give them oxygen to maintain their saturation above 92%. And as with all emergency department patients, if they are hypotensive, they should be given fluids. And now we move on to more specific treatment. Rapidly acting beta-2 agonists are the mainstay of treatment for acute asthma. They work by bronchodilation. The most often used one is salbutamol. It comes in different formulations, nebulizers, multi-dose inhaler, and in some countries an IV form. For mild to moderate asthma, multi-dose inhaler alone is good enough for treatment. For severe asthma patient, since they may not be able to coordinate their breath with a multi-dose inhaler, nebulizers is the more appropriate choice. In countries where IV form salbutamol is available, it's often also given with patients in severe asthma. One nebulized dose of salbutamol is equivalent to four to six puffs by the multi-dose inhaler. In patients who have a severe asthma exacerbation, three doses should be given back-to-back, that is continuously without any pause between treatment. In those who are in mild on moderate exacerbation, the doses can be given every 20 minutes to 40 minutes depending on how sick the patient is. In terms of side effects, the major side effects of salbutamol is tachycardia. This is usually well tolerated by patients. The second side effects is hypokalemia. You might recall that salbutamol puffers is one of the treatment for hypokalemia. In patients who have had a lot of salbutamol puffers treatment, you might wish to draw another set of electrolytes to check for it. Anticholinergics are used since they have bronchodilating property. The one that's used most often is epitropium. It can be given via nebulizer or puffers. Again, MDIs can be used in patients with mild to moderate asthma exacerbation who can currently their breaths. While the nebulized version is used in patients with severe attack. Epitropium is given in conjunction with salbutamol in the first three rounds of treatment. In sick patients, they're given back-to-back. In mild to moderate patients, they're given every 20 to 40 minutes depending on the severity. Epinephrine is given to the patient if the asthma is triggered by an allergic reaction. Epinephrine also has bronchodilator effects. It can also be used as a vasopressor to increase the patient's blood pressure after adequate IV fluid resuscitation. Steroids decrease the airway inflammation and edema. It can be given as IV or PO. The IV form should be given in patients only if they cannot tolerate PO intake. A usual choice is IV hydrocortisone 100 to 200 milligrams. In terms of PO, either prenazone or prenazolone 50 milligrams is given. In some centers, dexamethasone is given instead. That all depends on your local practice. Antibiotics should only be given to patients with a documented pneumonia on the chest x-ray. The next few treatment targets in the patients with severe asthma exacerbations. Magnesium is a smooth and rustic relaxant and can increase bronchodilation. 2 grams IV is given over 30 minutes. What about non-invasive positive pressure airway ventilation such as BIPAP? Even though there have not been large randomized trials looking at BIPAP in patients with asthma exacerbation, there has been some promising results in small series. The use depends on your local practice again. Lastly, intubation and mechanical ventilation. Patients should be intubated if they have decreased level of consciousness, tiring out, or have gone into cardiac or respiratory arrest. The intubated asthmatic patient is a very complicated patient. It is beyond the scope of our discussion here. However, there will be some extra resources on the page should you be interested. Let's say we're treating our patients and they are feeling better. Who gets to go home? The patient needs to be in no respiratory distress, and on their last FEV1 have more than 75% of the expected number. This also has to be at least two hours since the last treatment with a bronchodilator. In terms of discharge medication, the patient goes home with a subutomal puffer. It's best to be used with an arrow chamber. The patient is instructed to take one to two puffs every four hours. The patients also send home on steroids. Either penicillin or penicillin 50 mg for another four days to make up for a total of five days of treatment, or one more dose of dexamethasone 16 mg. If that's what they've been given when they're in the emergency department. Clearly, the patient should be instructed to come back should they feel worse in any way. In summary, we discussed the different treatment options available for asthma exacerbations. Let's see if we can review them. We start with oxygen IV fluids, then go into subutomal either with nebulizers or MDIs. For the first three treatments with subutomal, we add an epitropium, either nebulizers or through MDI puffers. Steroid is given. Epinephrine is given if the patient is triggered by an allergy or is still in hypotension after adequate IV fluid resuscitation. In sick patients, magnesium should be given. And in those not responding, either non-invasive positive pressure ventilation like a BiPAP or intubation with mechanical ventilation should be used. We hope you find this useful. Thank you for watching.