Status Asthmaticus Guidelines

While there are no specific guidelines for managing status asthmaticus, the use of beta-agonists (via inhalation nebulizer or intravenous treatment), intravenous corticosteroids, and, in extreme cases, mechanical ventilation have been alluded to in previous sections.

The most important guideline is prevention. Adherence to the guidelines of the National Heart-Lung and Blood Institute in the management of asthma in an outpatient setting results in future prevention of recurrent attacks of status asthmaticus. This has been studied by Miller at al [72] ; adherence to an asthma protocol resulted in less usage of rescue bronchodilator and systemic corticosteroid therapy.

In 2023 the Global Initiative for Asthma (GINA) published guidelines for the management of difficult-to-treat and severe asthma which stress the importance of distinguishing between severe asthma and uncontrolled asthma, as the latter is a much more common reason for persistent symptoms and exacerbations, and it may be more easily improved. The most common problems that need to be excluded before a diagnosis of severe asthma can be made are the following [84] :

Poor inhaler technique Poor medication adherence

Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as upper airway dysfunction, cardiac failure, or lack of fitness

Comorbidities and complicating conditions such as rhinosinusitis, gastroesophageal reflux, obesity, and obstructive sleep apnea

Ongoing exposure to sensitizing or irritant agents in the home or work environment.

GINA recommends optimizing management and reviewing the response at three to six months. Optimization measures include [84] :

Asthma self-management education with referral to an asthma educator, if available Check inhaler technique and address any adherence issues Consider life-style interventions such as smoking cessation, healthy diet, exercise, weight loss Treat comorbidities and an identified modifiable risk factors

Consider adding non-biologic medications such as long-acting beta2-agonist (LABA) bronchodilator to medium/high doses of ICS

If asthma is still uncontrolled after 3-6 months, referral to a specialist or severe asthma clinic is recommended. [84]

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Media Gallery

Figure depicting antigen presentation by the dendritic cell, with the lymphocyte and cytokine response leading to airway inflammation and asthma symptoms.