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CO N T I N U I N G P R O F E S S I O N A L D E V E L O P M E N T
4 Page 51 4 Page 52 4 Page 53
Asthma multiple Irene Smith’s practice Guidelines on how to
choice questionnaire profile on back pain write a practice profile

Pharmacological management of
acute asthma exacerbations in adults
NS689 Hazeldine V (2013) Pharmacological management of acute asthma exacerbations in adults.
Nursing Standard. 27, 33, 43-49. Date of submission: October 19 2012; date of acceptance: January 17 2013.

Aims and intended learning outcomes

Abstract
The management of patients who present with
Acute exacerbations of asthma can be life threatening. This article acute severe asthma can be challenging and is
provides an overview of the pathophysiology, diagnosis and management crucial in ensuring positive outcomes. Early
of acute severe asthma in adults. An understanding of the signs and recognition and treatment of acute severe
symptoms of the disorder, and treatment options will ensure rapid decision asthma has a direct effect on mortality and
making when time is crucial during an exacerbation. A proactive approach morbidity rates. This article aims to improve
to managing acute severe asthma may substantially improve patient the healthcare practitioner’s knowledge
outcomes and reduce the need for readmission to hospital. and understanding of the diagnosis and
management of a patient presenting with
Author acute severe asthma in an acute hospital
Victoria Hazeldine setting. After reading this article and
Advanced nurse practitioner, Sheffield Teaching Hospitals, Sheffield. completing the time out activities you should
Correspondence to: [email protected] be able to:
Describe
 the pathophysiology of
Keywords asthma.
Provide
 a definition of an acute exacerbation
Acute asthma, airway inflammation, oxygen therapy, of asthma.
patient assessment, pharmacological therapy Diagnose
 acute severe asthma.
Discuss
 current guidelines for the
Review management of an acute exacerbation
All articles are subject to external double-blind peer review and checked of asthma.
for plagiarism using automated software. Explain
 essential treatment in the
management of patients with acute
Online severe asthma.

Guidelines on writing for publication are available at

www.nursing-standard.co.uk. For related articles visit the archive and Introduction
search using the keywords above. Asthma is a chronic inflammatory airway
disorder that has been increasing in
prevalence over the past decade (Global
Initiative for Asthma (GINA) 2012).
However, in the UK advances in the
recognition and treatment of the condition
have meant that asthma is steadily declining,
although it affects an estimated 3.8 million
individuals (Health and Social Care
Information Centre 2013).

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 Learning zone respiratory disorders

Although there have been major Pathophysiology

advances in the diagnosis and management Asthma is generally described as a disorder
of asthma, exacerbations will always remain characterised by chronic variable airway
a complication. In addition to poor inflammation and airflow obstruction.
concordance with treatment and management During an acute exacerbation of asthma,
of the disease, inadequate recognition and airway inflammation and obstruction
control of an exacerbation of asthma is worsen (British Thoracic Society (BTS) and
associated with high levels of morbidity Scottish Intercollegiate Guidelines Network
and mortality. Despite a reduction in (SIGN) 2012), potentially becoming life
deaths related to asthma in the UK, where threatening. Patients who die during an
approximately three people die from asthma exacerbation of asthma have been found
per day (Asthma UK 2010), early recognition to have grossly inflamed airways. This
combined with effective management of these respiratory functionality rapidly deteriorates
patients can save lives. However, the diagnosis and the airway lumen becomes occluded by
of these patients can present the practitioner mucus plugging composed of plasma proteins
with some difficulty. and glycoproteins. The airway wall then
becomes oedematous and is infiltrated with
TABLE 1 inflammatory cells (Chung et al 2011).
Studies by Brasier et al (2008) and Fitzpatrick
Levels of severity of acute asthma exacerbations
et al (2010), using bronchoalveolar lavage fluid
Severity Signs and symptoms from patients experiencing life-threatening
Near-fatal Raised partial pressure of carbon dioxide and/or asthma, found a large number of eosinophils,
asthma requirement for mechanical ventilation with raised neutrophils and mast cells on examination.
inflation pressures These cells contribute to epithelial damage,
extensive mucus plugging and endothelial
Life-threatening Any one of the following in a patient with
asthma severe asthma: permeability, resulting in severe airway oedema
(Lugogo and MacIntyre 2008).
Clinical signs Measurements Complete time out activity 1
Altered conscious level Peak expiratory flow
<33% best or predicted
Exhaustion Oxygen saturation <92%
Defining asthma exacerbation
According to current guidelines (BTS and
Arrhythmia Partial pressure of
SIGN 2012, GINA 2012), exacerbations of
oxygen <8.0kPa
asthma are defined as episodes of:
Hypotension Normal partial pressure Dyspnoea.

of carbon dioxide Cough.

(4.6-6.0kPa)
Wheezing.

Cyanosis Chest
 tightness.
Silent chest Variable
 airflow obstruction.
Airway
 hyperresponsiveness.
Poor respiratory effort
Or a combination of these signs and
Acute severe Any one of the following: symptoms.
asthma Peak expiratory flow 33-50% best or predicted Some studies (Woodcock 2008, McDonald
Respiratory rate ≥25 breaths/minute
and Gibson 2012) and the BTS and SIGN
Heart rate ≥ 110 beats/minute
(2012) guideline found two main variations
Inability to complete sentences in one breath
in the presentation of asthma exacerbations.
(Adapted from British Thoracic Society and Scottish Intercollegiate Guidelines These are well managed and poorly managed
Network 2012)
exacerbations. Patients who are well managed
maintain regular contact with their GP or
TABLE 2 practice nurse, have up-to-date knowledge
about their peak flow and lung performance,
Conditions related to asthma and associated arterial blood gas analysis
and rarely have exacerbations. In comparison,
Hypoxaemia Partial pressure of oxygen <10kPa those who are poorly controlled prove
Hypocapnia Partial pressure of carbon dioxide <4.7kPa more challenging for practitioners. They
do not maintain regular asthma checks and
Respiratory alkalosis pH >7.45 and partial pressure of carbon dioxide
often have exacerbations. In these patients,
<4.7kPa
exacerbations are more difficult to control

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 and can often lead to severe asthma and an accessory muscles and tachypnoea are useful
increased mortality rate. in increasing ventilation. However, both can
The symptoms displayed by the patient instigate a rise in intrathoracic pressures. Lung
should be quantified by peak expiratory hyperinflation is primarily related to a large
flow (PEF) or forced expiratory volume in increase in expiratory airway resistance. This,
one second (FEV1). These measurements are in turn, results in a short expiratory time.
most useful when there is a documented best The accumulation of air in the lungs increases
reading of PEF or FEV1 for the patient within alveolar pressure and if left untreated can prove
two years of acute presentation (Papiris et al fatal (Papiris et al 2002).
2002). Clinical guidance for the assessment and Tachypnoea, a rise in intrathoracic pressure
management of acute asthma exacerbations and inability to move air out of the alveoli is
is available. BTS and SIGN (2012) detail the generally indicated in patients as the inability to
severity of clinical presentation (Table 1). complete full sentences. This is one of the first
In a multi-centre clinical study by Ramnath signs that a patient is unable to exhale fully and
et al (2007), evidence showed that patients with his or her respiratory rate has increased.
sudden-onset asthma had an increased risk of It is widely documented that there are several
intubation if the correct treatment was not clinical conditions that affect the volume of
started early enough. Papiris et al (2009) found oxygen used in mL/minute (VO2). The work
that morbidity and mortality rates are mainly of breathing alone can increase VO2 by 40%.
related to an underestimation of the severity of The cardiovascular system can assist the
the exacerbation, a delay in referring the patient respiratory system’s demands by increasing
to hospital and/or inadequate emergency heart rate to ensure effective delivery of oxygen
treatment. The significance of early recognition to tissues. However, there can be signs of
of acute severe asthma and effective management right heart strain in some cases, and this can
is paramount to improve patient outcomes. be seen on an electrocardiogram as right axis
Complete time out activity 2 deviation (Papiris et al 2002). Therefore, the
use of a baseline electrocardiogram should be
considered as part of initial assessment.
Diagnosis Arterial blood gas (ABG) analysis can be
The diagnosis of acute severe asthma can useful in the diagnosis and management of 1 Consider the
be challenging for practitioners. The term acute severe asthma. Although ABG analysis physiological changes
acute severe asthma is widely used, relating can seem complicated, there are some key that occur in the lungs
mostly to a combination of presenting signs features that are often seen in acute asthma of a patient with
and symptoms (Papiris et al 2009). The exacerbations (Table 2). One sign that the patient asthma. Describe the
clinical evaluation of a patient presenting with is rapidly deteriorating is when a previously physiological changes
suspected acute severe asthma should be rapid low partial pressure of carbon dioxide (PaCO2) that can occur during an
and thorough. A complete history should be normalises. This could be a sign of fatigue exacerbation of asthma.
taken as soon as possible, including previous in a patient with severe asthma who is now Consider how these
hospital admissions, mechanical ventilation, tiring, and could be a trigger for mechanical changes may appear
comorbidities and medications administered ventilation. Chest radiographs are not useful when recording a
(BTS and SIGN 2012, GINA 2012). in the diagnosis of severe acute asthma as they patient’s observations.
Thorough examination and history taking will generally be normal. However, they are a
should exclude any complicating factors such valuable tool in excluding other complications. 2 Think about
as chronic obstructive pulmonary disease, Another feature of acute asthma exacerbations a patient who has
cardiogenic and non-cardiogenic pulmonary could be flattening of the diaphragm and presented with
oedema, pulmonary emboli, pneumonia, widening intercostal muscles as a result of lung symptoms of an
atelectasis, pneumomediastinum (presence of air hyperinflation (Joarder and Crundwell 2009). exacerbation of asthma.
in the mediastinal tissues) and pneumothorax A set of baseline blood tests should be Look at Table 1 and
(Restrepo and Peters 2008). obtained, including urea and electrolytes, identify which level
Patients with acute severe asthma will magnesium, full blood count, C-reactive of severity applies to
automatically attempt to compensate for protein and clotting screen. Blood tests should the patient. Did you
any airflow obstruction. There are several exclude complicating factors such as anaemia recognise the severity
clinical features that should be viewed as and infection. Electrolyte disturbances such of the exacerbation
warning signs of ventilatory failure. These are as hypokalaemia, hypophosphataemia and immediately and
known as ‘red flags’, and include tachypnoea, hypomagnesaemia can also occur in acute what led you to your
tachycardia, use of accessory muscles severe asthma. Once a full clinical examination conclusions?
during breathing and agitation. The use of is completed, a concise management plan

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should be initiated for the patient. The use This is because of the portability and ease of
of effective treatments, with only minimal use of equipment, and low cost.
time delay, could ensure there is no further
deterioration in the patient’s condition.
Complete time out activity 3 Treatment
The practitioner should have comprehensive
Peak expiratory flow knowledge of BTS and SIGN (2012), and GINA
One of the deciding factors of acute severe (2012) guidelines, as well as the pharmacological
asthma is whether a patient’s PEF is within treatments available. The timely administration
the range of 33-50% of his or her best or of a combination of oxygen, beta2 agonists,
predicted PEF. This, however, is dependent ipratropium bromide and corticosteroids is
on a recorded PEF for the patient being essential to improve patient outcomes. It is
available from within the past two years this aggressive treatment that aids reversibility
(BTS and SIGN 2012). PEF and FEV1 are the of airway symptoms and prevents further
maximum amount of air that can be exhaled deterioration in the patient’s condition.
in one second. The severity of asthma can be Guidelines help to ensure that practice is
classified as a percentage of what the patient’s standardised globally and is evidence based
normal or best PEF or FEV1 is. PEF or FEV1 (BTS and SIGN 2012, GINA 2012). This has
are useful and valid measures of airway meant that, although there are concerns about
calibre (BTS and SIGN 2012). A significant increasing mortality, most patients survive acute
number of patients, however, do not know exacerbations of asthma (McFadden 2003).
what their normal baseline PEF is and they
grossly overestimate it, resulting in early Oxygen therapy
discharge from hospital and possible relapses Although treatment of asthma has improved,
(Asthma UK 2010). the number of deaths caused by asthma was
There are suggestions that a nomogram reported to be approximately 2,387 deaths
prediction tool should be used in such cases. in adults per year between 1994 and 1998,
The prediction tool used at present is based on reducing to an estimated 1,600 deaths in adults
age and height, but does not consider patient in 2000 and approximately 1,200 deaths in
demographics. Work needs to be completed to 2012 (Sturdy et al 2005, Royal College of
establish a more significant and effective tool Physicians 2013).
(Braganza and Thomson 2008). Functional During asthma exacerbations, the
assessments, such as PEF, and serial monitoring increase in intrathoracic pressure forces
of these measures may provide a useful the bronchial lumen to close completely on
objective guide to estimate severity and clinical exhalation, meaning that air can enter but
response to therapy (Papiris et al 2009). cannot escape (Schilling-McCann 2008).
This indicates the importance of obtaining An inhibition of alveolar ventilation creates
a baseline value if possible. a ventilation/perfusion mismatch, causing
Primary care providers continue to ensure hypoxaemia. Hypoxaemia is a low partial
that patients with asthma are educated in the pressure of oxygen or low oxyhaemoglobin
control of symptoms and prevention strategies. saturation. Hypoxaemia is common in a severe
One multi-centre clinical trial by Silverman asthmatic crisis and is easily corrected with
et al (2007) found that the use of spirometry the administration of relatively low
to obtain an FEV1 is accurate and can be concentrations of supplemental oxygen.
easily performed in an emergency department. Hypoxaemia is a preventable cause of deaths
However, patients do not always present in an associated with asthma (Harrison et al 2002).
emergency department, and equipment and The BTS and SIGN (2012) guideline advises
training involved in spirometry mean it is not using oxygen as an initial treatment for all
always a practical measurement. The study patients presenting with acute severe asthma
concluded that FEV1 or PEF should in hospital. However, they do not give specific
be measured on admission and again guidance on the delivery of oxygen for this
15-20 minutes after bronchodilator therapy group of patients. The BTS (2008) developed
during the acute phase (Silverman et al 2007). guidance for the use of oxygen therapy in
Although spirometry is generally preferred emergencies, and this should be followed when
and viewed as an accurate assessment of lung a patient is hypoxic.
function, the most commonly used method is a There is a lack of randomised controlled
serial PEF meter recording in a hospital setting. trials evaluating the use of oxygen in patients

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 with acute asthma and few literature reviews. which device works best are limited, the
However, given that hypoxaemia is a safest choice for severe acute asthma is
preventable cause of deaths related to asthma oxygen-driven nebulisation.
and its pathophysiology, it is vital that oxygen When administering nebulised salbutamol,
is used in the treatment of patients with acute care should be taken to use adequate flow rates.
asthma. The use of inspired oxygen can relieve This is because aerosol particle size depends on
hypoxaemia; however, it does not assist with nebuliser flow rate, among other factors. The
bronchodilation or alveolar ventilation. higher the flow rate, the smaller the particle
Even if a patient with asthma appears to size. Only aerosol particles with a median
have a target oxygen saturation that is >92% diameter of 0.8-3.0 micrometres are deposited
and is breathless, supplemental oxygen should in the small airways and alveoli, whereas larger
be used via nasal cannula at 2-6L/minute or particles are mostly deposited in the pharynx
a venturi mask delivering 35-40% oxygen and upper airway (Papiris et al 2009). Therefore,
(BTS 2008). Guidelines suggest aiming for it is important to check the manufacturers’
target oxygen saturations of 94-98%. Oxygen recommendations for which flow rates should
therapy should be commenced at a flow rate be used with their devices to deliver particle sizes
of 2-6L/minute via nasal cannula or a simple equivalent to 1-3 micrometres.
face mask delivering 5-10L/minute or a venturi Innes et al (2002) undertook a randomised
mask delivering 35-60% oxygen (BTS 2008). controlled trial comparing the dose of
Practitioners should have a good salbutamol administered to those with acute
understanding of how to administer the correct severe asthma in the UK and the United States
amount of oxygen using clinical guidelines for (US). The initial dose was much higher in the US
support. They should also have knowledge of and gave an initial better response with regard
how to monitor the effects of oxygen, deciding to FEV1 than in the UK. However, although
when to decrease or increase oxygen flow to there was a better initial response, there was no
achieve the desired level of saturations (94-98%), real difference in patient outcome and length of 3 David is a 19 year
avoiding hypoxaemia or hyperoxaemia. hospital stay between both countries. old with asthma who
Complete time out activity 4 Debate continues on whether continuous presents to the
or bolus nebulisation should be administered emergency department.
Selective beta2 agonists to those with acute severe asthma. As the admitting nurse,
The most commonly used beta2 agonist in Randomised controlled trials have found that list the signs and
the UK is salbutamol. This agent mediates there was no appreciable difference between symptoms of an acute
bronchodilation via stimulation of beta2 continuous and intermittent nebulisation of asthma exacerbation
receptors on smooth muscle of the airways, in salbutamol in relation to spirometry results, that you might expect to
turn mediating relaxation of these muscles. The clinical symptoms or hospitalisation rates see in David. Are there
BTS and SIGN (2012) guideline recommends (Besbes-Ouanes et al 2000, Rodrigo and any signs and symptoms
that 5mg salbutamol is administered via Rodrigo 2002). The BTS and SIGN (2012) that would be cause for
an oxygen-driven nebuliser within the first guideline suggests that ‘back to back’ or concern? What
five minutes of a patient presenting with continuous nebulisation therapy should be investigations would you
acute severe asthma. Salbutamol should be administered until there are clinical signs carry out and why?
administered repeatedly until the patient shows of improvement. In particular, nebulisation
clinical signs of improvement, at which point it therapy should continue until there is an 4 According to your
can be administered every four hours. increase in PEF to at least 75% of a patient’s local policy for asthma,
Salbutamol can be administered by either normal or best PEF. what documentation
wet/oxygen-driven nebulisation or via a Adverse effects of beta2 agonists in is important when
metered dose/spacer device inhaler. Cates asthma mainly affect the cardiovascular caring for patients
et al (2006), in a systematic review, examined system, commonly reported as tachycardia experiencing asthma
the efficacy of holding chambers (spacers) or arrhythmias (Besbes-Ouanes et al 2000, exacerbations? Consider
versus nebulisers for beta2 agonist treatment Innes et al 2002). Although arrhythmias the importance of
of acute asthma. Only randomised controlled were less common, in some cases so few PEF monitoring, why
trials were selected for the review, and results were seen that they were not reported on. would some patients
suggested that there were no significant Heart rate was documented to slow after not have a baseline
differences between the two delivery two hours of continuous nebulisation back recorded? What factors
methods. It was recommended that the choice to baseline (Rodrigo and Rodrigo 2002). can influence patient
of delivery method should reflect patient Other adverse effects of beta2 agonists concordance with
preference, practice situations and formal include hypokalaemia, tremor and worsening asthma treatments?
economic evaluation. Since data regarding ventilation/perfusion mismatch.

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 Learning zone respiratory disorders

Antimuscarinics should be stopped when the patient shows

The recommended drug of choice to control clinical signs of improvement. A double-blind
exacerbations of asthma in clinical practice is trial of tapering corticosteroids by Barnes
ipratropium bromide. The BTS and SIGN (2012) et al (1998) found that drugs can be stopped
advise that combining nebulised ipratropium abruptly and do not need tapering, following
bromide with a nebulised beta2 agonist produces recovery from an acute asthma exacerbation.
significantly greater bronchodilation than a
beta2 agonist alone, using a dose of 0.5mg Magnesium sulphate
every 4-6 hours in the acute phase. Evidence There is evidence to suggest that magnesium
supports the addition of nebulised ipratropium sulphate has bronchodilator effects in adults
bromide to improve lung function, reduce the (Mohammed and Goodacre 2007). Magnesium
need for additional clinical treatment and reduce sulphate has been shown to have beneficial
subsequent asthma exacerbations (Stoodley et al effects on smooth muscle relaxation and
1999, Rodrigo and Rodrigo 2002). A systematic inflammation (Cairns and Kraft 1996). Rowe
review with meta-analysis confirmed that the and Camargo (2008) carried out a systematic
early administration of inhaled anticholinergic review of the literature, including randomised
agents with beta2 agonists led to a reduction in controlled or quasi-randomised controlled trials,
admission rates of 30% in both children and relating to the efficacy of intravenous magnesium
adults (Rodrigo and Rodrigo 2002). therapy versus placebo in the treatment of
severe acute asthma. They found that, although
Corticosteroids patients did not have any clinical benefit from
Corticosteroids are widely recognised to be the early use of magnesium sulphate, those with
the most potent and effective drugs for the severe acute asthma appear to benefit in terms
treatment of inflammation. Corticosteroids of pulmonary function and reduced hospital
reduce inflammation in asthma, decrease the admissions. In contrast, Silverman et al (2007)
number and sensitivity of beta-adrenergic found that, although there was some clinical
receptors, and inhibit the migration and improvement on administering magnesium
function of inflammatory cells, especially sulphate to patients with acute asthma, hospital
eosinophils (Gibson et al 2001). It has been admission rates did not improve.
identified that corticosteroids reduce mortality, Mohammed and Goodacre (2007) undertook
relapses, subsequent hospital admission and a systematic review and meta-analysis of
requirements for beta2 agonist therapy (BTS randomised and quasi-randomised controlled
and SIGN 2012). The BTS and SIGN (2012) trials of intravenous and nebulised magnesium
recommend that a dose of 40-50mg oral sulphate in patients with acute asthma
prednisolone is given in the first 15 minutes of exacerbations. The analysis suggested that the
a patient presenting at hospital with acute severe BTS and SIGN (2012) guideline is not entirely
asthma. This is because some benefits from consistent with the evidence. Mohammed and
corticosteroid treatment are not usually evident Goodacre (2007) found that evidence for the
5 Consider the
before six to 12 hours (Papiris et al 2002). use of intravenous magnesium sulphate in adults
BTS and SIGN (2012)
Several randomised controlled trials on the is uncertain. Given the low risk of serious side
guideline. When a
use of corticosteroids for severe acute asthma effects from magnesium sulphate, it would
patient presents with
in hospitalised patients were reviewed by seem reasonable to use intravenous magnesium
acute severe asthma,
Manser et al (2008). All trials reviewed agreed sulphate in adults with life-threatening
what treatments would
that the use of corticosteroids improved symptoms in whom any potential benefit would
you initiate and in what
pulmonary function, and reduced relapse justify the risk of treatment.
order? Think about the
and length of hospitalisation. The review Beta2 agonists can reduce serum
mechanisms of each
also suggested that there is no benefit from magnesium levels by up to 15%. This could
treatment and describe
intravenous versus oral use unless the patient mean that the use of magnesium in acute
how each one would
is vomiting. asthma exacerbations would not only have
work.
Side effects associated with a high dose the beneficial effects of bronchodilation,
of corticosteroids include hyperglycaemia, but would also assist in the prevention of
6 Now that you have
hypokalaemia, mood alterations, hypertension, hypomagnesaemia. The BTS and SIGN (2012)
completed the article,
metabolic alkalosis and peripheral oedema. recommend that the practitioner considers
you might like to write
Hyperglycaemia is the most common side administering a single dose of intravenous
a practice profile.
effect, with the others being reported only magnesium sulphate to patients with acute
Guidelines to help you
rarely. If hyperglycaemia occurs, the use of severe asthma who have not had a good
are on page 53.
corticosteroids should be reassessed, and they initial response to inhaled bronchodilator

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 therapy or who are experiencing symptoms a patient with severe acute asthma presents,
approaching those of life-threatening or because his or her response and actions directly
near-fatal asthma. affect patient outcomes (Papiris et al 2002).
Complete time out activity 5 Knowledge of the mechanisms of exacerbations
of acute severe asthma and effective treatments
is essential. Although there are measures such
Conclusion as PEF to estimate the severity of episodes, an
The rapid assessment of a patient with asthma understanding of patient symptoms is key to
during an exacerbation is important. The diagnosis and management NS
practitioner faces a complex challenge when Complete time out activity 6

References
Asthma UK (2010) Fighting for treatment of acute asthma. Joarder R, Crundwell N (Eds) Near-fatal asthma: recognition and
Breath. The Hidden Lives of Cochrane Database of Systematic (2009) Chest X-Ray in Clinical management. Current Opinion in
People with Severe Asthma. Reviews. Issue 2, CD000052. Practice. Springer-Verlag, London. Pulmonary Medicine. 14, 1, 13-23.
Asthma UK, London.
Chung KF, Bel EH, Wenzel SE (Eds) Lugogo NL, MacIntyre NR (2008) Rodrigo G, Rodrigo C (2002)
Barnes PJ, Rodger IW, Thomson NC (2011) European Respiratory Life-threatening asthma: Continuous versus intermittent
(Eds) (1998) Asthma. Basic Monograph 51. Difficult-to-Treat pathophysiology and management. beta-agonists in the treatment of
Mechanisms and Clinical Severe Asthma. European Respiratory Care. 53, 6, 726-735. acute adult asthma: a systematic
Management. Third edition. Respiratory Society, Sheffield. review with meta-analysis. Chest.
Academic Press, London. Manser R, Reid D, Abramson MJ 122, 1, 160-165.
Fitzpatrick AM, Higgins M, Holguin F, (2008) Corticosteroids for acute
Besbes-Ouanes L, Nouira S, Brown LA, Teague WG, National severe asthma in hospitalised Rowe B, Camargo CA (2008) The
Elatrous S, Knani J, Boussarsar M, Institutes of Health/National Heart, patients. Cochrane Database of role of magnesium sulphate in the
Abroug F (2000) Continuous versus Lung, and Blood Institute’s Severe Systematic Reviews. Issue 1, acute and chronic management of
intermittent nebulization of Asthma Research Program (2010) CD001740. asthma. Current Opinion in
salbutamol in acute severe asthma: The molecular phenotype of severe Pulmonary Medicine. 14, 1, 70-76.
a randomized, controlled trial. asthma in children. Journal of McDonald VM, Gibson PG (2012)
Annals of Emergency Medicine. Allergy and Clinical Immunology. Exacerbations of severe asthma. Royal College of Physicians (2013)
36, 3, 198-203. 125, 4, 851-857. Clinical and Experimental Allergy. National Review of Asthma Deaths.
42, 5, 670-677. www.rcplondon.ac.uk/projects/
Braganza G, Thomson NC (2008) Gibson PG, Saltos N, Fakes K (2001) national-review-asthma-deaths
Acute severe asthma in adults. Acute anti-inflammatory effects McFadden ER (2003) Acute severe (Last accessed: March 27 2013.)
Medicine. 36, 4, 209-212. of inhaled budesonide in asthma: asthma. American Journal of
a randomized controlled trial. Respiratory and Critical Care Schilling-McCann JA (2008)
Brasier AR, Victor S, Boetticher G American Journal of Respiratory and Medicine. 168, 7, 740-759. Critical Care Nursing Made
et al (2008) Molecular phenotyping Critical Care Medicine. 163, 1, 32-36. Incredibly Easy! Second edition.
of severe asthma using pattern Mohammed S, Goodacre S (2007) Lippincott Williams and Wilkins,
recognition of bronchoalveolar Global Initiative for Asthma (2012) Intravenous and nebulised Philadelphia, PA.
lavage-derived cytokines. Journal of Global Strategy for Asthma magnesium sulphate for acute
Allergy and Clinical Immunology. Management and Prevention. www. asthma: systematic review and Silverman RA, Flaster E, Enright PL,
121, 1, 30-37. ginasthma.org/local/uploads/files/ meta-analysis. Emergency Medicine Simonson SG (2007) FEV1
GINA_Report_2012Feb13.pdf (Last Journal. 24, 12, 823-830. performance among patients with
British Thoracic Society (2008) accessed: March 27 2013.) acute asthma: results from a
Guideline for Emergency Oxygen Use Papiris S, Kotanidou A, Malagari K, multicentre clinical trial. Chest.
in Adult Patients. BTS, London. Harrison BDW, Slack R, Berrill WT, Roussos C (2002) Clinical review: 131, 1, 164-171.
Burr ML, Stableforth DE, Wright SC severe asthma. Critical Care. 6, 1,
British Thoracic Society, Scottish (2002) Results of a national 30-44. Stoodley RG, Aaron SD, Dales RE
Intercollegiate Guidelines Network confidential enquiry into asthma (1999) The role of ipratropium
(2012) British Guideline on the deaths. Asthma Journal. 5, 180-186. Papiris S, Manali E, Kolilekas L, bromide in the emergency
Management of Asthma. A National Triantafillidou C, Tsangaris I (2009) management of acute asthma
Clinical Guideline. BTS, London; Health and Social Care Information Acute severe asthma: new exacerbation: a metaanalysis of
SIGN, Edinburgh. Centre (2013) Quality and approaches to assessment and randomized clinical trials. Annals of
Outcomes Framework 2011/12 treatment. Drugs. 69, 17, 2363-2391. Emergency Medicine. 34, 1, 8-18.
Cairns CB, Kraft M (1996) Results. qof.ic.nhs.uk (Last accessed:
Magnesium attenuates the neutrophil March 27 2013.) Ramnath R, Clark S, Camargo CA Sturdy P, Butland B, Anderson H
respiratory burst in adult asthmatic (2007) Multicenter study of clinical et al (2005) Deaths certified as
patients. Academic Emergency Innes NJ, Stocking JA, Daynes TJ, features of sudden-onset versus asthma and use of medical services:
Medicine. 3, 12, 1093-1097. Harrison BD (2002) Randomised slower-onset asthma exacerbations a national case-control study.
pragmatic comparison of UK and requiring hospitalization. Thorax. 60, 11, 909-915.
Cates CJ, Crilly JA, Rowe BH (2006) US treatment of acute asthma Respiratory Care. 52, 8, 1013-1020.
Holding chambers (spacers) versus presenting to hospital. Thorax. Woodcock A (2008) Asthma
nebulisers for beta-agonist 57, 12, 1040-1044. Restrepo RD, Peters J (2008) exacerbations. Thorax. 63, 1, 88.

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 Learning zone assessment

Write a practice profile

YOU CAN GAIN A CERTIFICATE OF LEARNING BY READING THIS
LEARNING ZONE ARTICLE AND THEN WRITING A PRACTICE PROFILE

What do I do now? Type ‘Practice profile’ in the subject acquired as a result of reading
Using the information in the section field for confirmation of receipt. the article?
below as a guide, write a practice Subscribers can submit profiles at What can I apply immediately to
profile of between 750 and 1,000 www.nursing-standard.co.uk by my practice or patient care?
words that is related to a learning clicking on the CPD link on the Is there anything that I did not
zone article. It may help to read this left-hand side of the homepage. understand, need to explore or
week’s practice profile on page 52 You will be informed of your result read about further, to clarify my
and ‘In practice’ below. in writing. A certificate is awarded understanding?
Write ‘Practice profile’ at the top for successful completion of the What else do I need to do/know to
of your entry followed by your practice profile. You are entitled extend my professional development
name, the title of the article, which to one retake if you are unsuccessful. in this area?
is Pharmacological management of Feedback is not provided: What other needs have I identified
acute asthma exacerbations in adults a certificate indicates that you in relation to my professional
(NS689). have been successful. Indicate development?
Complete the cut-out form below and on the form if you wish your How might I achieve the above?
attach it to your practice profile using practice profile to be considered for
a paperclip. Failure to do so will publication in Nursing Standard In practice
mean that your practice profile (see page 52). After reading a learning zone
cannot be considered for a certificate. Add a copy to your professional article on ‘wound care’, Amajit,
You are entitled to unlimited free portfolio – copies of practice profiles a senior staff nurse on a surgical ward,
entries. Using an A4 envelope, send are not returned. approached the nurse manager with
for your free assessment to: Practice concerns about wound infections.
Profile, RCN Publishing Company, Framework for reflection Following an audit, which Amajit
Freepost PAM 10155, Harrow, Consider these points before undertook, a protocol for dressing
Middlesex HA1 3BR by April 17 submitting your practice profile. wounds was established that led to a
2014. You can email practice What have I learned from this article reduction in infections on the ward
profiles to practiceprofile@ and how does it relate to my practice? and across the directorate. Amajit
rcnpublishing.co.uk. You must To what extent were intended used this experience for her practice
provide the same information that learning outcomes met? profile and is now taking part in
is requested on the cut-out form. What knowledge or skills have I a regional research project.

Practice profile submission form

First name: Number of article: I would like my practice profile to be
considered for publication in
Surname: Permanent address: Nursing Standard:

Job title: yes

Place of work: no

Please cut out this form and send it with

your practice profile in an envelope no
smaller than A4 size to:
Full title and date of article: Postcode:

Daytime telephone: Practice Profile

RCN Publishing Company
Email: Freepost PAM 10155
Harrow, Middlesex HA1 3BR

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