Asthma emergency: how to use new formulations

The first update in more than a decade outlines how to use new medication in a first aid situation.

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Patients with asthma now have updated advice on how to use new inhalers and preparations in an emergency.

In its first update in a decade, the National Asthma Council’s first aid advice includes simplified flow charts and QR codes to support people having an acute asthma attack.

The charts advise patients to use their own reliever if possible, or to use a blue/grey puffer (short-acting bronchodilators such as Asmol, Ventolin or Zempreon) if available.

But it now also includes instructions on using budesonide/formoterol combinations, which have been added to the PBS in recent years. 

Advice on using budesonide/formoterol in acute asthma emergencies had been added for situations in which the combination inhaler was the only available option, National Asthma Council Australia director and respiratory physician Professor Peter Wark told TMR.

“Some people are using inhaled budesonide/formoterol either as maintenance reliever therapy or as anti-inflammatory reliever therapy. Their only reliever may be budesonide/formoterol, so we have incorporated that as an option on the first aid chart as to how to use these devices if people have acute severe asthma.

“First responders and carers are often relying upon the patient’s own medication, and if all they are carrying is budesonide/formoterol then they need to know how to use that.”

Patients who have budesonide/formoterol combinations should be sat comfortably upright, calmed and reassured if possible.

Those who use Symbicort Turbuhaler, DuoResp Spiromax or BiResp Spiromax should be given one puff of their inhaler and watched for four minutes.

The flow chart then advises people on how to proceed if the patient is still breathless, getting worse or breathing normally.

If they are still breathless, they should be given one more puff, and the ambulance called if they still can’t breathe normally in a few minutes. Patients should continue receiving one puff every four minutes until the ambulance arrives – up to three more doses.

If they are getting worse or no better, an ambulance should be called immediately, and the patient should continue getting one puff every four minutes until the ambulance arrives – up to three more doses.

If the patient is breathing normally then get them to a doctor for a check-up.

One difference with the Symbicort Rapihaler is that patients should initially be given two puffs before being watched for four minutes. They should also receive two puffs instead of one in the above scenarios.

Professor Wark said the four-by-four rule should continue to be followed for blue/grey inhalers: give four puffs, wait four minutes and repeat if necessary.

“There’s often a default decision in emergency departments to give 12 puffs at the start, but that’s probably not necessary for the vast majority of people with acute asthma.

“Even if you give a big dose, you still have to wait for a response. It doesn’t work immediately, and there is usually about a five-to-10-minute lag for there to be an optimal response from all short-acting beta agonists and formoterol.

“So as much as you’d like it to happen as quickly as possible, inevitably you’re waiting at least four minutes before your effect is starting to have an impact.”

After four puffs, continue to deliver the medication as needed, Professor Wark said.

“If the person is still struggling and is symptomatic, call triple zero and get help.

“You can continue to administer the bronchodilator as much as is needed, but if a person has a continual need for salbutamol, you’ll need to get additional help to get them to a place where that can be provided, and they can have further support.”

The National Asthma Council updated its charts for adults and children aged 12 and over and children under 12 and the how-to video library.

Professor Wark said QR codes had been added as a quick way of communicating more information to first aiders or first responders who were not familiar with using puffers and spaces during acute asthma.

Fast and effective treatment for acute asthma was crucial to prevent serious outcomes, Professor Wark said.

“We hope that all health professionals will talk to their asthma patients about the First Aid for Asthma charts and especially parents or carers of children with asthma,” Professor Wark said in a statement.

“In Australia, one in four children and one in 10 adults live with asthma and any may experience an asthma attack.”

“Asthma deaths are entirely preventable and effective first aid in asthma will save a life, so training in first aid is important for any adult in a caring role of a child with asthma,” Professor Wark said.

“However, even without formal training, the First Aid for Asthma chart provides simple to follow instructions to support someone experiencing severe acute asthma.”

The National Asthma Council updated its Australian Asthma Handbook in May to include updated clinical advice, clarify dosages and inhalations for different treatment regimes, and more detailed dosing information for single-inhaler combinations of corticosteroids and long-acting beta2 agonists.