Oxygen treatment for acute severe asthma

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David Inwald (D.Inwald@ich.ucl.ac.uk), MRC clinical training fellowa,
Mark Roland, clinical research fellowb,
Lieske Kuitert, consultant in respiratory medicinec,
Sheila A McKenzie, consultant in paediatric respiratory medicined,
Andy Petros, consultant in paediatric intensive care medicinee

^a Portex Department of Anaesthesia, Intensive Care and Respiratory Medicine, Institute of Child Health, London WC1N 1EH
^b Department of Respiratory Medicine, St Bartholomew's and the Royal London School of Medicine and Dentistry, London EC1A 7BE
^c Royal London Hospital, London E1 1BB
^d Queen Elizabeth Children's Service, Royal London Hospital, London E1 1BB
^e Paediatric Intensive Care Unit, Great Ormond Street Hospital, London WC1N 3JF

Correspondence to: D Inwald

Accepted 8 March 2001

Deaths from asthma in England and Wales dropped by about 6% a year in people aged 5-64 from 1983 to 1995,1 but about 20 children and 1600 adults still die in the United Kingdom every year from acute asthma. Profound hypoxaemia may be a readily preventable cause of some of these deaths. The British Thoracic Society's asthma guidelines advise oxygen as first line treatment in hospital for all patients in cases of acute severe asthma.2 However, the guidelines do not advise treatment with oxygen in primary care in children and do not insist on its use in adults. The recent death of a child in a primary care setting after administration of salbutamol nebulised with air prompted us to question whether treatment with oxygen should be recommended in all cases of acute severe asthma, including those presenting in primary care.

Summary points

Asthma causes 1600 deaths in the United Kingdom every year

Progressive hypoxaemia is probably an important cause of death

Oxygen should be the first treatment given to any patient with acute severe asthma

Nebulisation of β₂ agonists with air during severe attacks may worsen hypoxaemia

Patients with acute severe asthma should receive β₂ agonists nebulised with oxygen

Methods

A systematic review was not possible as there have never been any randomised controlled trials of oxygen in acute severe asthma. We therefore present a traditional literature review and our opinion based on it. We selected 24 publications from our personal collections and from Medline searches. Using the search terms “asthma” and “hypoxaemia or hypoxemia or hypoxia or oxygen” and “salbutamol or albuterol” yielded 204 papers, of which 11 were included in this review. The other 13 papers that we evaluated were from our personal collections.