Managing acute asthma in dental practice

Acute asthma attacks can be fatal. Ask patients with asthma to bring their reliever inhaler with them when attending for dental treatment. Many patients with asthma have an asthma action plan, or, at least, a good understanding of how to manage their asthma.

If an acute asthma attack occurs, perform a rapid physical examination to evaluate the severity of the attack (see Initial assessment of the severity of an acute asthma attack in adults and children). Wheezing is an unreliable indicator of the severity of an asthma attack and may be absent in a severe attack. Cyanosis indicates life-threatening asthma—patients require urgent transfer to hospital.

Note: Patients with severe asthma may not wheeze. Cyanosis indicates life-threatening asthma.
Table 1. Initial assessment of the severity of an acute asthma attack in adults and children

Severity

Signs

Mild or moderate

can walk and can speak whole sentences in one breath

for young children: can move around and can speak in phrases

oxygen saturation greater than 94% [NB1]

Severe

any of these findings:

use of accessory muscles of neck or intercostal muscles during inspiration

‘tracheal tug’ during inspiration

subcostal recession (‘abdominal breathing’)

unable to complete sentences in one breath because of dyspnoea

obvious respiratory distress

oxygen saturation 90 to 94% [NB1]

Life-threatening

any of these findings:

reduced consciousness or collapse

exhaustion

cyanosis

oxygen saturation less than 90% [NB1]

poor respiratory effort, soft or absent breath sounds

Note:

NB1: If oxygen therapy has already been started, it is not necessary to stop oxygen to measure pulse oximetry. Oxygen saturation levels are a guide only and are not definitive; clinical judgment should be applied.

Source: Adapted from National Asthma Council Australia. Australian asthma handbook Version 2.0 [online]. Melbourne: National Asthma Council Australia; 2019; Accessed April 2019. [URL]

An acute asthma attack is initially treated with a short-acting bronchodilator (eg salbutamol, terbutaline)—see Management of an acute asthma attack in dental practice for first-aid management in dental practice.

Using a spacer device with a pressurised metered dose inhaler enables better drug penetration into the lungs, and is easier to use effectively than an inhaler alone. Spacers are essential for management of a severe asthma attack, because these patients cannot inhale the drug effectively. However, salbutamol should never be withheld on the grounds that a spacer is not available.

Note: Spacers are essential for management of a severe asthma attack.

If the patient recovers swiftly after an acute asthma attack:

  • Temporise the dental state.
  • Make another appointment to complete the dental treatment (if needed).
  • When the patient is breathing easily, discharge from care.
  • Advise the patient to take their asthma medication as prescribed and seek medical review.
Figure 1. Management of an acute asthma attack in dental practice

Stop dental treatment. Sit the patient upright.

If the asthma attack is mild or moderate:

  • Give 4 puffs of salbutamol inhaler via a spacer, 1 puff at a time. Shake the inhaler before each puff.
  • Ask the patient to take 4 breaths in and out of the spacer after each puff [NB1].
  • Wait 4 minutes.
  • If there is little or no improvement, give another 4 puffs using the technique above.
  • Assess the patient’s status. If there is little or no improvement, manage as for a severe attack (see below).

If the asthma attack is severe or life threatening:

  • Call 000.
  • Start supplemental oxygen and airway support if needed.
  • Give salbutamol inhaler via a spacer, shaking the inhaler before each puff:
    • adult and child 6 years or older: 12 puffs
    • child younger than 6 years: 6 puffs.
  • Give 1 puff at a time, asking the patient to take 4 breaths in and out of the spacer after each puff [NB1].
  • If a spacer is not available but a nebuliser is available, give salbutamol 5 mg by nebuliser driven by oxygen.
  • Reassess within minutes.
  • While waiting for assistance to arrive:
    • repeat salbutamol dose as needed, at least every 20 minutes, using the technique above
    • if life-threatening, give salbutamol continuously
    • monitor the patient.
Note: NB1: If a spacer is not available, ask the patient to hold their breath for 4 seconds (or as long as is comfortable) after each puff.