What is the recommended treatment for an asthma attack?

Treatment of Acute Asthma Attack

Immediately administer high-flow oxygen (40-60%), nebulized beta-agonists (salbutamol 5-10 mg or terbutaline 5-10 mg), and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV) to all patients presenting with an acute asthma attack. 1, 2, 3

Initial Assessment and Severity Classification

Before initiating treatment, rapidly classify severity to guide management intensity:

Severe asthma features include: 2, 3

• Too breathless to complete sentences in one breath
• Respiratory rate >25 breaths/min (adults) or >50 breaths/min (children)
• Heart rate >110 beats/min (adults) or >140 beats/min (children)
• Peak expiratory flow (PEF) <50% of predicted or personal best

Life-threatening features include: 2, 3

• PEF <33% of predicted or personal best
• Silent chest, cyanosis, or feeble respiratory effort
• Exhaustion, confusion, or drowsiness
• Bradycardia or hypotension (late ominous signs)

Immediate Treatment Protocol

Oxygen Therapy

• Deliver high-flow oxygen at 40-60% via face mask 2, 3
• Target oxygen saturation (SpO₂) >92% 1, 2
• Continue oxygen throughout treatment until patient stabilizes 1

Beta-Agonist Bronchodilators

Adults: 1, 2, 3

• Salbutamol 5-10 mg OR terbutaline 5-10 mg via oxygen-driven nebulizer
• Alternative: 10-20 puffs (200 mcg per puff) via metered-dose inhaler with large volume spacer 1
• Repeat every 15-30 minutes if no improvement 1
• Once improving, continue every 4 hours 1

Children: 1

• Salbutamol 5 mg or terbutaline 10 mg nebulized (half doses in very young children)
• Repeat up to every 30 minutes if not improving 1

Systemic Corticosteroids

Critical point: Oral administration is equally effective as IV and should be preferred when patient can swallow 1

Adults: 1, 2, 3

• Prednisolone 30-60 mg orally OR
• Hydrocortisone 200 mg IV (if vomiting or severely ill)
• Continue prednisolone 30-60 mg daily or hydrocortisone 200 mg every 6 hours until recovery 1

Children: 1

• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg)
• Hydrocortisone IV if unable to take oral medication

Important: Short courses (up to 2 weeks) do not require tapering—can be stopped abruptly from full dose 1

Life-Threatening Asthma: Additional Interventions

When life-threatening features are present, immediately add: 1, 2, 3

Ipratropium Bromide

• Adults: 0.5 mg nebulized, added to beta-agonist 1, 2
• Children: 100 mcg nebulized 1, 2
• Repeat every 6 hours until improvement begins 1

IV Bronchodilators (if inadequate response)

• Aminophylline: 250 mg IV over 20 minutes (adults) or 5 mg/kg over 20 minutes (children), followed by maintenance infusion of 1 mg/kg/hour 1
• Critical warning: Do NOT give bolus aminophylline to patients already taking oral theophyllines 1
• Alternative: Salbutamol or terbutaline 250 mcg IV over 10 minutes (adults) 1

Monitoring During Treatment

Essential Parameters 1, 2

• Measure PEF 15-30 minutes after starting treatment, then before and after each nebulizer treatment
• Continuous pulse oximetry maintaining SpO₂ >92%
• Repeat arterial blood gases within 2 hours if initial PaO₂ <8 kPa (60 mmHg) or if patient deteriorates
• Monitor heart rate, respiratory rate continuously

Response Assessment at 15-30 Minutes

If improving: 1

• Continue oxygen and steroids
• Reduce nebulized beta-agonist frequency to every 4 hours
• Continue monitoring

If NOT improving: 1

• Continue oxygen and steroids
• Increase nebulized beta-agonist frequency to every 15-30 minutes
• Add ipratropium if not already given
• Consider IV aminophylline or parenteral beta-agonist

Criteria for ICU Transfer

Transfer immediately to intensive care unit (accompanied by physician prepared to intubate) if: 1, 2

• Deteriorating PEF despite treatment
• Worsening or persistent hypoxia (PaO₂ <8 kPa) despite 60% oxygen
• Hypercapnia (PaCO₂ >6 kPa)
• Exhaustion, feeble respirations, confusion, or drowsiness
• Coma or respiratory arrest

Hospital Admission Criteria

Immediate referral to hospital is required for: 1

• Any life-threatening features
• Features of severe attack persisting after initial treatment
• PEF 15-30 minutes after nebulization <33% of predicted or best value
• Lower threshold for admission in afternoon/evening presentations, recent nocturnal symptoms, previous severe attacks with rapid onset, or concerns about patient's ability to assess severity 1

Treatments to AVOID

Critical pitfalls: 1, 3

• Never give sedatives—absolutely contraindicated as they worsen respiratory depression 1, 3
• No antibiotics unless bacterial infection clearly present 1, 3
• No chest physiotherapy—unnecessary and potentially harmful 1

Discharge Criteria and Planning

Patients should not be discharged until: 1

• Stable on discharge medications for 24 hours
• PEF >75% of predicted or personal best
• Diurnal PEF variability <25%
• No nocturnal symptoms
• Inhaler technique verified and documented

Discharge medications must include: 1

• Prednisolone 30+ mg daily for 1-3 weeks (no taper needed) 1
• Inhaled corticosteroids at higher dose than pre-admission
• Inhaled beta-agonists as needed
• Written self-management plan
• GP follow-up within 1 week and respiratory clinic within 4 weeks 1

Contemporary Considerations

While the core guideline recommendations above remain standard practice 1, 2, 3, recent evidence suggests that combination ICS/FABA (fast-acting beta-agonist) inhalers as rescue therapy may reduce exacerbations compared to SABA alone in patients with mild-moderate asthma 4, 5. However, for acute severe attacks requiring emergency treatment, the immediate protocol remains high-dose nebulized beta-agonists with systemic corticosteroids as outlined above 2, 3.