What are the steps for emergency asthma treatment protocol?

Emergency Asthma Treatment Protocol

Immediate Treatment (First Hour)

Administer oxygen, high-dose inhaled beta-agonists, and systemic corticosteroids immediately—these three interventions form the cornerstone of emergency asthma management and should be initiated without delay. 1

Step 1: Oxygen Administration

• Administer supplemental oxygen via nasal cannula or face mask to maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Continue oxygen monitoring until clear response to bronchodilator therapy occurs 1

Step 2: Inhaled Short-Acting Beta-Agonists (First-Line Bronchodilator)

• Give albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer every 20 minutes for 3 doses in the first hour 1
• Alternative: 4-12 puffs of albuterol via MDI with spacer every 20 minutes for 3 doses if patient can cooperate effectively 1, 2
• After initial 3 doses, continue every 1-4 hours based on response 1, 2
• For severe exacerbations (PEF <40% predicted), consider continuous nebulization rather than intermittent dosing 1

Step 3: Systemic Corticosteroids (Administer Immediately)

• Give prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg immediately 1
• Oral administration is preferred—equally effective as IV but less invasive 1
• Do not delay corticosteroid administration; clinical benefits may not appear for 6-12 hours 3, 4

Step 4: Add Ipratropium for Severe Exacerbations

For patients with severe exacerbations or those not responding adequately to initial beta-agonist therapy, add ipratropium bromide 0.5 mg to the nebulizer with albuterol 1, 5, 2

• Repeat every 20 minutes for 3 doses, then every 6 hours until improvement 1, 2
• This combination reduces hospitalization rates, particularly in severe airflow obstruction 2

Step 5: Reassess at 15-30 Minutes After Initial Treatment

Measure peak expiratory flow (PEF) or FEV₁, assess symptoms, vital signs, and oxygen saturation 1, 2

If Improving (PEF >50-75% predicted):

• Continue oxygen and systemic corticosteroids 1
• Continue nebulized beta-agonist every 4 hours 1
• Consider discharge if PEF >75% predicted after observation 1

If NOT Improving (PEF remains <50% predicted or severe symptoms persist):

• Give nebulized beta-agonist more frequently, up to every 15-30 minutes 1
• Continue ipratropium if not already added 1
• Consider IV magnesium sulfate 2g over 20 minutes for severe refractory cases 2, 6
• Arrange for hospital admission 1

Step 6: Consider Additional Interventions for Life-Threatening Features

Life-threatening features include:

• PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, coma, or PaCO₂ ≥42 mmHg 1, 5, 2

For life-threatening exacerbations:

• Give IV aminophylline 250 mg over 20 minutes OR subcutaneous terbutaline 250 µg over 10 minutes 1
• Do NOT give bolus aminophylline to patients already taking oral theophyllines 1
• Consider ICU transfer if deteriorating PEF, worsening hypoxia (PaO₂ <8 kPa), hypercapnia (PaCO₂ >6 kPa), exhaustion, confusion, or drowsiness 1

Step 7: Monitoring During Treatment

• Measure and record PEF 15-30 minutes after starting treatment, then according to response 1
• Continue high-dose steroids: prednisolone 30-60 mg daily OR IV hydrocortisone 200 mg every 6 hours 1
• Obtain chest X-ray if suspected pneumothorax, pneumonia, or pneumomediastinum 1, 6

Common Pitfalls to Avoid

• Do NOT administer sedatives of any kind—contraindicated in acute asthma 1, 2
• Do NOT give antibiotics unless bacterial infection (pneumonia/sinusitis) is confirmed 1, 2
• Do NOT delay corticosteroid administration—underuse is a common factor in preventable asthma deaths 1, 5
• Do NOT rely solely on clinical assessment—use objective measurements (PEF/FEV₁) as severity is often underestimated 1, 5
• Avoid chest physiotherapy and mucolytics—not helpful in acute management 1, 2

Criteria for Hospital Admission

Admit if any of the following persist after initial treatment: 1

• Any life-threatening features present
• PEF <33% predicted after initial treatment
• Features of severe attack persist (inability to complete sentences, pulse >110, respirations >25, PEF <50% predicted)
• Lower threshold for admission if: afternoon/evening presentation, recent nocturnal symptoms, previous severe attacks, poor social circumstances 1