How should a paramedic manage an acute asthma or COPD exacerbation?

Prehospital Management of Acute Asthma and COPD Exacerbations

Paramedics should immediately administer oxygen to maintain SpO₂ 88-92% for COPD exacerbations and >90% (>95% in pregnant patients) for asthma, followed by nebulized bronchodilators (albuterol 2.5-5 mg or salbutamol 5 mg via oxygen-driven nebulizer), and should not delay transport while administering treatment—bronchodilators can be repeated during transport to a maximum of 3 treatments in the first hour. 1, 2

Immediate Assessment and Oxygen Delivery

For COPD Exacerbations

• Target oxygen saturation of 88-92% using nasal cannula or face mask 2
• Over-oxygenation (SpO₂ >92%) is associated with increased hypercapnia, respiratory acidosis, and mortality 2, 3
• Use titrated oxygen delivery rather than high-flow oxygen to reduce mortality risk 2

For Asthma Exacerbations

• Target SpO₂ >90% in adults (>95% in pregnant patients or those with heart disease) 1
• Administer high-flow oxygen via face mask 2, 1
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy 1

Primary Bronchodilator Treatment

First-Line Therapy

• Administer albuterol (salbutamol) 2.5-5 mg via oxygen-driven nebulizer 1, 2
• Alternative: 4-12 puffs via MDI with spacer every 20 minutes for 3 doses 1
• For children: salbutamol 5 mg or terbutaline 10 mg (half doses in very young children) 2

Critical Transport Consideration

• Do not delay transport to administer bronchodilator treatment 1
• Repeat treatment during transport: maximum 3 bronchodilator treatments during first hour, then 1 per hour 1
• Reassess patient 15-30 minutes after starting treatment 1

Adjunctive Bronchodilator Therapy

Ipratropium Bromide for Severe Exacerbations

• Add ipratropium 0.5 mg via nebulizer for severe asthma exacerbations 1
• Can be mixed with albuterol in nebulizer if used within one hour 4
• Note: Ipratropium as single agent has not been adequately studied for acute COPD exacerbations and may have slower onset than beta-agonists 4

Systemic Corticosteroids

Asthma Exacerbations

• Administer prednisolone 1-2 mg/kg orally (maximum 40 mg) for moderate-to-severe exacerbations 2, 1
• Give early in treatment course 1

COPD Exacerbations

• Administer systemic corticosteroids at modest dose (40 mg) for moderate and severe exacerbations 2
• Short course of 5-7 days without tapering 2

Critical Warning Signs Requiring Immediate Hospital Transport

Life-Threatening Asthma Features

• Unconsciousness or confusion 2
• Silent chest, cyanosis, or poor respiratory effort 2
• Inability to complete sentences 1
• Use of accessory muscles, paradoxical breathing 1

Severe COPD Exacerbation Indicators

• Loss of alertness 2
• Hypercapnic respiratory failure (PCO₂ >45 mmHg, pH <7.35) 2
• Need for ventilatory support 2

Special Considerations

Oxygen Delivery During Nebulization

• For COPD patients, use air-driven nebulizers when available or titrate oxygen flow to maintain SpO₂ 88-92% during nebulization 2
• Avoid high-flow oxygen (>92% saturation) as it increases risk of hypercapnia and mortality in COPD 2, 3

Face Mask Precautions

• When using face mask for nebulization, ensure proper fit to avoid leakage around mask 4
• Solution contact with eyes can cause temporary blurring of vision, pupil enlargement, or precipitation of narrow-angle glaucoma 4

Treatment Sequence

• Initiate oxygen and first bronchodilator dose within first 15-30 minutes 1
• Begin transport immediately—do not wait for treatment completion 1
• Continue treatments en route to hospital 1

Common Pitfalls to Avoid

• Never delay transport to complete nebulizer treatments—this is the most critical error paramedics make 1
• Avoid over-oxygenation in COPD patients (SpO₂ >92%), which increases mortality risk 2, 3
• Do not use ipratropium as sole agent for acute COPD exacerbations due to slower onset 4
• Do not attempt intubation in severe asthma until most expert available provider (ideally anesthetist) is present 2