What is the management for a patient with asthma experiencing an acute attack with a Forced Expiratory Volume (FEV) of 60% after using salbutamol (albuterol)?

Management of Acute Severe Asthma with FEV 60% After Salbutamol Use

This patient requires immediate hospitalization with oral corticosteroids (Answer A), as they meet criteria for acute severe asthma that has not adequately responded to initial bronchodilator therapy. 1

Severity Assessment

This patient has acute severe asthma based on FEV 60% of predicted (equivalent to PEF <50%), which defines severe disease even after using salbutamol. 1, 2 The British Thoracic Society guidelines clearly state that patients with PEF <50% of predicted or best have acute severe asthma and require aggressive management. 1

Immediate Management Algorithm

First-Line Treatment (Already Partially Done)

• Oxygen 40-60% via face mask 1, 2
• Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 1, 3
• Systemic corticosteroids: Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1, 2

Response Assessment at 15-30 Minutes

Since this patient has already used salbutamol and is presenting with persistent severe features (FEV 60%), they fall into the "not improving" category. 1, 4 Research shows that approximately 30% of patients demonstrate a poor response pattern to salbutamol, characterized by more severe obstruction at presentation and requiring additional interventions. 4

Why Each Answer is Right or Wrong:

Answer A (Oral corticosteroids + hospitalization): CORRECT

• Hospitalization is mandatory because features of acute severe asthma persist after initial salbutamol use (PEF/FEV <50%). 1
• Systemic corticosteroids are essential and should be given immediately—prednisolone 30-60 mg orally or IV hydrocortisone 200 mg. 1, 2
• The British Thoracic Society explicitly states: "Any features of acute severe asthma present after initial treatment" is an absolute criterion for hospital admission. 1, 2

Answer B (Add salmeterol + hospitalization): INCORRECT

• Salmeterol is a long-acting beta-agonist (LABA) that has NO role in acute asthma management. 2
• LABAs have slow onset of action and are used for chronic maintenance therapy, not acute exacerbations. 2
• This represents a dangerous misunderstanding of asthma pharmacology.

Answer C (Add ipratropium): PARTIALLY CORRECT but INCOMPLETE

• Ipratropium 0.5 mg should be added to nebulized beta-agonists if the patient is not improving after 15-30 minutes. 1
• However, this answer omits the critical need for systemic corticosteroids and hospitalization, both of which are mandatory. 1, 2
• Ipratropium is an adjunct therapy, not a replacement for steroids and admission. 1, 3

Answer D (Salbutamol with spacer): INCORRECT

• While MDI with spacer can deliver equivalent bronchodilation to nebulization when properly dosed, 5 this patient has already failed initial salbutamol therapy. 4
• The severity (FEV 60%) mandates hospitalization regardless of delivery method. 1, 2
• Simply repeating the same medication via different device without adding corticosteroids and arranging admission is inadequate and dangerous. 1

Complete Management Protocol for This Patient

Immediate Actions (First Hour)

• Admit to hospital 1, 2
• Continue oxygen 40-60% to maintain SaO₂ >92% 1, 3
• Give prednisolone 30-60 mg orally (or IV hydrocortisone 200 mg if unable to take oral) 1, 2
• Nebulized salbutamol 5 mg every 15-30 minutes initially 1
• Add ipratropium 0.5 mg to nebulizer, repeat every 6 hours 1

If Still Not Improving After 15-30 Minutes

• Continue oxygen and steroids 1
• Increase nebulized beta-agonist frequency to every 15-30 minutes 1
• Consider IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 μg over 10 minutes 1
• Obtain chest radiograph to exclude pneumothorax 1

Critical Pitfall to Avoid

Never give sedatives of any kind to patients with acute asthma, as this can precipitate respiratory failure. 1, 3 The underuse of corticosteroids is a major factor in preventable asthma deaths. 1, 3

Monitoring During Hospitalization

• Repeat PEF/FEV measurements every 15-30 minutes initially, then 4 times daily 1
• Continuous pulse oximetry maintaining SaO₂ >92% 1, 3
• Monitor for life-threatening features: silent chest, cyanosis, exhaustion, confusion, bradycardia 1, 2, 3

Transfer to ICU Criteria

Transfer with physician prepared to intubate if: 1, 3

• Deteriorating PEF despite treatment
• Persistent hypoxia or developing hypercapnia
• Exhaustion, confusion, drowsiness, or coma
• Respiratory arrest