What is the recommended management approach for asthma?

Emergency Department Management of Acute Asthma

Immediately assess severity using objective criteria and initiate high-flow oxygen (40-60%) plus nebulized bronchodilators and systemic corticosteroids for all patients presenting with acute asthma exacerbations—delays in treatment can be fatal. 1, 2

Initial Severity Assessment

Rapidly categorize patients into severity levels using these specific clinical parameters:

Mild Exacerbation:

• Able to speak in complete sentences 1
• Heart rate <110 beats/min 1
• Respiratory rate <25 breaths/min 1
• Peak expiratory flow (PEF) >50% predicted or personal best 1

Severe Exacerbation:

• Cannot complete sentences in one breath 1, 2
• Heart rate >110 beats/min 1, 2
• Respiratory rate >25 breaths/min 1, 2
• PEF <50% predicted or personal best 1, 2

Life-Threatening Features (require immediate ICU consideration):

• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia, confusion, exhaustion, or coma 1
• Hypotension 1

Immediate Treatment Protocol

For ALL Severity Levels:

1. Oxygen therapy: Administer 40-60% high-flow oxygen immediately to all patients 1, 2

2. Nebulized bronchodilators: Give salbutamol 5 mg OR terbutaline 10 mg via oxygen-driven nebulizer 1, 2

   • If no nebulizer available: deliver 2 puffs of β-agonist via large volume spacer and repeat 10-20 times 1

3. Systemic corticosteroids: Administer prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1, 2

Critical Pitfall: Underuse of corticosteroids is a major contributor to asthma deaths—never withhold systemic steroids in acute presentations 1, 3

Reassessment at 15-30 Minutes

Monitor response after initial nebulizer treatment:

If PEF improves to >75% predicted/best:

• Step up usual maintenance treatment 1
• Arrange follow-up within 48 hours 1

If PEF 50-75% predicted/best:

• Continue prednisolone 30-60 mg 1
• Step up maintenance therapy 1
• Follow-up within 48 hours 1

If ANY features of severe asthma persist:

• Add ipratropium bromide 0.5 mg to nebulizer 1, 2
• Consider subcutaneous terbutaline 1
• Arrange hospital admission 1

Additional Treatment for Life-Threatening Exacerbations

When life-threatening features are present:

• Add ipratropium 0.5 mg to each nebulization 1, 2
• Consider IV aminophylline 250 mg over 20 minutes (caution if patient already taking theophyllines) 1
• Obtain chest radiography to exclude pneumothorax 1
• Continuous monitoring with pulse oximetry 2
• Never administer sedatives—they are absolutely contraindicated and worsen respiratory depression 4

Hospital Admission Criteria

Admit immediately if:

• Any life-threatening features present 1
• PEF remains <33% predicted after initial treatment 1
• Any features of acute severe asthma persist after initial treatment 1

Lower threshold for admission when:

• Attack occurs in afternoon or evening 1
• Recent nocturnal symptoms or hospital admission 1
• Previous severe attacks 1
• Poor social circumstances or inability to assess own condition 1

ICU Transfer Criteria

Transfer to ICU with physician escort prepared to intubate if:

• Deteriorating PEF despite treatment 1
• Worsening exhaustion or feeble respirations 1
• Persistent or worsening hypoxia or hypercapnia 1
• Confusion, drowsiness, coma, or respiratory arrest 1

Discharge Planning

Do not discharge until:

• Patient stable on discharge medications for 24 hours 1, 2
• PEF >75% predicted or personal best 1, 2
• PEF diurnal variability <25% 1
• Inhaler technique verified and documented 1, 2

All discharged patients must receive:

• Oral prednisolone course (continue 3-10 days total) 3
• Inhaled corticosteroids plus bronchodilators 1
• Personal peak flow meter 1
• Written asthma action plan 1, 2, 3
• Primary care follow-up within 24 hours for severe exacerbations, 48 hours for moderate 1, 3
• Respiratory specialist follow-up within 4 weeks 1, 2

Common Pitfalls to Avoid

• Underestimating severity: Patients may not exhibit all abnormalities even with severe disease—presence of ANY severe feature should trigger aggressive treatment 1
• Delaying systemic corticosteroids: This is a leading cause of preventable asthma deaths 1, 3
• Overreliance on bronchodilators alone: Anti-inflammatory treatment with corticosteroids is essential 3, 4
• Premature discharge: Ensure objective improvement (PEF >75%) before discharge 1, 2