What is the immediate treatment for an asthma attack at the emergency room (ER) level?

Emergency Management of Acute Asthma Attack

Immediately administer high-flow oxygen (40-60%) via face mask, nebulized salbutamol 5-10 mg (or terbutaline 10 mg) via oxygen-driven nebulizer, and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV) as first-line therapy for any acute asthma exacerbation presenting to the emergency department. 1, 2

Initial Assessment and Recognition of Severity

Acute Severe Asthma Features:

• Too breathless to complete sentences 3
• Respiratory rate >25 breaths/min (adults) or >50 breaths/min (children) 3, 2
• Heart rate >110 bpm (adults) or >140 bpm (children) 3, 2
• Peak expiratory flow (PEF) <50% predicted or personal best 3

Life-Threatening Features (requiring immediate aggressive intervention):

• PEF <33% predicted 3, 2
• Silent chest, cyanosis, or poor respiratory effort 3, 2
• Exhaustion, confusion, altered consciousness, or agitation 3, 2
• Oxygen saturation <92% despite supplemental oxygen 1, 2

Immediate Treatment Protocol (First 15-30 Minutes)

Oxygen Therapy:

• Deliver high-flow oxygen at 40-60% via face mask to maintain SpO2 >92% 3, 1
• This is non-negotiable—inadequate oxygen delivery is a critical pitfall that contributes to preventable deaths 2

Bronchodilator Therapy:

• Nebulized salbutamol 5-10 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 3, 1
• For children: salbutamol 5 mg (half dose for very young children) 3, 2
• Metered-dose inhalers with spacer are equally effective and preferred when appropriate 4

Systemic Corticosteroids (do not delay):

• Oral prednisolone 30-60 mg OR intravenous hydrocortisone 200 mg 3, 1
• For very ill patients, give both 3
• In children: prednisolone 1-2 mg/kg (maximum 40 mg) 2, 5
• Critical pitfall: Underuse of early corticosteroids is a major factor in preventable asthma deaths 2

Add Ipratropium Bromide:

• Add ipratropium 0.5 mg to nebulizer (100 mcg in children) 3, 1
• Repeat every 6 hours until improvement 3, 2
• This decreases hospitalization rates and should be used routinely in moderate-severe cases 6

Avoid:

• No sedatives of any kind 3
• Do not delay treatment for investigations 2

Monitoring During Initial Treatment

Objective Measurements:

• Repeat PEF measurement 15-30 minutes after starting treatment 1, 2
• Continuous pulse oximetry maintaining SpO2 >92% 1, 2
• Chart PEF before and after each bronchodilator dose, minimum 4 times daily 2, 5

Investigations:

• Chest radiograph to exclude pneumothorax 3, 1
• Arterial blood gas only if: initial PaO2 <8 kPa (60 mmHg), elevated or rising PaCO2, or clinical deterioration 1
• No other investigations are needed for immediate management 3, 2

Subsequent Management Based on Response

IF PATIENT IS IMPROVING (after 15-30 minutes):

• Continue oxygen 40-60% 3
• Continue prednisolone 30-60 mg daily OR hydrocortisone 200 mg every 6 hours 3
• Reduce nebulized β-agonist frequency to every 4-6 hours 3, 2

IF PATIENT IS NOT IMPROVING (after 15-30 minutes):

• Continue oxygen and steroids 3
• Increase nebulized β-agonist frequency to every 15-30 minutes 3
• Ensure ipratropium 0.5 mg is added to nebulizer, repeat 6-hourly 3
• Consider hospital admission 1

IF PATIENT IS STILL NOT IMPROVING OR HAS LIFE-THREATENING FEATURES:

• Intravenous aminophylline: 5 mg/kg over 20 minutes (children) or 250 mg over 20 minutes (adults), followed by continuous infusion 3, 2
• Caution: Omit loading dose if patient already taking oral theophyllines 3, 2
• Alternative: IV salbutamol or terbutaline 250 mcg over 10 minutes 3
• Consider IV magnesium sulfate in severe exacerbations 6

Criteria for ICU Transfer

Transfer immediately with physician prepared to intubate if:

• Deteriorating PEF despite aggressive therapy 3, 2
• Worsening or persistent hypoxia or hypercapnia 3, 2
• Exhaustion, feeble respirations, confusion, drowsiness, or coma 3, 2
• Respiratory arrest 2

Intubation considerations:

• Use ketamine and succinylcholine for rapid sequence intubation 4
• Consider noninvasive positive pressure ventilation before intubation in moderate-severe cases 6

Discharge Criteria

Patients must meet ALL of the following before discharge:

• On discharge medication for 24 hours with verified inhaler technique 3, 2
• PEF >75% predicted or personal best with diurnal variability <25% 3, 2
• Oxygen saturation stable on room air 1

Discharge Medications:

• Prednisolone 30-60 mg daily for 7-14 days (no taper required) 4
• Inhaled corticosteroids (essential for all patients receiving oral steroids) 4
• Continue bronchodilators 3, 2
• Provide own PEF meter and written self-management plan 3, 2

Follow-up:

• Primary care follow-up within 1 week 3, 2
• Respiratory clinic appointment within 4 weeks 3

Critical Pitfalls to Avoid

• Underestimating severity: Regard each emergency visit as potentially severe until proven otherwise 2
• Delaying corticosteroids: Give early—this impacts ICU admission rates and prevents relapse 2, 7
• Inadequate oxygen delivery: Use high-flow oxygen via face mask, not just nasal cannula 2
• Giving sedatives: Absolutely contraindicated in acute asthma 3
• Bolus aminophylline to patients on theophyllines: Risk of toxicity unless specific criteria met 3