Management of Asthma Exacerbation with PEF 60%
Give salbutamol with a spacer (up to 20 puffs) and reassess in 15-30 minutes before considering ipratropium. 1
Severity Classification
This patient presents with moderate asthma exacerbation, not acute severe asthma, based on the following assessment 1, 2:
- Able to speak in sentences (not just words) - indicates NOT severe
- PEF 60% (above the 50% threshold for severe asthma)
- Normal oxygen saturation (no hypoxemia)
- Wheezing present but no silent chest
The British Thoracic Society defines acute severe asthma as requiring **PEF <50% predicted or best**, inability to complete sentences, pulse >110 bpm, or respirations >25/min 1, 2. This patient does not meet these criteria.
Initial Management Approach
First-Line Treatment
Administer additional salbutamol via MDI with spacer 1:
- Give 2 puffs every few seconds up to maximum 20 puffs total if no nebulizer available 1
- This approach is as effective as nebulized beta-agonists in moderate exacerbations 1, 3
- The patient has only taken 2 puffs at home, which is insufficient dosing for an acute exacerbation
Reassessment Protocol
Monitor response at 15-30 minutes after salbutamol administration 1, 4:
- Remeasure peak expiratory flow
- Reassess symptoms and vital signs
- Determine if PEF improves to >75% predicted (can step up usual treatment) or remains 50-75% (needs systemic corticosteroids)
When to Add Ipratropium
Ipratropium is NOT first-line for moderate exacerbations 1, 2. Add ipratropium only if:
- Features of acute severe asthma persist after initial beta-agonist treatment (PEF remains <50%) 1
- Life-threatening features develop 2
- Patient requires hospital admission 1, 4
The British Thoracic Society specifically recommends adding ipratropium for severe attacks or when severe features persist after initial treatment, not as immediate first-line therapy 1, 2.
Additional Management
Systemic Corticosteroids
Administer prednisolone 30-60 mg orally if PEF remains 50-75% after bronchodilator treatment 1, 4:
- Corticosteroids should be given within the first hour for moderate-to-severe exacerbations 4, 3
- Continue for minimum 5 days, typically 5-10 days total 2, 4
Follow-Up Requirements
Arrange review within 48 hours for moderate exacerbations 2:
- Monitor symptoms and PEF on chart 1
- Provide written self-management plan 2
- Verify inhaler technique 5
- Step up maintenance therapy as needed 1
Common Pitfalls to Avoid
- Do not immediately jump to ipratropium - this patient needs adequate beta-agonist dosing first 1
- Do not underestimate severity - while this is moderate, failure to respond requires escalation 1, 5
- Do not discharge without reassessment - response to treatment must be documented before leaving 1
- Lower threshold for admission if symptoms worsen in afternoon/evening, recent nocturnal symptoms, or previous severe attacks 1, 2