Management of Acute Asthma Attack
Immediately administer high-flow oxygen (40-60%), nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer, and oral prednisolone 30-60 mg (or IV hydrocortisone 200 mg) as first-line treatment for any acute asthma exacerbation. 1, 2
Initial Assessment and Severity Classification
Rapidly assess severity using these objective criteria:
- Cannot complete sentences in one breath
- Respiratory rate >25 breaths/min
- Pulse >110 beats/min
- Peak expiratory flow (PEF) <50% of predicted or personal best
Life-threatening features: 2, 4
- Silent chest, cyanosis, or poor respiratory effort
- Confusion, exhaustion, or altered consciousness
- Bradycardia or hypotension
- PEF <33% of predicted
Immediate Treatment Protocol
First 15-30 Minutes
- Oxygen 40-60% via face mask to maintain SaO₂ >92%
- Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer
- Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV if unable to take oral medication
Reassess at 15-30 minutes by measuring PEF and clinical response 1
If Patient Improves (PEF >50-75% predicted)
- Continue oxygen 40-60% 1
- Continue prednisolone 30-60 mg daily 1
- Repeat nebulized salbutamol every 4-6 hours 1
- Monitor PEF every 4 hours 1
- Consider discharge if PEF >75% predicted with <25% diurnal variability after 24 hours on treatment 1
If No Improvement or Deterioration
Escalate treatment immediately: 3, 1
- Increase nebulized salbutamol frequency to every 15-30 minutes
- Add ipratropium bromide 0.5 mg to nebulizer every 6 hours
- Continue oxygen and systemic corticosteroids
- Consider IV aminophylline 250 mg over 20 minutes (only if not already on theophyllines) 3
- Arrange immediate hospital admission 1
Hospital Admission Criteria
Admit if any of the following are present: 1, 4
- Any life-threatening features
- Severe asthma features persisting after initial treatment
- PEF <33% after treatment
- Attack occurring in afternoon/evening
- Recent nocturnal symptoms or previous severe attacks
- Previous hospitalizations or ICU admissions
- Patient unable to assess their own condition
Pediatric Modifications
For children, adjust dosing as follows: 3, 2
- Prednisolone 1-2 mg/kg (maximum 40 mg) orally
- Salbutamol 2.5 mg for children <2 years; 5 mg for children ≥2 years via nebulizer
- Half doses for very young children
- Consider MDI with large volume spacer (1 puff every few seconds, maximum 20 puffs) as alternative to nebulizer 3
Alternative Delivery Methods
If nebulizer unavailable: 3
- Give 2 puffs of β-agonist via large volume spacer
- Repeat 10-20 times as needed
- This may be as effective as nebulized therapy in children 3
Critical Pitfalls to Avoid
- Administer sedatives during an acute attack
- Underestimate severity based on patient appearance alone
- Delay systemic corticosteroid administration
- Rely solely on bronchodilators without anti-inflammatory treatment
- Attempt intubation without most experienced physician (ideally anesthetist) present 3
Monitoring During Treatment
Continuous monitoring includes: 1
- Pulse oximetry to maintain SaO₂ >92%
- PEF measurement before and after each nebulization (minimum 4 times daily)
- Heart rate and respiratory rate every 15-30 minutes initially
- Clinical assessment for deterioration
Discharge Criteria
Patient may be discharged when: 1
- Stable on discharge medications for 24 hours
- PEF >75% of predicted or personal best
- Diurnal PEF variability <25%
- Verified inhaler technique documented
- Written self-management plan provided
- Follow-up arranged within 24-48 hours 2
Special Consideration: Catastrophic Sudden Severe Asthma
For patients with history of near-fatal asthma: 3
- Maintain pre-arranged emergency action plan
- Consider direct ICU admission based on history
- Patient should carry duplicate emergency medications
- May require home oxygen cylinder and resuscitation equipment
- Consider pre-loaded epinephrine 0.5 mg subcutaneous for self-administration if previous treatments failed