What is the initial management for a patient experiencing an acute attack of bronchial asthma?

Management of Acute Bronchial Asthma Attack

Immediately administer high-flow oxygen (40-60%) via face mask to maintain SaO₂ >92%, nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer, and oral prednisolone 30-60 mg (or IV hydrocortisone 200 mg if unable to take oral medication). 1, 2, 3

Initial Assessment and Recognition

Recognize acute severe asthma by the following clinical features 1:

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

Life-threatening features requiring immediate ICU consideration include 3:

• PEF <33% predicted
• Silent chest on auscultation
• Cyanosis or weak respiratory effort
• Altered mental status or confusion
• PaCO₂ ≥42 mmHg

Immediate First-Line Treatment

Oxygen Therapy

• Administer high-flow oxygen (40-60%) via face mask or nasal cannula 1, 3
• Target SaO₂ >92% (>95% in pregnant patients or those with cardiac disease) 3
• Use continuous pulse oximetry for monitoring 2

Bronchodilator Therapy

Nebulized beta-agonist is the cornerstone of acute treatment 1, 2:

• Salbutamol 5 mg via oxygen-driven nebulizer 1
• Alternative: Terbutaline 10 mg via oxygen-driven nebulizer 1
• Administer every 20 minutes for the first hour (3 doses total) 3
• For children: use half doses in very young children 4

Alternative delivery method when nebulizer unavailable 4:

• Metered-dose inhaler (MDI) with large volume spacer device
• Give 1 puff every few seconds until improvement (maximum 20 puffs)
• Use face mask in very young children

Add Ipratropium Bromide

• Add ipratropium 0.5 mg to nebulizer for severe exacerbations 2, 3
• Repeat every 20 minutes for 3 doses, then every 6 hours 1, 2
• This combination is particularly important for patients not responding rapidly to beta-agonist alone 3

Systemic Corticosteroids

Administer corticosteroids immediately—clinical benefits may not appear for 6-12 hours, making early administration essential 3:

• Adults: Prednisolone 30-60 mg orally (preferred route) 1, 2
• Alternative: Hydrocortisone 200 mg IV if patient cannot tolerate oral route 1, 2
• Children: Prednisolone 1-2 mg/kg body weight orally (maximum 40 mg) 4

Reassessment at 15-30 Minutes

Measure PEF and reassess clinical status after initial treatment 1, 2:

If Patient Improves

• Continue oxygen 40-60% 2
• Continue prednisolone 30-60 mg daily (or hydrocortisone 200 mg IV every 6 hours) 2
• Reduce nebulized salbutamol frequency to every 4-6 hours 2
• Monitor PEF every 4 hours 2

If Patient Does NOT Improve

Escalate treatment immediately 2:

• Continue oxygen and corticosteroids 2
• Increase salbutamol nebulization frequency to every 15-30 minutes 2
• Ensure ipratropium 0.5 mg is added to nebulizer every 6 hours 2
• Consider IV magnesium sulfate 2 g over 20 minutes for life-threatening exacerbations or severe exacerbations remaining after 1 hour of intensive treatment 3

Critical Pitfalls to Avoid

Never administer sedatives of any kind during an acute asthma exacerbation 1, 2—this is a potentially fatal error that can precipitate respiratory failure.

Do not underestimate severity based on initial presentation 2—patients can deteriorate rapidly, particularly those with catastrophic sudden severe asthma who may progress from minimal symptoms to life-threatening status within minutes to hours 4.

Avoid bolus administration of aminophylline in patients already taking oral theophyllines 1—risk of toxicity outweighs benefits, and aminophylline should no longer be used in children at home 4.

Do not rely solely on bronchodilators without anti-inflammatory treatment 2—systemic corticosteroids are essential even if initial bronchodilator response appears adequate.

Monitoring During Treatment

Continuous monitoring parameters 2, 3:

• Pulse oximetry to maintain SaO₂ >92%
• PEF measurement before and after each nebulization (minimum 4 times daily)
• Respiratory rate and heart rate every 15-30 minutes initially
• Arterial blood gas if PEF <25% predicted, severe distress, or suspected hypoventilation 2

Hospitalization Criteria

Admit to hospital if 2:

• Life-threatening characteristics present
• Severe exacerbation persisting after initial treatment
• PEF <33% after treatment
• Recent nocturnal symptoms or previous severe attacks
• Inability to assess own condition

Special Considerations

General Practice Setting

See the patient without delay and regard each case as acute severe asthma until proven otherwise 4. If treating at home, improvement requires objective confirmation (PEF measurement) before leaving 4. Patients require self-management plan and review within 48 hours 4.

Impending Respiratory Failure

Recognize signs requiring immediate intubation consideration 3:

• Inability to speak
• Worsening confusion or altered mental status
• Intercostal retraction with worsening fatigue
• Rising PaCO₂ ≥42 mmHg
• Exhaustion despite maximal therapy

When intubation becomes necessary, do not attempt until the most expert available physician (ideally an anesthetist) is present 4.