What is the immediate management for a patient presenting with an acute asthma exacerbation?

Acute Asthma Exacerbation Management

Immediate Recognition and Assessment

Begin treatment immediately while assessing severity—do not delay bronchodilators or corticosteroids to "complete the assessment first." 1

Recognize severe exacerbation features: 2, 1

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

Identify life-threatening features requiring immediate ICU consideration: 2, 1

• PEF <33% of predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Altered mental status, confusion, or exhaustion
• Bradycardia or hypotension (ominous signs of impending arrest)
• Normal or elevated PaCO₂ (≥42 mmHg) in a breathless patient (indicates respiratory failure)

First-Line Immediate Treatment (Start ALL Simultaneously)

High-Dose Inhaled Beta-Agonist

Administer salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer OR 4-8 puffs via metered-dose inhaler (MDI) with spacer every 20 minutes for 3 doses. 2, 1, 3 Both delivery methods are equally effective when properly administered. 1

Systemic Corticosteroids (Critical—Never Delay)

Give prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg immediately—do not wait to "see if bronchodilators work first." 2, 1 Oral administration is as effective as IV and less invasive. 1 Clinical benefits require 6-12 hours minimum, making early administration essential. 4

Oxygen Therapy

Administer high-flow oxygen via face mask to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease). 1

Additional Treatment for Severe/Life-Threatening Features

If life-threatening features are present at initial assessment: 2, 1

• Add ipratropium bromide 0.5 mg to nebulized beta-agonist every 20 minutes for 3 doses, then as needed—this combination reduces hospitalizations, particularly in severe airflow obstruction. 2, 1

• Consider IV magnesium sulfate 2 g over 20 minutes for patients with severe refractory asthma or PEF <40% after initial treatment—this significantly increases lung function and decreases hospitalization necessity. 1

• Give IV aminophylline 250 mg over 20 minutes OR salbutamol/terbutaline 250 µg over 10 minutes (but never give bolus aminophylline to patients already taking oral theophyllines). 2

Reassessment Protocol (15-30 Minutes After Initial Treatment)

Measure PEF and assess clinical response: 1

Good response (PEF ≥70% predicted):

• Continue oxygen, oral corticosteroids
• Transition to albuterol every 4-6 hours as needed
• Observe 30-60 minutes after last bronchodilator before discharge 1

Incomplete response (PEF 40-69% predicted):

• Continue intensive treatment every 20-60 minutes
• Admit to hospital ward 1

Poor response (PEF <40% predicted):

• Admit to hospital
• Consider ICU if life-threatening features present 1

Critical Pitfalls to Avoid

Never administer sedatives of any kind to patients with acute asthma—this is absolutely contraindicated. 2, 1

Do not underestimate severity—patients, families, and clinicians frequently fail to recognize dangerous exacerbations due to inadequate objective measurements. 2, 1 Always measure PEF or FEV₁.

Do not delay corticosteroids while "trying bronchodilators first"—they must be given immediately as benefits take 6-12 hours to manifest. 1, 4

Avoid methylxanthines (theophylline/aminophylline) in most cases due to erratic pharmacokinetics and significant side effects without superior efficacy. 1

Do not delay intubation once deemed necessary—it should be performed semi-electively before respiratory arrest occurs. 1

Hospital Admission Criteria

Immediate hospital referral required for: 2, 1

• Any life-threatening features
• Features of severe attack persisting after initial treatment
• PEF <33% of predicted after treatment
• Patients seen in afternoon/evening (lower threshold)
• Previous severe attacks, especially with rapid onset
• Concern over patient's ability to assess severity or poor social circumstances

Discharge Planning (After Stabilization)

Discharge criteria: 1

• PEF ≥70% of predicted or personal best
• Minimal or absent symptoms
• Oxygen saturation stable on room air
• Patient stable 30-60 minutes after last bronchodilator

Discharge medications: 1

• Continue oral corticosteroids for 5-10 days (no taper needed for courses <10 days)
• Initiate or continue inhaled corticosteroids
• Provide written asthma action plan
• Verify inhaler technique before discharge 1

Arrange follow-up within 1 week with primary care and within 4 weeks with specialist. 1