What is the management plan for a patient with status asthmaticus?

Status Asthmaticus Assessment and Management

Immediate Assessment

Rapidly assess severity using objective measurements before initiating treatment to identify life-threatening features and guide management intensity. 1

Severe Asthma Features

• Cannot complete sentences in one breath 1
• Pulse >110 beats/min 1
• Respiratory rate >25 breaths/min 1
• Peak expiratory flow (PEF) <50% predicted or personal best 1

Life-Threatening Features (Require ICU Consideration)

• PEF <33% predicted or personal best 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, drowsiness, or coma 1
• Oxygen saturation <92% on room air 2

Critical pitfall: Patients with severe or life-threatening attacks may not appear distressed and may not exhibit all these abnormalities—the presence of any single feature should alert you. 1

---

Immediate Treatment (First 15-30 Minutes)

Oxygen Therapy

• Administer 40-60% oxygen immediately via face mask 1
• Maintain oxygen saturation >92% 1
• CO₂ retention is NOT aggravated by oxygen therapy in asthma 1

Bronchodilator Therapy

• Nebulized salbutamol 5 mg OR terbutaline 10 mg with oxygen as driving gas 1, 3
• Alternative: Albuterol 4-12 puffs via MDI with large volume spacer if nebulizer unavailable 2, 4
• Add ipratropium bromide 0.5 mg to nebulizer immediately—this reduces hospitalization rates 2, 4

Systemic Corticosteroids (Critical—Start Immediately)

• Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 1
• Give both if patient is very ill 1
• Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration essential 2, 4

Additional Measures for Life-Threatening Features

• IV aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour maintenance infusion 1
• Omit loading dose if patient already receiving oral theophyllines 1
• Chest radiograph to exclude pneumothorax 1
• Arterial blood gases if any life-threatening features present 1

Critical pitfall: Never use sedatives—they are absolutely contraindicated in asthma exacerbations and can worsen respiratory depression. 2, 5, 4, 3

---

Reassessment at 15-30 Minutes

Repeat PEF measurement and clinical assessment to determine response and guide next steps. 1

If Patient Is Improving

• Continue 40-60% oxygen 1
• Continue prednisolone 30-60 mg daily OR IV hydrocortisone 200 mg every 6 hours 1
• Nebulized β-agonist every 4 hours 1
• Continue ipratropium 0.5 mg every 6 hours until improvement established 1

If Patient Is NOT Improving

• Continue oxygen and steroids 1
• Increase nebulized β-agonist frequency to every 15-30 minutes 1
• Continue ipratropium 0.5 mg every 6 hours 1
• Consider IV aminophylline if not already started 1
• Prepare for possible ICU transfer 1

---

Ongoing Monitoring

• Repeat PEF measurement 15-30 minutes after each treatment 1
• Continuous pulse oximetry—maintain SaO₂ >92% 1
• Chart PEF before and after each nebulized treatment, minimum 4 times daily 1
• Repeat arterial blood gases within 2 hours if initial PaO₂ <8 kPa (60 mmHg), initial PaCO₂ was normal or raised, or patient deteriorates 1

---

ICU Transfer Criteria

Transfer to ICU accompanied by a physician prepared to intubate if: 1

• Deteriorating PEF despite maximal therapy 1
• Worsening or persistent hypoxia or hypercapnia 1
• Exhaustion, feeble respirations, confusion, or drowsiness 1
• Coma or respiratory arrest 1

---

Discharge Criteria (Do Not Discharge Until ALL Met)

• Patient on discharge medications for 24 hours with inhaler technique checked and documented 1
• PEF >75% predicted or personal best 1
• PEF diurnal variability <25% 1
• No nocturnal symptoms 4

Discharge Medications and Follow-Up

• Prednisolone 30-60 mg daily for 1-3 weeks (NOT a 5-6 day Medrol dose pack—this is insufficient) 2, 4
• Inhaled corticosteroids (continue or increase dose) 1, 2
• Albuterol nebulizer or inhaler every 4 hours as needed 2, 4
• Peak flow meter with written asthma action plan 1, 2
• GP follow-up within 1 week 1, 2
• Respiratory specialist follow-up within 4 weeks 1, 2

Critical pitfall: Do NOT discharge with inadequate steroid duration—post-exacerbation asthma requires 1-3 weeks of systemic corticosteroids, not shorter courses. 2, 4

---

Additional Critical Pitfalls

• Do NOT prescribe antibiotics unless bacterial infection is clearly documented—viral triggers do not respond to antibiotics 2, 5, 4
• Do NOT rely solely on clinical assessment—physicians' subjective assessments of airway obstruction are often inaccurate; use objective PEF measurements 6
• If patient is vomiting and cannot tolerate oral medications, switch to IV hydrocortisone 200 mg every 6 hours immediately 4
• Increasing use of short-acting β-agonists (>2 days/week) indicates inadequate control and need for controller therapy intensification 5