What is the best course of treatment for a patient with asthma, recent viral respiratory infection, and previous course of steroids, presenting with tachycardia, hypoxemia, and having already received albuterol (albuterol)?

Immediate Hospital Transfer Required

This patient requires immediate emergency department evaluation and likely hospital admission based on severe hypoxemia (oxygen saturation 85-92%), tachycardia (HR 144), and inadequate response to initial albuterol therapy. 1, 2

Critical Assessment Findings Indicating Severity

This patient meets multiple criteria for acute severe asthma requiring hospitalization:

• Oxygen saturation <92% indicates severe hypoxemia and warrants immediate admission 2
• Heart rate >110 bpm (patient has HR 144) indicates severity 1, 2
• Recent steroid course "a few weeks ago" with recurrent symptoms suggests inadequate treatment duration and high-risk patient 1, 2
• Only 4 puffs of albuterol today is insufficient for acute severe asthma - guidelines recommend up to 10-20 puffs via spacer or continuous nebulization 1

Immediate Actions Before Transport

While arranging emergency transport, administer:

• Give dexamethasone immediately (or prednisolone 30-60 mg if available) - systemic steroids take 6-12 hours to work, so early administration is critical 1, 2
• Administer additional albuterol: 10-20 puffs via spacer device (2 puffs repeated 10-20 times) or nebulized 5 mg if available 1
• Provide supplemental oxygen if available (40-60%) to maintain saturation >90% 1
• Call emergency medical services immediately - do not attempt to transport privately 1

Why Hospital Admission is Mandatory

The British Thoracic Society guidelines specify immediate hospital referral for:

• Any features of severe attack persisting after initial treatment 1
• Lower threshold for admission in patients with recent hospital admission or previous severe attacks 1
• Attacks occurring in afternoon/evening (higher risk) 1
• Recent nocturnal symptoms or worsening symptoms 1

Expected Hospital Management

Upon arrival, the patient should receive:

• Continuous oxygen therapy to maintain saturation >90% 1
• Nebulized albuterol 5 mg every 15-30 minutes initially, then every 4 hours if improving 1
• Add ipratropium bromide 0.5 mg nebulized to each albuterol treatment - this reduces hospitalization rates in severe exacerbations 1, 2
• Systemic corticosteroids: prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours 1
• Peak flow monitoring 15-30 minutes after treatment and regularly thereafter 1

Critical Pitfall in This Case

The previous steroid course was likely too short - the patient's relapse "a few weeks ago" demonstrates inadequate treatment duration. 2 Standard 5-6 day steroid tapers are often insufficient. Upon discharge from hospital, this patient will require prednisolone 30-60 mg daily for 1-3 weeks (not days) to prevent recurrence. 1, 2, 3

Additional Pitfalls to Avoid

• Never give sedatives - absolutely contraindicated in asthma exacerbations as they worsen respiratory depression 1, 2, 3
• Do not give antibiotics unless bacterial infection is documented - viral respiratory infections do not require antibiotics 1, 2, 4
• Do not delay transport to "see if treatment works" - this patient's vital signs mandate immediate evaluation 1, 2

Intensive Care Considerations

If the patient develops any of the following during transport or in the emergency department, intensive care unit admission is required:

• Deteriorating peak flow or worsening hypoxia despite 60% oxygen 1
• Exhaustion, feeble respiration, confusion, or drowsiness 1
• Hypercapnia (PaCO₂ >6 kPa or 45 mmHg) 1