What is the current prehospital management for a patient with an acute asthma exacerbation?

Prehospital Management of Acute Asthma Exacerbation

EMS providers should immediately administer supplemental oxygen to maintain SaO₂ >90% and high-dose inhaled short-acting beta-agonists (albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer), with treatment not delaying transport to the hospital. 1, 2

Immediate Prehospital Interventions

Oxygen Administration

• Administer high-flow oxygen (40-60%) via face mask or nasal cannula immediately to maintain SaO₂ >90% (>95% in pregnant patients or those with cardiac disease) 1, 2, 3
• Continue oxygen monitoring throughout transport until clear response to bronchodilator therapy occurs 2

Bronchodilator Therapy

• Administer albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer/holding chamber 1, 2, 3
• EMS providers should have standing orders allowing them to provide albuterol consistent with their legally authorized scope of practice and local medical directives 1
• Treatment can be repeated during transport to a maximum of 3 bronchodilator treatments during the first hour, then 1 per hour 1
• Do not delay patient transport to the hospital while administering bronchodilator treatment 1

Alternative Bronchodilator Options

• If beta-agonist treatment is not possible, subcutaneous epinephrine (0.3-0.5 mg) or terbutaline (0.25 mg) can be administered for severe exacerbations 1
• Subcutaneous epinephrine or terbutaline should be given every 20 minutes for up to 3 doses if needed 1

Severity Assessment During Transport

Features of Severe Exacerbation

• Inability to complete sentences in one breath 1, 2
• Respiratory rate >25 breaths/min 1, 2
• Heart rate >110 beats/min 1, 2
• Peak expiratory flow (PEF) <50% of predicted or personal best (if measurable) 1, 2

Life-Threatening Features Requiring Immediate Hospital Transport

• PEF <33% of predicted or personal best 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, or coma 1
• Patients presenting with apnea or coma should be intubated immediately 1

Equipment Requirements for EMS

EMS providers should have available a nebulizer, an inhaler plus a spacer/holding chamber, or both for beta-agonist administration. 1

Delivery Method Considerations

• Nebulizer therapy may be preferred for patients unable to cooperate effectively with MDI use due to age, agitation, or more severe exacerbations 1
• MDI with valved holding chamber is as effective as nebulized therapy in mild-to-moderate exacerbations when administered with appropriate technique by trained personnel 1
• For nebulizer delivery, use oxygen-driven nebulization at gas flow of 6-8 L/min 1

Critical Pitfalls to Avoid

• Never delay transport to complete multiple bronchodilator treatments - treatment can continue en route 1
• Do not underestimate severity based on subjective assessment alone - objective measurements (oxygen saturation, respiratory rate, heart rate) are essential 1, 2
• Avoid giving bolus aminophylline to patients already taking oral theophyllines 1
• Do not attempt intubation in the field unless absolutely necessary (apnea/coma) - this should be performed by the most expert available provider 1

Transport Priorities

• Maintain continuous oxygen administration during transport 1, 2
• Monitor oxygen saturation continuously 2
• Reassess patient response after each bronchodilator treatment 1
• Alert receiving facility of severity assessment and treatments administered 1
• Transport all patients with life-threatening features or severe exacerbations persisting after initial treatment immediately 3