What is the management approach for a patient presenting with acute asthma, characterized by symptoms such as wheezing, shortness of breath, chest tightness, and cough?

Management of Acute Asthma Exacerbation

Acute asthma requires immediate administration of oxygen, high-dose inhaled beta-agonists, and systemic corticosteroids—with severity assessed objectively through peak expiratory flow (PEF) and vital signs, not symptoms alone. 1

Clinical Presentation and Chief Complaints

Cardinal symptoms include progressive worsening of shortness of breath, cough, wheezing, and chest tightness that fails to respond to usual bronchodilator therapy. 1 Patients may present with:

• Dyspnea ranging from exertional (mild) to at rest (severe) 1
• Cough with or without sputum production 1
• Chest tightness and audible wheezing 1
• Inability to complete sentences in one breath (severe exacerbation marker) 1, 2

Physical Examination Findings

General Examination - Severity Indicators

Severe exacerbation features that demand immediate aggressive treatment include: 1, 2

• Respiratory rate >25 breaths/min in adults 1, 3
• Heart rate >110 beats/min in adults 1, 3
• Use of accessory muscles of respiration 1
• Inability to speak in complete sentences 1, 2
• Agitation or altered level of consciousness 1

Life-threatening features requiring immediate ICU consideration: 1, 2

• Silent chest (absence of wheezing despite severe obstruction) 1, 2
• Cyanosis 1, 2
• Feeble respiratory effort or exhaustion 1, 2
• Bradycardia or hypotension (ominous signs of impending arrest) 1, 2
• Confusion, drowsiness, or altered mental status 1, 2

Objective Measurements - Critical for Assessment

Peak expiratory flow (PEF) is the single most important objective measure and must be obtained: 3

• PEF >50-75% predicted/personal best = moderate exacerbation 1
• PEF <50% predicted/personal best = severe exacerbation 1, 3
• PEF <33% predicted/personal best = life-threatening exacerbation 1, 3

Pulse oximetry should be measured immediately, with oxygen saturation cut-off of 90-92% indicating hypoxemia. 1 However, normal oxygen saturation does not exclude severe exacerbation—this is a critical pitfall. 4

Arterial blood gas measurements are essential in severe cases: 1

• Normal or elevated PaCO₂ (≥42 mmHg) in a breathless patient = life-threatening attack indicating respiratory muscle fatigue 3, 4
• Severe hypoxia (PaO₂ <60 mmHg) despite oxygen therapy 3
• Low pH or respiratory acidosis 3

Management Algorithm

Immediate Initial Treatment (First 15-30 Minutes)

Step 1: Oxygen Administration 2, 4

• Administer 40-60% oxygen via mask to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease) 2

Step 2: High-Dose Inhaled Beta-Agonist 2, 5

• Albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 1, 2
• Alternative: 4-8 puffs via MDI with spacer 2
• Administer every 20 minutes for 3 doses 2, 5

Step 3: Systemic Corticosteroids Immediately 1, 2

• Prednisolone 40-60 mg orally (preferred route) 1, 2
• Alternative: IV hydrocortisone 200 mg if unable to take oral 2
• Do not delay corticosteroids—clinical benefits require 6-12 hours minimum, so early administration is critical 1, 6

Reassessment at 15-30 Minutes

Measure PEF and vital signs after initial treatment: 3, 2

Good Response (PEF >70% predicted): 2

• Continue albuterol every 4-6 hours as needed 2
• Continue oral corticosteroids for 5-10 days (no taper needed) 2
• Initiate or continue inhaled corticosteroids 2
• Arrange follow-up within 1 week 1

Incomplete Response (PEF 50-69% predicted): 2

• Add ipratropium bromide 0.5 mg to nebulized albuterol every 20 minutes for 3 doses 1, 2
• Continue frequent nebulized treatments 2
• Consider hospital admission 2

Poor Response (PEF <50% predicted or life-threatening features): 2

• Immediate hospital transfer 1, 2
• Continue oxygen and frequent nebulized treatments 2
• Add ipratropium bromide 0.5 mg to each nebulizer treatment 2
• Consider IV magnesium sulfate 2 g over 20 minutes for severe refractory cases 2, 7

Hospital Management for Severe/Refractory Cases

Continue intensive treatment: 2, 7

• Nebulized albuterol every 15-20 minutes or continuous nebulization 2
• Ipratropium bromide 0.5 mg every 20 minutes for 3 doses, then every 4-6 hours 2
• Systemic corticosteroids: prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours 2
• Oxygen to maintain SaO₂ >90% 2

Adjunctive therapies for severe exacerbations: 2, 7

• IV magnesium sulfate 2 g over 20 minutes (reduces hospitalizations in severe airflow obstruction) 2
• Chest X-ray to exclude pneumothorax, consolidation, or pulmonary edema 2

ICU Transfer Criteria

Immediate ICU transfer if: 2, 4

• Life-threatening features persist (silent chest, cyanosis, altered mental status) 2
• Deteriorating PEF despite treatment 2
• Worsening or persistent hypoxia 2
• Rising PaCO₂ or respiratory acidosis 4
• Exhaustion, confusion, or impending respiratory arrest 2, 7

Critical Pitfalls to Avoid

Never underestimate severity—patients, families, and clinicians frequently fail to recognize dangerous exacerbations due to inadequate objective measurements. 1, 2 Always measure PEF or FEV₁. 2

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

Do not delay corticosteroids while "trying bronchodilators first"—they must be given immediately. 2

Normal oxygen saturation does not exclude severe exacerbation—assess PEF and clinical features. 4

Avoid bolus aminophylline in patients already taking oral theophyllines. 1

Do not delay intubation once respiratory failure is imminent—it should be performed semi-electively before respiratory arrest. 2, 7

Discharge Criteria

Patients may be discharged when: 2

• PEF ≥70% of predicted or personal best 2
• Symptoms minimal or absent 2
• Oxygen saturation stable on room air 2
• Patient stable for 30-60 minutes after last bronchodilator dose 2

At discharge, ensure: 2

• Oral corticosteroids for 5-10 days (no taper needed for courses <10 days) 2
• Initiate or continue inhaled corticosteroids 2
• Provide written asthma action plan 2
• Verify inhaler technique 2
• Arrange follow-up within 1 week 1, 2