What is the initial management for a patient presenting to the emergency room (ER) with severe asthma, considering their past medical history and current medications?

Management of Severe Asthma in the Emergency Room

Immediately administer high-flow oxygen (40-60% via face mask or reservoir mask at 15 L/min if SpO₂ <85%), nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer, and systemic corticosteroids (prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg) within the first few minutes of arrival. 1, 2

Initial Assessment and Recognition

Upon arrival, rapidly assess for features of severe or life-threatening asthma:

Severe asthma features: 3, 1

• Cannot 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

Life-threatening features: 3, 2

• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, altered consciousness, or coma
• SpO₂ <92%

First-Line Treatment Protocol (First Hour)

Step 1: Oxygen Therapy

• Target SpO₂ >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Use high-flow oxygen 40-60% via face mask or reservoir mask at 15 L/min if initial SpO₂ <85% 3, 2
• Continue oxygen monitoring until clear response to bronchodilator therapy occurs 1

Step 2: Nebulized Beta-Agonists

• Administer salbutamol 5 mg OR terbutaline 10 mg via oxygen-driven nebulizer 3, 1
• Repeat every 20 minutes for 3 doses in the first hour 1, 2
• If no nebulizer available, give 2 puffs via large volume spacer and repeat (up to 20 puffs maximum) 3

Step 3: Systemic Corticosteroids (Administer Immediately)

• Give prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg 3, 1
• Critical point: Corticosteroids take 6-12 hours to show clinical effect, so early administration is essential 1, 4
• Continue high-dose steroids: prednisolone 30-60 mg daily OR IV hydrocortisone 200 mg every 6 hours 1

Step 4: Add Ipratropium for Severe Cases

• Add ipratropium bromide 0.5 mg to nebulized beta-agonist for severe exacerbations or inadequate response to initial therapy 1, 5, 6
• Can be mixed in the nebulizer with albuterol if used within one hour 7

Reassessment at 15-30 Minutes

Measure PEF or FEV₁, assess symptoms, vital signs, and oxygen saturation 1:

If PEF >75% predicted: 3

• Step up usual treatment
• Consider discharge with close follow-up

If PEF 50-75% predicted: 3

• Repeat nebulized beta-agonist
• Give prednisolone 40 mg if not already administered
• Wait 30 minutes and reassess

If PEF <50% predicted or severe features persist: 3

• Arrange hospital admission
• Continue intensive treatment

Additional Interventions for Life-Threatening or Refractory Cases

Intravenous Magnesium Sulfate

• Give IV magnesium sulfate 2g over 20 minutes for severe exacerbations unresponsive to initial treatment 8, 5, 6

Parenteral Beta-Agonists or Aminophylline

• Consider IV aminophylline 250 mg over 20 minutes OR subcutaneous terbutaline 250 µg for life-threatening exacerbations 3, 1
• Caution: Use aminophylline with extreme caution if patient already taking theophyllines 3

Arterial Blood Gas Monitoring

• Repeat arterial blood gases within 2 hours if initial PaO₂ <8 kPa or if PaCO₂ was normal/elevated 2

Critical Pitfalls to Avoid

Absolutely contraindicated: 1

• Sedatives of any kind—never administer in acute asthma
• Antibiotics unless bacterial infection (pneumonia/sinusitis) is confirmed

Avoid treatments lacking evidence: 8

• Aggressive hydration or large volumes of liquids
• Mucolytics
• Chest physiotherapy
• Over-the-counter antihistamines or cold remedies

Criteria for Hospital Admission

Admit if any of the following persist after initial treatment: 3, 1, 2

• Any life-threatening features present
• PEF <33% predicted after treatment
• Features of severe attack persist after 1-2 hours of intensive treatment
• PEF <50% predicted with inadequate response

Criteria for ICU Transfer

Transfer immediately if: 2

• Deteriorating PEF despite treatment
• Worsening or persisting hypoxia
• Hypercapnia
• Exhaustion, confusion, drowsiness, or altered mental status
• Patient unconscious or confused—call ICU/anesthesia immediately and do not attempt intubation until most expert available doctor is present 3

Monitoring During Treatment

• Measure and record PEF 15-30 minutes after starting treatment, then according to response 1
• Monitor oxygen saturation continuously until clear response occurs 1, 8
• Assess for signs of clinical deterioration requiring escalation of care 2

Special Considerations

High-risk patients requiring extra vigilance: 3

• Previous ICU admissions or intubations
• Recent hospitalizations or frequent ED visits
• Poor perception of airflow obstruction severity
• History of sudden severe (brittle) asthma

Stay with the patient until ambulance arrives if arranging transfer 3