What is the recommended management for a patient presenting with an acute asthma exacerbation?

Acute Asthma Exacerbation Management

Immediately administer high-dose inhaled albuterol (5 mg via nebulizer or 4–8 puffs via MDI with spacer every 20 minutes for three doses), systemic corticosteroids (prednisolone 40–60 mg orally or IV hydrocortisone 200 mg), and supplemental oxygen to maintain SaO₂ >90%, all within the first 15–30 minutes. 1

Initial Assessment and Severity Recognition

Measure peak expiratory flow (PEF) or FEV₁ within the first 15–30 minutes, as failure to obtain objective measurements is the most common preventable cause of asthma deaths. 1 Never rely solely on subjective clinical impression—patients, families, and clinicians frequently underestimate severity. 1

Severe Exacerbation Features

• Inability to speak a full sentence in one breath 1, 2
• Respiratory rate >25 breaths/min 1, 2
• Heart rate >110 beats/min 1, 2
• PEF <50% of predicted or personal best 1, 2

Life-Threatening Features (Immediate ICU Consideration)

• PEF <33% of predicted 1, 2
• Silent chest, cyanosis, or feeble respiratory effort 1, 2
• Bradycardia or hypotension 1, 2
• Altered mental status (confusion, drowsiness, exhaustion) 1, 2
• Normal or elevated PaCO₂ ≥42 mmHg in a breathless patient 1, 2
• Severe hypoxia (PaO₂ <8 kPa) despite oxygen therapy 1

Immediate Treatment Protocol (First Hour)

Oxygen Therapy

Deliver 40–60% oxygen via face mask or nasal cannula, targeting SaO₂ >90% (>95% in pregnancy or cardiac disease). 1, 2 Oxygen does not worsen CO₂ retention in asthma. 1

Bronchodilator Therapy

Administer nebulized albuterol 5 mg (or terbutaline 10 mg) every 20 minutes for three doses. 1, 2 For children weighing <15 kg, use half the adult dose (2.5 mg albuterol). 1, 2 Alternatively, give 4–8 puffs via MDI with spacer every 20 minutes—both delivery methods are equally effective when properly administered. 1, 3

Systemic Corticosteroids (Must Be Given Immediately)

Do not delay corticosteroid administration while "trying bronchodilators first"—steroids must be given immediately, as clinical benefits require a minimum of 6–12 hours to manifest. 1, 4

• Adults: Prednisolone 40–60 mg orally OR IV hydrocortisone 200 mg 1, 2
• Children: Prednisolone 1–2 mg/kg (maximum 40–60 mg) 1, 2
• Oral administration is as effective as IV when tolerated and is preferred. 1

Ipratropium Bromide for Moderate-to-Severe Exacerbations

Add ipratropium bromide 0.5 mg to each nebulized treatment (or 8 puffs via MDI) every 20 minutes for three doses, then as needed. 1, 5 This combination reduces hospitalizations, particularly in patients with severe airflow obstruction. 1, 5

Reassessment After Initial Treatment (15–30 Minutes)

Re-measure PEF/FEV₁ and reassess symptoms and vital signs to guide further management. 1

Good Response (PEF >75% Predicted)

• Step up usual maintenance therapy 1
• Continue monitoring with a PEF chart 1
• Arrange follow-up within 48 hours 1

Incomplete Response (PEF 50–75% Predicted)

• Continue nebulized β-agonist every 4–6 hours 1, 2
• Ensure prednisolone has been administered 1
• Consider hospital admission if severe features persist 1

Poor Response (PEF <50% Predicted or Severe Features Persist)

• Increase nebulized β-agonist frequency to every 15–30 minutes or consider continuous nebulization 1, 2
• Repeat ipratropium bromide 0.5 mg every 20 minutes 1
• Arrange immediate hospital admission 1, 2

Adjunctive Therapies for Refractory Cases

Intravenous Magnesium Sulfate

Consider IV magnesium sulfate 2 g over 20 minutes for severe exacerbations with PEF <40% after initial treatment or life-threatening features. 1, 5 This significantly increases lung function and decreases hospitalization necessity. 1

Intravenous Aminophylline or Beta-Agonists

For life-threatening exacerbations unresponsive to initial measures, consider IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 µg over 10 minutes. 1, 2 Never give a bolus aminophylline to patients already receiving oral theophyllines. 1, 2

Critical Pitfalls to Avoid

• Sedatives are absolutely contraindicated in acute asthma and must never be administered. 1, 2
• Do not delay corticosteroid administration while "trying bronchodilators first"—both must be given immediately. 1
• Never rely solely on subjective assessment—objective PEF/FEV₁ measurement is essential to avoid underestimation of severity. 1
• Do not underestimate severity based on patient appearance alone—patients frequently fail to recognize dangerous exacerbations. 1

Hospital Admission Criteria

Immediate admission is required for: 1, 2

• Any life-threatening feature present
• Persistent severe attack after initial therapy
• PEF <33% predicted after treatment
• PEF <50% predicted after 1–2 hours of intensive therapy

Lower threshold for admission applies when: 1

• Presentation occurs in the afternoon/evening
• Recent nocturnal or worsening symptoms
• Previous severe attacks requiring intubation/ICU
• ≥2 hospitalizations or ≥3 emergency visits in the past year
• Poor social circumstances limiting reliable monitoring

ICU Transfer Criteria

Transfer to ICU is indicated when: 1

• Deteriorating PEF despite treatment
• Exhaustion or altered mental status
• Rising arterial CO₂ (≥42 mmHg)
• Worsening hypoxia despite oxygen
• Silent chest, cyanosis, or feeble respiratory effort
• Respiratory arrest or impending respiratory failure

Discharge Planning (After Stabilization)

Patients may be discharged when: 1

• PEF ≥70–75% of predicted or personal best
• Symptoms are minimal or absent
• SaO₂ is stable on room air
• Patient remains stable for 30–60 minutes after the last bronchodilator dose

At discharge, ensure: 1

• Continue oral corticosteroids for 5–10 days (no taper needed for courses <10 days)
• Initiate or continue inhaled corticosteroids
• Verify and document correct inhaler technique
• Provide a written asthma action plan with peak-flow zones
• Supply a peak-flow meter if the patient does not already have one
• Arrange follow-up with primary care within 1 week and specialist within 4 weeks