What is the management of an asthma attack?

Management of Asthma Attack

Immediately administer high-dose nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer AND oral prednisolone 30-60 mg (adults) or 1-2 mg/kg (children, maximum 40 mg) within the first few minutes of presentation, while simultaneously providing supplemental oxygen to maintain SpO₂ >90% (>95% in pregnancy or cardiac disease). 1, 2

Initial Assessment (First 5 Minutes)

Severity classification determines treatment intensity and disposition:

Severe Exacerbation Features 1, 2

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min (adults) or >50 breaths/min (children)
• Heart rate >110 beats/min (adults) or >140 beats/min (children)
• Peak expiratory flow (PEF) <50% of predicted or personal best

Life-Threatening Features Requiring ICU Consideration 1, 2

• PEF <33% predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Altered mental status (confusion, drowsiness, exhaustion)
• Bradycardia or hypotension
• Normal or elevated PaCO₂ ≥42 mmHg in a breathless patient

Immediate Treatment Protocol (First Hour)

First-Line Therapy 1, 2, 3

• Oxygen: 40-60% via face mask to maintain SpO₂ >90% (>95% in pregnancy/cardiac disease)
• Nebulized salbutamol: 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer every 20 minutes for 3 doses
  • Alternative: 4-8 puffs via MDI with spacer every 20 minutes for 3 doses
  • Children <15 kg: use half doses (2.5 mg salbutamol)
• Systemic corticosteroids: Prednisolone 30-60 mg PO (adults) or 1-2 mg/kg PO (children, max 40 mg)
  • If vomiting or critically ill: IV hydrocortisone 200 mg (adults) or 4-7 mg/kg (children)

Add Ipratropium for Moderate-to-Severe Cases 1, 2

• Ipratropium bromide 0.5 mg added to nebulizer with second and third doses of salbutamol (can be mixed in same nebulizer)
• Continue every 4-6 hours after initial three doses

Reassessment at 15-30 Minutes 1, 2

Measure PEF, respiratory rate, heart rate, SpO₂, and clinical appearance:

Good Response (PEF >75% predicted) 1

• Continue usual maintenance therapy with modest step-up
• Monitor symptoms and PEF on chart
• Arrange follow-up within 48 hours

Incomplete Response (PEF 50-75% predicted) 1, 2

• Continue nebulized salbutamol every 4-6 hours
• Continue oral prednisolone 30-60 mg daily for 5-10 days (no taper needed)
• Consider hospital admission if severe features persist

Poor Response (PEF <50% predicted or persistent severe features) 1, 2

• Increase nebulizer frequency to every 15-30 minutes
• Continue ipratropium every 4-6 hours
• Arrange immediate hospital admission

Escalation for Refractory Cases 1, 2

If No Improvement After 1 Hour of Intensive Treatment:

• IV magnesium sulfate 2 g over 20 minutes (adults) or 25-75 mg/kg up to 2 g (children)
• Consider continuous nebulization of salbutamol
• IV aminophylline 250 mg over 20 minutes (adults) or 5 mg/kg over 20 minutes followed by 1 mg/kg/h infusion (children)
  • NEVER give bolus aminophylline to patients already on oral theophylline 1

Hospital Admission Criteria 1, 2

Admit immediately if:

• Any life-threatening features present
• PEF <33% predicted after treatment
• PEF <50% predicted after 1-2 hours of intensive treatment
• Features of severe attack persist after initial treatment
• Presentation in afternoon/evening with recent nocturnal symptoms
• Previous severe attacks requiring intubation or ICU admission

ICU Transfer Criteria 1, 2

Transfer accompanied by physician prepared to intubate if:

• Deteriorating PEF despite therapy
• Worsening or persistent hypoxia or hypercapnia
• Exhaustion, feeble respirations, confusion, or drowsiness
• Impending respiratory arrest

Monitoring Throughout Treatment 1

• Continuous pulse oximetry maintaining SaO₂ >92%
• Repeat PEF measurement 15-30 minutes after starting treatment
• Chart PEF before and after each bronchodilator dose
• Monitor respiratory rate, heart rate, and clinical appearance continuously

Critical Pitfalls to Avoid 1, 2

• NEVER administer sedatives of any kind—this is absolutely contraindicated and potentially fatal 1, 2
• Do NOT delay corticosteroids while "trying bronchodilators first"—both must be given immediately 1, 2
• Do NOT underestimate severity—always measure PEF or FEV₁ objectively 1
• Do NOT give bolus aminophylline to patients on oral theophylline 1

Discharge Criteria 1, 2

Patient may be discharged when:

• PEF ≥70-75% of predicted or personal best
• PEF diurnal variability <25%
• Minimal or absent symptoms
• Stable oxygen saturation on room air for 30-60 minutes after last bronchodilator dose
• Been on discharge medications for 24 hours

Discharge Requirements 1, 2

• Verify and document correct inhaler technique
• Provide written self-management plan with PEF zones
• Supply peak flow meter if patient doesn't have one
• Continue oral prednisolone 30-60 mg daily for 5-10 days total (no taper needed for courses <10 days)
• Initiate or optimize inhaled corticosteroids
• Arrange primary care follow-up within 1 week
• Arrange respiratory specialist follow-up within 4 weeks

Special Considerations for Children 1, 4

• Use half doses (salbutamol 2.5 mg) for children weighing <15 kg 1
• Prednisolone dosing: 1-2 mg/kg (maximum 40-60 mg) 1, 4
• Aminophylline should no longer be used in children at home 1
• Children >5 years can reliably use peak flow meters for monitoring 2