Acute Asthma Exacerbation Management

Initial Treatment

The American Thoracic Society recommends beginning high-dose inhaled short-acting beta-agonist (SABA) therapy immediately with albuterol 2.5-5 mg via nebulizer or 4-8 puffs via metered-dose inhaler (MDI) with spacer every 20 minutes for 3 doses, combined with systemic corticosteroids and oxygen to maintain SaO₂ >90% 1, 2
Administer high-flow oxygen at 40-60% immediately via face mask or nasal cannula to maintain SaO₂ >90% (>95% in pregnant patients or those with cardiac disease) 2
Continue oxygen monitoring until clear response to bronchodilator therapy occurs 1

The British Thoracic Society recommends assessing severity using objective measurements, including peak expiratory flow (PEF) and forced expiratory volume in one second (FEV₁), with failure to make these measurements being a common cause of preventable asthma deaths 2, 4
Severe exacerbation features include inability to complete sentences in one breath, respiratory rate >25 breaths/min, heart rate >110 beats/min, and PEF <50% of predicted or personal best 2, 4

The American College of Chest Physicians recommends adding ipratropium bromide 0.5 mg via nebulizer or 8 puffs via MDI to albuterol for all moderate-to-severe exacerbations 1, 2
Administer IV magnesium sulfate 2 g over 20 minutes for life-threatening features or severe exacerbations not responding after 1 hour of intensive treatment 1, 2

Repeat PEF measurement 15-30 minutes after starting treatment and after 3 doses of bronchodilator (60-90 minutes total) 1, 2
Discharge criteria include PEF >75% of predicted or personal best, symptoms minimal or absent, patient stable for 30-60 minutes after last bronchodilator dose, and oxygen saturation stable on room air 1

Continue oral corticosteroids for 5-10 days (no taper needed for courses <10 days) 1, 3
Initiate or continue inhaled corticosteroids at discharge 1, 3
Provide written asthma action plan before discharge and arrange follow-up with primary care within 1 week 1, 4