Management of Asthma Exacerbation

Initial Assessment and Severity Classification

The American College of Allergy, Asthma, and Immunology recommends assessing severity based on symptoms, signs, and lung function (PEF or FEV1), with classifications including mild, moderate, severe, and life-threatening 2
In infants, assessment depends more on physical examination than objective measurements, with signs of serious distress including use of accessory muscles, wheezing, paradoxical breathing, cyanosis, and respiratory rate >60 breaths/min 4

The American Thoracic Society recommends administering oxygen through nasal cannulae or mask to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease) 1, 2, 3
Monitor oxygen saturation continuously until clear response to bronchodilator therapy 1, 3

The National Asthma Education and Prevention Program recommends albuterol (short-acting β2-agonist) as first-line treatment for all asthma exacerbations, with administration options including nebulizer and MDI with spacer 1, 2
Administration dosing: 2.5-5 mg via nebulizer or 4-12 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2

The American College of Chest Physicians recommends administering early systemic corticosteroids for all moderate-to-severe exacerbations, with oral prednisone 40-60 mg in single or divided doses for adults 1, 2, 3
For children: 1-2 mg/kg/day (maximum 60 mg/day) 1

The American Academy of Allergy, Asthma, and Immunology recommends adding ipratropium bromide to β2-agonist therapy for severe exacerbations, with dosing: 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2, 3

The European Respiratory Society recommends considering magnesium sulfate for patients with severe refractory asthma, with standard adult dose: 2 g IV administered over 20 minutes 1, 2

The American College of Emergency Physicians recommends initial assessment and treatment within first 15-30 minutes, including oxygen, first dose of albuterol, and systemic corticosteroids 1, 2
Reassess patient 15-30 minutes after starting treatment, and measure PEF or FEV₁ before and after treatments 1, 2

The American Thoracic Society recommends hospital admission for any life-threatening features, features of acute severe asthma present after initial treatment, and lower threshold for admission with history of recent nocturnal symptoms, recent hospital admission, or previous severe attacks 2
In infants, lack of response to short-acting β2-agonist therapy indicates need for hospitalization 4

The European Respiratory Society recommends discharge criteria including clinical stability, improved oxygen saturation and lung function (FEV1 and PEF), normal breath rate, and absence of chest wall indrawing 5
Appropriate home care and written asthma action plan arranged 5

The Journal of Allergy and Clinical Immunology recommends that EMS providers should not delay patient transport to the hospital while administering bronchodilator treatment, with treatment repeated during transport to a maximum of 3 bronchodilator treatments during the first hour and then 1 per hour 4