Asthma Exacerbations: ER and Inpatient Management

Initial Assessment

History, physical (auscultation, use of accessory muscles), PEV or FEV₁, oxygen saturation, other tests as indicated.

Classify Severity of Asmtha

If impending or actual respiratory arrest

• Start ABCs, then admit to PICU.
• Intubation, Mechanical Ventilation with 100% FiO₂
• Nebulized beta₂-agonist and anticholinergic
• Intravenous steroid

If FEV₁ or PEF < 50% (Severe Exacerbation)

• Oxygen to achieve O₂saturation => 90%
• Inhaled high-dose beta₂-agonist and anticholinergic by nebulization every 20 minutes or continuously for one hour
• Oral steroid

If FEV₁ or PEF > 50%

• Oxygen to achieve O₂ saturation => 90%
• Inhaled beta₂agonist by metered dose inhaler or nebulizer, up to three treatments in first hour
• Oral steroids if not immediate response or if patient recently took oral steroids

Repeat Assessment

Symptoms, physical examination, PEF, O₂saturation, other tests as needed.

Reclassify after above treatment

Moderate Exacerbation

• FEV₁ or PEF 50-80% of predicted/personal best
• Physical exam: moderate symptoms
• Inhaled short-acting beta₂-agonist every 60 minutes
• Systemic steroid
• Continue treatment 1-3 hours, provided there is an improvement

Severe Exacerbation

• FEV₁ or PEF < 50% of predicted/personal best
• Physical exam: severe symptoms at rest, accessory muscle use, chest retraction,
• History: High-risk patient
• No improvement after initial therapy
• Oxygen
• Inhaled short-acting beta₂-agonist hourly or continuously + inhaled anticholinergic
• Systemic steroid

Classify Response

Good Response:

• Discharge Patient to Home (see below)
• FEV₁ or PEF => 70%
• Response sustained 60 minutes after last treatment
• No distress
• Physical exam: normal

Incomplete Response

• Decide whether to discharge to home or admit (see below) on case-by-case basis
• FEV₁ or PEF => 50% by < 70%
• Mild-to-moderate symptoms

Poor Response

• Admit to Intensive Care Unit (see below)
• FEV₁ or PEF < 50%
• PCO₂=> 42 mmHg
• Physical exam: symptoms severe, drowsiness, confusion

Outcomes, by response level

Discharge to home

• Continue treatmet with inhaled beta₂-agonist
• Continue course of oral steroid
• Patient education
• review medication use
• review/initiate action plan
• recommend close medical follow-up

Admit to Hospital Ward

• Inhaled beta₂-agonist + inhaled anticholinergic
• Systemic steroid
• Oxygen
• Monitor FEV₁ or PEF, and SaO₂
• When improved, discharge home, as above.

Admit to Hospital Intensive Care

• Inhaled beta₂-agonist hourly or continuously + inhaled anticholinergic
• Intravenous steroid
• Oxygen
• Possible intubation and mechanical ventilation
• When improved, step down to ward status, as above.