Home Management of Asthma Exacerbations

Assess Symptoms and Peak Flow

• Patients at high risk for asthma-related death (see high risk criteria) should receive immediate clinical attention after initial treatment.  More intensive therapy may be required.

Mild to Moderate Exacerbation

• FEV1 or PEF 50-80% of predicted/personal best
• Signs and Symptoms
• Cough, breathlessness, wheeze, chest tightness (correlates imperfectly with severity of the exacerbation) or
• Waking at night due to asthma, or
• Decreased ability to perform usual activities

Severe Exacerbation

• FEV1 or PEF < 50% predicted or personal best
• Signs and Symptoms
• Marked wheezing and shortness of breath
• Cyanosis
• Trouble walking or talking due to asthma
• Accessory muscle use
• Suprasternal retractions
• Advise patient to IMMEDIATELY
• Take up to 3 treatments of 4-6 puffs of beta2-agonist every 20 minutes prn
• Start oral steroid (see doses below)
• Contact clinician
• Proceed to emergency department or call ambulance or 9-1-1

If Less Than Severe Exacerbation

Instruct Patient

• Inhaled short-acting beta2-agonist
• Up to three treatments of 2-4 puffs by MDI at 20 minute intervals, or
• Single nebulizer treatment
• Assess symptoms and/or peak flow after 1 hour

Assess response to treatment

Good Response

• FEV1 or PEF > 80% predicted or personal best and/or
• Signs or Symptoms
• No wheezing, shortness of breath, cough, chest tightness and
• Response to beta-agonist sustained for 4 hours
• Instruct Patient
• May continue 2-4 puffs beta2-agonist every 3-4 hours for 24-48 hours prn
• For patients on inhaled steroids, double dose for 7-10 days
• Contact clinician within 48 hours for instructions

Incomplete Response (Moderate Exacerbation)

• FEV1 or PEF 50-80% of predicted or personal best or
• Signs and Symptoms
• Persistent wheezing, shortness of breath, cough or chest tightness
• Instruct Patient
• Take 2-4 puffs beta2-agonist every 2-4 hours for 24-48 hours prn
• Add oral steroid (see doses below)
• Contact clinician urgently (same day) for instructions

Poor Response (Severe Exacerbation)

• FEV1 or PEF < 50% or
• Signs and Symptoms
• Marked wheezing, shortness of breath, cough, or chest tightness
• Distress is severe and nonresponsive
• Reponse to beta2-agonist lasts < 2 hours
• Instruct Patient to IMMEDIATELY
• Take up to 3 treatments of 4-6 puffs of beta2-agonist every 20 minutes prn
• Start oral steroid (see doses below)
• Contact clinician
• Proceed to emergency department or call ambulance or 9-1-1

Oral Steroid Doses

• Child:  1-2 mg/kg/day, maximum 60 mg/day, for 3-10 days
• Adult:  40-60 mg, single or 2 divided doses for 3-10 days