5th January 2024

Management of acute asthma exacerbation in adults

Determining severity

The severity of asthma is graded as follows:

Table1. Asthma severity classification

SIGN Asthma Guideline Quick Reference Guide 2019 [Internet]. British Thoracic Society; 2019. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2019/

Assess the need for hospital admission

All patients with life-threatening asthma should be admitted to hospital. All patients with features of severe asthma persisting after initial bronchodilator therapy should be admitted. Patients with moderate asthma with worsening symptoms after initial treatment, or those who have had previous life-threatening attacks should be admitted.

Treatment of acute asthma

• Maintain a saturation of 94-98% with supplemental oxygen if required
• Beta 2 agonist bronchodilator (Salbutamol) via nebuliser. In patients with acute severe or life-threatening asthma, nebuliser should be oxygen-driven. Use intravenous Beta 2 agonist if inhaled therapy cannot be used reliably.
• Nebulised Ipratropium bromide (0.5 mg 4-6 hourly) for acute severe or life-threatening exacerbation or for those with inadequate response to initial Beta 2 agonist.
• Steroid to all patients with asthma exacerbation. Continue with prednisolone (40-50 mg daily) until recovery or minimum of 5 days.
• Single dose of intravenous magnesium sulphate (1.2-2 g infusion over 20 minutes) can be given in acute severe or life-threatening asthma who have had inadequate response to initial bronchodilators.
• Antibiotics should only be given in case of bacterial infection.

Any patient with one of the following features should be referred to critical care:

• Any patient who is requiring ventilatory support.
• Patients with severe or life-threatening asthma who fail to respond to therapy as:
  • Worsening PEF
  • Worsening hypoxia
  • Hypercapnia
  • Acidosis on ABG
  • Exhaustion
  • Respiratory arrest
  • Confusion or altered consciousness