Acute Asthma

Acute Asthma

Acute Asthma Evaluation & Management

Initial Notes

  • Assess severity clinically.
  • Anaphylaxis: Epinephrine IM (0.3 mg ≥30 kg, 0.15 mg if 10–30 kg).
  • Thunderstorms during pollen seasons can trigger severe asthma attacks, while sandstorms usually only worsen symptoms without causing severe exacerbations.

Severity Classification

Category

Clinical Features

O₂ Sat

PEF

Action

Mild

Dyspnea with activity only, end-expiratory wheeze

>95%

≥75%

Inhaled/nebulized SABA; repeat PRN

Moderate

Dyspnea limits activity, accessory muscles, expiratory wheeze

90–95%

50–74%

SABA q20min ×1h + Oral steroids ± ED referral (if no improvement)

Severe

Dyspnea at rest interferes with speech, accessory muscles, inspiratory + expiratory wheeze

<90%

<50%

Urgent ED referral, likely admission

Life-threatening

Too dyspneic to speak, drowsy, silent chest

—

<25%

ICU / emergency transfer


Medication Doses

Drug

Children

Adults

Notes

Oxygen

Maintain >95%

Maintain >93%

Low-flow is recommended

Salbutamol 

2.5 mg (or 4 puffs) if <20 kg

5 mg (or 8 puffs) if >20 kg

5 mg (or 8 puffs)

q20min if needed

Ipratropium

0.25 mg (or 4 puffs)

0.5 mg (or 8 puffs)

With salbutamol in moderate/severe attacks

Prednisolone

1–2 mg/kg/day (max 40 mg ×5d)

50 mg/day ×5d

Start within 1h if mod/severe


If a STAT Steroid dose is needed before discharge (e.g. moderate/severe attack):

Adults: Hydrocortisone 100 mg IV or Dexamethasone 8–10 mg IM/IV once.

Children: Hydrocortisone 4 mg/kg IV or Dexamethasone 0.6 mg/kg IM/IV (max 16 mg) once.

Risk Factors for Asthma Death

  • Prior ICU admission or intubation.
  • ≥2 hospitalizations or >3 ED visits in past year.
  • 1 SABA canister/month.
  • Chronic oral steroids (current/recent).
  • Major psychosocial/psychiatric illness.

Approaching Severe/Life-Threatening Asthma

Adults Red Flags

  • Words only, agitation
  • Accessory muscles
  • Pulse >120
  • O₂ sat <90%
  • PEF <50%
  • Silent chest/drowsy

Pediatric Red Flags

  • Unable to speak/drink, drowsy, silent chest
  • O₂ sat <92%
  • RR >60 (0–2 mo), >50 (2–12 mo), >40 (1–5 y)
  • HR >200 (0–3 y), >180 (4–5 y)

Immediate actions

  • Nebulized Salbutamol + Ipratropium with O₂ 6 L/min titrated as needed.
  • Give systemic corticosteroids as soon as possible.
  • Repeat nebs q20min until transfer

Transfer:

  • Activate EMS → Arrange ER transfer
  • If ICU/life-threatining features → Arrange it EARLY


 

Prepared & reviewed by: Dr. Fahad Saad Almutairi, Dr. Bader Thuwaini Alanazi