Assessing the seriousness of an asthma attack and promptly presenting to the emergency department is crucial. Assess the patient's airway, breathing, and circulation and initial vital signs.
- Quickly assess any patient with respiratory distress: vital signs, mental status (signs of tiring from work of breathing), lung examination (how well they are moving air), oxygen saturation.
- Consider comorbidities and advanced directives.
- Consider alternative diagnoses requiring other therapies (eg, congestive heart failure, pneumonia, pneumothorax, foreign body aspiration). Depending on patient history, a chest x-ray and/or ECG may be warranted.
Every patient should receive supplemental oxygen adjusted to maintain arterial oxygen saturation (SaO₂) between 92% and 98%.
- High-flow nasal cannula (HFNC) is a viable option for patients experiencing hypoxemia.
- For carefully selected patients with severe and resistant asthma, noninvasive ventilation (NIV) may be beneficial. Bilevel positive airway pressure (BiPAP) is well tolerated by pediatric patients with acute severe asthma and may reduce the need for intubation and mechanical ventilation.
- Indications for intubation include coma, altered consciousness, cardiac or respiratory arrest, paradoxical breathing pattern, refractory hypoxemia, and failure of NIV.
- Ventilator management in the intubated asthmatic is critical and includes lower tidal volumes.
- Inhaled beta-2 agonists: For patients presenting with acute asthma exacerbations, it is recommended to use inhaled short-acting beta-2 agonists (SABAs) such as albuterol. Beta-agonist therapy may be given in line with mechanical ventilation.
- Epinephrine: In cases of anaphylaxis or angioedema, supplementing standard asthma therapy with intramuscular (IM) epinephrine 0.3 mg is advised. For children, dosing is 0.01 mg/kg, up to 0.3 mg.
- Corticosteroids: All patients experiencing an acute asthma exacerbation should receive corticosteroids. Studies show that oral corticosteroids are as effective as intravenous (IV) therapy. Oral steroids are preferred unless intubation is imminent or the patient is severely ill, is unable to swallow or is vomiting, or is suspected to have impaired gastrointestinal transit or absorption. IM dexamethasone is an option if oral or IV administration are not possible.
- Anticholinergic medications: In cases of severe acute asthma, treatment recommendations include adding ipratropium (0.5 mg) along with the first 3 albuterol treatments.
- Magnesium:
- For children with persistent severe asthma and hypoxemia after initial treatment or a peak expiratory flow of less than 60% after 1 hour of care, the addition of magnesium is beneficial in reducing the need for hospital admission. A recommended dose is 40 mg/kg/day (up to a maximum of 2 g) of IV magnesium sulfate.
- For severe exacerbations in adults, recommended dosing is 2 g over 20 minutes.
