Acute severe asthma Treatment

Treatment

Life-threatening or severe asthma.
Salbutamol 5mg nebulized with oxygen.
If PEF remains <75%, repeat salbutamol and give prednisolone 30mg PO.
Monitor oxygen saturation, heart rate, and respiratory rate.

Immediate management of acute severe asthma
Assess severity of attack. Warn ITU if attack severe.
Start treatment immediately (prior to investigations).
Sit patient up and give high-dose O2 in: 100% via non-rebreathing bag.
Salbutamol 5mg (or terbutaline 10mg) plus ipratropium bromide 0.5mg nebulized with O2.
Hydrocortisone 100mg IV or prednisolone 40-50mg PO or both if very ill.
CXR to exclude pneumothorax.
If life-threatening features (above) present:
Inform ITU, and seniors.
Add magnesium sulphate (MgSO4) 1.2-2g IV over 20min.
Give salbutamol nebulizers every 15min, or 10mg continuously per hour.

Further management
If improving
40-60% O2.
Prednisolone 40-50mg/24h PO.
Nebulized salbutamol every 4h.
Monitor peak flow and oxygen saturations.

If patient not improving after 15-30min
Continue 100% O2 and steroids.
Hydrocortisone 100mg IV or prednisolone 30mg PO if not already given.
Give salbutamol nebulizers every 15min, or 10mg continuously per hour.
Continue ipratropium 0.5mg every 4-6h.

If patient still not improving
Discuss with seniors and ITU.
Repeat salbutamol nebulizer every 15min.
MgSO4 1.2-2g IV over 20min, unless already given.
Consider aminophylline; if not already on a theophylline, load with eg 5mg/kg IVI over 20min,1 then 500µg/kg/h where kg is ideal body weight, p434—eg in a small adult: 750mg/24h; large adult 1200mg/24h. Adjust dose according to plasma theophylline, if available. Do levels if infusion lasts >24h. Alternatively, give salbutamol IVI, eg 3-20µg/min. IPPV may be required.
If no improvement, or life-threatening features are present, consider transfer to ITU, accompanied by a doctor prepared to intubate.