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Acute Asthma Exacerbation

Stacy Blank


  • History of asthma or a history concerning for asthma

  • Progressive worsening of symptoms: dyspnea, chest tightness, wheezing, and cough

  • Physical exam with wheezing, poor air movement, tachypnea, increased work of breathing, hypoxemia

  • Often use of peak flows is cited in the literature (PEF \<200 L/min or PEF \<50% predicted indicates severe obstruction, PEF \<70% predicted indicates moderate exacerbation)

    • May be useful although often does not change management acutely


  • Generally aimed at ruling out causes for exacerbation and other diagnoses; these are not required but should be considered in pts being admitted for inpatient management:

    • EKG, trop, BNP, D-dimer to assess for cardiac cause (ACS, CHF, PE)

    • CXR to rule out underlying process (PNA, PTX, atelectasis)

    • ABG/VBG not routinely needed unless ill-appearing, tachypneic, or lethargic/altered

  • Dangerous signs and possible ICU if:

    • Tachypnea >30 and/or significantly increased work-of-breathing

    • Hypercapnia or even normocapnia (these pts are usually hyperventilating; a normal CO2 in a severe asthma exacerbation could indicate impending respiratory failure)

    • Altered mental status

    • Requiring continuous nebulizers


  • Continuous pulse ox with oxygen therapy to maintain O2 >92 %

  • Continuous albuterol nebulizer or Duonebs until able to space to q1h>>q2h, etc

  • Steroids with dosing based on severity of illness (there is no data behind exact dosing of steroids).

    • Start with IV methylpred 125mg q6h in severe exacerbation/ICU patients

    • Can start with oral prednisone 60mg q12h in less severe exacerbation/floor pts

    • Plan to transition from IV to PO and then likely to send pt home to finish course of 40-60 mg pred daily for 5-7 days.

  • IV mag sulfate 4g over 20 minutes for severe exacerbation

  • Keep pt NPO until off continuous nebs/respiratory effort is improved. Consider IV fluids with pt’s comorbidities (HFrEF, renal disease) vs. increased insensible losses with resp effort

  • If pt is not responding to therapies, has worsening respiratory status, or blood gas concerning for respiratory acidosis needs ICU care for BiPAP vs mechanical ventilation

  • Note: We do not start empiric antibiotics unless there is concern for bacterial infection

Prior to discharge:

  • Ensure that pt is on appropriate controller medications (see outpatient management)

  • Evaluate for causes of acute exacerbation to prevent future events (noncompliance, resp viruses, allergies, exposures, etc.)

Last update: 2022-06-26 16:15:15