Management of asthma exacerbations in adults: Emergency department or urgent care

Features that help with assessment of severity (may or may not be present):

Impending respiratory failure:
- Cyanosis, inability to maintain respiratory effort, depressed mental status, SpO₂ <90%
- PaCO₂ >40 mmHg
Severe exacerbation:
- Speaks in single words
- Sits hunched forward
- Agitated, diaphoretic
- Respiratory rate >30 breaths/minute
- Heart rate >120 beats/minute
- SpO₂ (on air) <90%
- PEF ≤50% predicted or personal best
Mild to moderate exacerbation:
- Talks in phrases or sentences
- Prefers sitting to lying
- Not agitated
- Respiratory rate 16 to 30 breaths/minute
- Heart rate 100 to 120 beats/minute
- SpO₂ >90%
- PEF >50% but <80% predicted or personal best

PEF: peak expiratory flow; ICU: intensive care unit; SABA: short-acting beta agonist (eg, albuterol); SpO₂: pulse oxygen saturation; COPD: chronic obstructive pulmonary disease; MDI: metered dose inhaler; GC: glucocorticoid; PaCO₂: carbon dioxide tension.

* Titrate oxygen to SpO₂ 93 to 95% for patients with severe exacerbations, particularly if at risk for hypercapnia. Aim for SpO₂ >95% in pregnant patients. Titrate to SpO₂ 88 to 92%, if asthma-COPD overlap.

¶ Magnesium sulfate is 4.06 mmol/g (2 g = 8.1 mmol).

Δ Please refer to the UpToDate topic on treatment of asthma exacerbations in adults.

◊ Adding ipratropium to albuterol nebulizer treatments is preferred for patients with severe exacerbations; alternatively, SABA/ipratropium can be given via MDI 4 to 8 inhalations every 20 minutes, as needed for up to 3 hours.

§ The dose and duration of therapy can be modified based on the patient's past history of response, severity of exacerbation, and response to current treatment.

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Management of asthma exacerbations in adults: Emergency department or urgent care