Severe Asthma Management Algorithm

Evidence-based management of severe asthma exacerbations following GINA 2024 guidelines and latest clinical recommendations.

Emergency Protocol Updated 2024 GINA Guidelines

Quick Assessment Tool

Respiratory Rate

Oxygen Saturation

Peak Flow

Severe Asthma Management Algorithm

1

Initial Assessment & Recognition

Key Symptoms:

  • Severe dyspnea at rest
  • Inability to speak in complete sentences
  • Use of accessory muscles
  • Pulsus paradoxus >12 mmHg
  • Peak flow <40% predicted

Red Flags:

  • Altered mental status
  • Silent chest
  • Cyanosis
  • Bradycardia
  • Hypotension
2

Immediate Interventions

Oxygen Therapy

  • • High-flow oxygen (15 L/min)
  • • Target SpO₂ 94-98%
  • • Monitor for CO₂ retention

Bronchodilators

  • • Albuterol 5-10 mg via nebulizer
  • • Ipratropium 0.5 mg
  • • Repeat every 20 min × 3 doses

Systemic Steroids

  • • Methylprednisolone 125 mg IV
  • • Or Prednisone 50 mg PO
  • • Continue for 5-7 days
3

Response Assessment (30-60 minutes)

Good Response

  • • PEF >60% predicted
  • • SpO₂ >95% on room air
  • • Normal speech
  • • No accessory muscle use
Action:

Continue treatment, consider discharge with follow-up

Poor Response

  • • PEF <40% predicted
  • • SpO₂ <90%
  • • Severe dyspnea
  • • Accessory muscle use
Action:

Proceed to Step 4 - ICU admission

4

ICU Management (Severe Cases)

Advanced Therapies:

Magnesium Sulfate

2g IV over 20 minutes (single dose)

Heliox

70:30 helium-oxygen mixture

Non-invasive Ventilation

CPAP/BiPAP if no contraindications

Intubation Criteria:

  • Respiratory arrest
  • Altered mental status
  • Severe hypoxemia (SpO₂ <85%)
  • Respiratory acidosis (pH <7.25)
  • Hemodynamic instability

Note: Consider ketamine for induction (1-2 mg/kg IV) as it has bronchodilator properties.

5

Monitoring & Follow-up

Continuous Monitoring:

  • • SpO₂, HR, BP
  • • Respiratory rate
  • • Peak flow
  • • Mental status

Discharge Criteria:

  • • PEF >70% predicted
  • • SpO₂ >95% on room air
  • • Normal physical exam
  • • Stable for 4 hours

Follow-up Plan:

  • • PCP within 1 week
  • • Pulmonologist referral
  • • Asthma action plan
  • • Trigger avoidance

Medication Reference

Albuterol (Salbutamol)

Short-acting β₂-agonist

  • Dose: 5-10 mg nebulized
  • Frequency: Every 20 min × 3
  • Side effects: Tachycardia, tremor

Ipratropium

Anticholinergic

  • Dose: 0.5 mg nebulized
  • Frequency: Every 20 min × 3
  • Side effects: Dry mouth, blurred vision

Methylprednisolone

Systemic corticosteroid

  • Dose: 125 mg IV
  • Frequency: Single dose
  • Side effects: Hyperglycemia, insomnia

Magnesium Sulfate

Bronchodilator

  • Dose: 2g IV over 20 min
  • Frequency: Single dose
  • Side effects: Hypotension, flushing

Ketamine

Induction agent

  • Dose: 1-2 mg/kg IV
  • Use: Intubation induction
  • Side effects: Hypertension, emergence

Epinephrine

α and β agonist

  • Dose: 0.3-0.5 mg IM
  • Use: Anaphylaxis
  • Side effects: Tachycardia, HTN

Clinical Pearls

Key Points:

  • • Early recognition is crucial - don't wait for severe symptoms
  • • Oxygen first, then bronchodilators
  • • Steroids work within 4-6 hours
  • • Magnesium is underutilized but effective
  • • Consider intubation early if patient is tiring

Common Pitfalls:

  • • Delaying steroid administration
  • • Inadequate bronchodilator dosing
  • • Not monitoring for CO₂ retention
  • • Missing underlying triggers
  • • Inadequate follow-up planning