Management of

severe asthma
exacerbation

Levels of severity of acute

asthma exacerbations
Near-fatal asthma

Raised PaCO2
And/or
Requiring mechanical ventilation
with raised inflation pressures

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

Levels of severity of acute

asthma exacerbations
Life Threatening asthma
Clinical signs Measurements
Altered conscious level
PEF <33% best or
predicted
Exhaustion
SpO2 <92%
Arrhythmia
PaO2 <60mmHg
Hypotension
PaCO2 (35-45mmHg)
Cyanosis
Silent chest
Poor respiratory effort

Levels of severity of acute

asthma exacerbations
Acute severe asthma
Any one of:
PEF 33-50% best or predicted
respiratory rate 25/min
heart rate 110/min
inability to complete sentences in
one breath
British Guideline on the Management of Asthma-May 2011
www.brit-thoracic.org.uk

Patients at risk of developing

near-fatal or fatal asthma

Previous near-fatal asthma, eg previous

ventilation or respiratory acidosis
Previous admission for asthma
especially if in the last year
Requiring three or more classes of
asthma medication
Heavy use of 2 agonist
Repeated attendances at ED for asthma
care especially if in the last year
British Guideline on the Management of Asthma-May 2011
www.brit-thoracic.org.uk

Patients at risk of
developing near-fatal or
fatal asthma
Healthcare professionals must
be aware that patients with
severe asthma and one or more
adverse psychosocial factors are
at risk of death.

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

Treatment of acute asthma

in adults
Oxygen

Give supplementary oxygen to all

hypoxaemic patients to maintain an SpO2
level of 94-98%.

Lack of pulse oximetry should not prevent

the use of oxygen.

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

2 agonist
bronchodilators

Use high-dose inhaled 2 agonists as early as possible.

Reserve intravenous 2 agonists for those patients in whom
inhaled therapy cannot be used reliably.

In acute asthma with life threatening features the

nebulised route (oxygen-driven) is recommended.

In severe asthma that is poorly responsive to an initial

bolus dose of 2 agonist, consider continuous nebulisation
with an appropriate nebuliser.

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

Steroid therapy

Give steroids in adequate doses in all cases of acute

asthma. Prednisolone 40-50 mg daily or parenteral
hydrocortisone 400 mg daily (100 mg six-hourly).

Continue prednisolone 40-50 mg daily for at least five days

or until recovery.

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

Ipratropium Bromide

Add nebulised ipratropium bromide (0.5 mg 4-6

hourly) to 2 agonist treatment for patients with
acute severe or life threatening asthma or those
with a poor initial response to 2 agonist therapy.

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

Magnesium sulphate
Consider giving a single dose of IV
magnesium sulphate for
patients :

who have not had a good initial response to inhaled

bronchodilator therapy

life threatening or near fatal asthma.

British Guideline on the Management of Asthma-May 2011

www.brit-thoracic.org.uk

Non-invasive ventilation

A trial of NPPV before intubation and mechanical

ventilation should be considered in selected
patients with acute asthma and respiratory failure
(Evidence Category B).

Proc Am Thorac Soc Vol 6. pp 353356, 2009

Specific settings for

NPPV

Initial EP of 3 cm H2O, increase by 1 cm H2O every 15

minutes to a maximum pressure of 5 cm H2O.

The IP set at 8 cm H2O and increase by 2 cm H2O every 15

min to a maximum pressure of 15 cm H2O or until the RR
25 /min.

Settings should be individualized and guided by careful

evaluation of clinical response.

Proc Am Thorac Soc Vol 6. pp 353356, 2009

INDICATIONS FOR
INTUBATION
Clinical
Cardiac arrest
Respiratory arrest
Altered sensorium
Progressive exhaustion
Silent chest
Laboratory
Severe hypoxemia with maximal oxygen
delivery
Failure to reverse severe respiratory acidosis
despite intensive therapy

Proc Am Thorac Soc Vol 6. pp 353356, 2009

INITIAL VENTILATOR SETTINGS

Controlled mechanical ventilation at 10

breaths/min
Tidal volume at 78 ml/kg (ideal body weight)
Peak inspiratory flow at 60 L/min (constant flow)
or 8090 L/min (decelerating flow)
Fraction of inspired oxygen at 1.0

Proc Am Thorac Soc Vol 6. pp 353356, 2009