Immediate treatment

• Oxygen to maintain SpO₂ 94–98%.
• β₂ bronchodilator (salbutamol 5mg) via an oxygen-driven nebuliser.
• Ipratropium bromide 0.5mg via an oxygen-driven nebuliser.
• Prednisolone tablets 40–50mg or IV hydrocortisone 100mg.
• No sedatives of any kind.
• Chest X-ray if pneumothorax or consolidation are suspected or patient requires mechanical ventilation.

If life-threatening features are present:

• Discuss with senior clinician and ICU team.
• Consider IV magnesium sulphate 1.2–2g infusion over 20 minutes (unless already given).
• Give nebulised β₂ bronchodilator more frequently e.g. salbutamol 5mg up to every 15-30 minutes or 10mg per hour via continuous nebulisation (requires special nebuliser.
• Measure arterial blood gases.

Subsequent management

If patient is improving continue:

• Oxygen to maintain SpO₂ 94–98%.
• Prednisolone 40–50mg daily or IV hydrocortisone 100 mg 6 hourly.
• Nebulised β₂ bronchodilator with ipratropium 4–6 hourly.

If patient not improving after 15-30 minutes:

• Continue oxygen and steroids.
• Use continuous nebulisation of salbutamol at 5–10 mg/hour if an appropriate nebuliser is available. Otherwise give nebulised salbutamol 5 mg every 15–30 minutes.
• Continue ipratropium 0.5 mg 4–6 hourly until patient is improving.

If patient is still not improving:

• Discuss patient with senior clinician and ICU team.
• Consider IV magnesium sulphate 1.2–2 g over 20 minutes (unless already given).
• Senior clinician may consider use of IV β2 bronchodilator or IV aminophylline or progression to mechanical ventilation.

Monitoring

Repeat measurement of PEF 15–30 minutes after starting treatment

• Oximetry: maintain SpO₂ >94–98%.
• Repeat blood gas measurements within 1 hour of starting treatment if:
  • initial PaO₂ <8 kPa (60 mmHg) unless subsequent SpO₂ >92% or
  • PaCO₂ normal or raised or
  • patient deteriorates.
• Chart PEF before and after giving β₂ bronchodilator and at least 4 times daily throughout hospital stay.

Transfer to ICU accompanied by a doctor prepared to intubate if:

• Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
• Exhaustion, altered consciousness
• Poor respiratory effort or respiratory arrest.

Discharge

When discharged from hospital, patients should have:

• Been on discharge medication for 12–24 hours and have had inhaler technique checked and recorded.
• PEF >75% of best or predicted and PEF diurnal variability <25% unless discharge is agreed with respiratory physician.
• Treatment with oral steroids (prednisolone 40–50 mg until recovery - minimum 5 days) and inhaled steroids in addition to bronchodilators.
• Own PEF meter and written asthma action plan.
• GP follow up arranged within 2 working days.
• Follow-up appointment in respiratory clinic within 4 weeks.

Patients with severe asthma (indicated by need for admission) and adverse behavioural
or psychosocial features are at risk of further severe or fatal attacks.

• Determine reason(s) for exacerbation and admission
• Send details of admission, discharge and potential best PEF to GP.