Run back-to-back salbutamol nebs with ipratropium and give systemic steroids early; onset takes hours, so give NOW.
For a severe attack with an inadequate response to initial inhaled treatment, consider magnesium sulfate 2 g IV over 20 minutes once. Avoid sedatives in a non-intubated acute asthma attack.
A silent chest, exhaustion, deteriorating consciousness or rising PaCO₂ signals life-threatening asthma: call a senior airway/ICU clinician and assess urgently for intubation. Choose the induction agent for the patient’s haemodynamics; ketamine is an option, not a mandatory agent.
Once ventilated, allow a long expiratory time and tolerate appropriate hypercapnia. If abrupt hypotension is caused by suspected dynamic hyperinflation, briefly disconnect to permit exhalation; simultaneously assess other causes, including tension pneumothorax and drug-related vasodilatation.
GINA 2026: titrate oxygen to SpO₂ 92–95% in adults and adolescents with an exacerbation; supplemental oxygen is usually needed when SpO₂ is <92%. Do not withhold urgently needed oxygen if oximetry is unavailable.
Investigations
First tests: SpO2 and respiratory assessment, Peak expiratory flow.
Only if indicated: Arterial blood gas, Chest X-ray, Sodium, potassium, bicarbonate, urea and creatinine, Blood lactate.
Repeat monitoring: SpO2 and respiratory assessment, Peak expiratory flow.
Management pathways in this chapter
Mechanisms of Status Asthmaticus
Managing Near-Fatal Asthma in the ICU
Locked
Each pathway step by step, with its decision points
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.