AsthmaICU / resuscitation

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Wheeze, dyspnea; acute attack with respiratory alkalosis

ABCDE

Supplemental O₂ only if SpO₂ <92% (target ≤95%, GINA 2026); back-to-back salbutamol + ipratropium; steroids; IV magnesium if severe; senior/ICU if life-threatening.

Calculators:
  1. As soon as wheezing → Albuterol nebulizer (no contraindication)
  2. Exacerbation: Albuterol + Ipratropium + IV Magnesium + Oxygen + Prednisone 40–60 mg ×5 d
  3. Rising/normalizing PCO₂ (tiring) → ICU + intubate
  4. Controller step-up: inhaled corticosteroid → ICS + LABA → biologics. GINA 2026 Track 1 (preferred): low-dose ICS–formoterol is the preferred reliever (MART/AIR); SABA-only treatment no longer recommended for adults/adolescents
Decision tree
Life-threatening features (silent chest, exhaustion, normal/high CO₂)?
Yes
ICU + intubation; continuous salbutamol, ipratropium, IV magnesium, steroids
No
PEF <50% / not responding to initial nebs?
Yes
Acute severe: back-to-back nebs + ipratropium + steroids + IV magnesium; admit
No
Moderate: salbutamol + steroids; observe response; discharge with plan if PEF >75%

Order set

  • Peak flow
  • SpO₂/ABG if severe
  • Salbutamol + ipratropium neb
  • Steroids
  • IV magnesium if severe
  • CXR if atypical

Escalate / ICU

  • Silent chest / exhaustion
  • Normal or rising PaCO₂
  • SpO₂ <92% on maximal therapy
  • Altered mental state → intubate

Criteria

AdmitIncomplete response / severe features
ICULife-threatening: silent chest, exhaustion, normal/rising CO₂
IntubateExhaustion, ↓GCS, or rising CO₂ despite max therapy
VentilateRespiratory failure (lung-protective, watch gas trapping)
DischargePEF >75% best, SpO₂ ≥94% on air, steroids + inhaler technique + plan

Key

  • Normal/rising PCO₂ in an acute attack = ominous (patient tiring). PFT = severity.
  • Anaphylaxis coexisting with asthma features → intramuscular epinephrine (adrenaline) FIRST, then bronchodilators (GINA 2026).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Silent chest
  • Normal/rising PaCO₂
  • Exhaustion
Differentials
  • COPD
  • Anaphylaxis
  • Vocal cord dysfunction
  • Heart failure
Common mistakes
  • False reassurance from normalising CO₂
  • Discharging without steroids/plan
Disposition & follow-up

Response → ward/home with steroids; life-threatening → ICU.

Discharge package
MedicationsInhaled steroid ± LABA; oral steroid course; check inhaler technique
Follow-upAsthma review; written action plan
VaccinationInfluenza
LifestyleTrigger avoidance, smoking cessation
Warning symptomsIncreasing reliever use, night symptoms, breathlessness not relieved
💊 Treatment detail — doses & preparation
Salbutamol (albuterol)SABA
DoseNebuliser 2.5–5 mg q15–20 min ×3 then q1–4h; MDI 2–10 puffs via spacer
Preparation2.5/5 mg nebules + O₂-driven nebuliser at 6–8 L/min
MonitorHR, tremor, K⁺ (shifts intracellularly — used in hyperK), SpO₂
Ipratropium bromideSAMA
Dose500 mcg nebulised q4–6h (acute severe asthma/COPD)
Preparation500 mcg nebules; MDI 20 mcg/puff 2 puffs QID maintenance
MonitorDry mouth, glaucoma caution (mask seal)
Prednisolonecorticosteroid
DoseFlares: 40 mg OD ×1–2 wk then taper over 6–8 wk; COPD/asthma: 40–50 mg ×5 d (no taper)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Magnesium sulfate IVelectrolyte/antiarrhythmic
DoseTorsades: 2 g over 10–15 min. Asthma: 2 g over 20 min. Eclampsia: 4 g load then 1 g/h
Preparation2 g in 100 mL NS via pump; eclampsia 4 g in 100–200 mL
MonitorReflexes/RR if high doses (toxicity), Mg²⁺ level, renal function
Aminophyllinemethylxanthine — NOT recommended in acute asthma (GINA 2026)
DoseNot recommended for acute asthma exacerbations — no benefit over standard therapy and increased adverse effects; reserve only under specialist/ICU direction
PreparationIf ever used (specialist only): 5 mg/kg IV load over 20 min (omit if on theophylline), then 0.5–0.7 mg/kg/h; 250 mg/10 mL dilute in 100 mL NS/D5W
MonitorNarrow therapeutic window — levels (10–20 mg/L), arrhythmias, seizures
📖 GINA AsthmaReviewed July 2026

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