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Pulmonary · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Known asthma, 2 days of worsening wheeze; can speak only in phrases; RR 30, HR 120, SpO₂ 91%, PEF 35% of best
Red flags Silent chest Normal/rising PaCO₂ Exhaustion, confusion SpO₂ <92% Previous ICU admission for asthma Differential diagnosis COPD exacerbation Anaphylaxis Pneumothorax Heart failure ("cardiac asthma") Vocal cord dysfunction Foreign body When to admit, call ICU or discharge Admit: Acute severe attack not responding in 1 h, any life-threatening feature, previous near-fatal asthmaICU: Life-threatening features, rising PaCO₂, deteriorating PEF, exhaustionIntubate: Exhaustion, ↓GCS, respiratory arrest, rising CO₂ despite maximal therapyVentilate: Low rate, low tidal volume, long expiration, permissive hypercapnia (watch auto-PEEP)Key points Normal or rising PaCO₂ in an acute attack means the patient is tiring — prepare for intubation. Anaphylaxis with wheeze → IM adrenaline 0.5 mg first, then bronchodilators. Every admission is a failure of control — follow-up within 2–7 days and ICS-containing therapy for all. Never Sedate a patient with acute asthma outside ICU Be reassured by a normal PaCO₂ in a breathless patient Give routine antibiotics or aminophylline Discharge on a SABA-only plan Common mistakes False reassurance from normal CO₂ Under-dosed or delayed steroids Discharging without a controller and action plan Disposition and follow-up Ward for acute severe; ICU for life-threatening features. Asthma review within a week.
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