Immediate treatment of acute asthma in adults and adolescents in the ED

Assessment

All of:

Can walk, speak whole sentences in one breath

SpO₂ (room air) >94%

Any of:

Unable to complete sentences in one breath due to breathlessness

Use of accessory muscles of neck or intercostal muscles/tracheal tug/subcostal recession during inspiration

Obvious respiratory distress

SpO₂ (room air) ≤94%

Any of:

Reduced consciousness/collapse, exhaustion/confused/agitated

Cyanosis

Poor respiratory effort

SpO₂ (room air) <92%

Poor respiratory effort, soft/absent breath sounds

Immediate treatment

Start bronchodilators:

Salbutamol 12 actuations (100 microg per actuation) via pMDI and spacer (tidal breathing). If patient cannot use spacer, give 5 mg nebule via nebuliser.

Ipratropium 8 actuations (21 microg/actuation) via pressurised metered-dose inhaler and spacer every 20 minutes for first hour.

Start oxygen supplementation if SpO₂ <92% on room air and titrate to target 92–96% (or 88–92% if risk of hypercapnoea)

Arrange immediate transfer to higher-level care

Start bronchodilators:

Salbutamol 2 x 5 mg nebules via continuous nebulisation driven by oxygen

Ipratropium 500 microg added to nebulised solution every 20 minutes for first hour. 

Maintain SpO₂ 92–96% (or 88–92% if risk of hypercapnoea)

Repeat salbutamol 4–12 actuations every 20 minutes for the first hour, if needed (sooner if needed).

Then reduce to every 4–6 hours, if needed

Repeat salbutamol 12 actuations every 20 minutes for the first hour (sooner if needed)

Repeat bronchodilators 4–6 hourly for 24 hours. If salbutamol delivered via nebuliser, add 500 microg ipratropium to nebulised solution every 20 minutes for first hour. Repeat 4–6 hourly.

Repeat bronchodilators 4–6 hourly.

When dyspnoea improves, consider changing to salbutamol via pMDI plus spacer or intermittent nebuliser