Initial notes
- Assess severity clinically.
- Anaphylaxis: Epinephrine IM (0.3 mg ≥30 kg, 0.15 mg if 10–30 kg).
- Thunderstorms during pollen seasons can trigger severe attacks; sandstorms usually only worsen symptoms without causing severe exacerbations.
Severity classification
| Category | Clinical features | O₂ Sat | PEF | Action |
|---|---|---|---|---|
| Mild | Dyspnea with activity only, end-expiratory wheeze | >95% | ≥75% | Inhaled/nebulized SABA; repeat PRN |
| Moderate | Dyspnea limits activity, accessory muscles, expiratory wheeze | 90–95% | 50–74% | SABA q20min ×1h + oral steroids ± ED referral |
| Severe | Dyspnea at rest, interferes with speech, inspiratory + expiratory wheeze | <90% | <50% | Urgent ED referral, likely admission |
| Life-threatening | Too dyspneic to speak, drowsy, silent chest | — | <25% | ICU / emergency transfer |
Medication doses
| Drug | Children | Adults | Notes |
|---|---|---|---|
| Oxygen | Maintain >95% | Maintain >93% | Low-flow recommended |
| Salbutamol | 2.5 mg (or 4 puffs) if <20 kg · 5 mg (or 8 puffs) if >20 kg | 5 mg (or 8 puffs) | q20min if needed |
| Ipratropium | 0.25 mg (or 4 puffs) | 0.5 mg (or 8 puffs) | With salbutamol in moderate/severe attacks |
| Prednisolone | 1–2 mg/kg/day (max 40 mg ×5d) | 50 mg/day ×5d | Start within 1 h if mod/severe |
STAT steroid before discharge (moderate/severe)
- Adults: Hydrocortisone 100 mg IV or Dexamethasone 8–10 mg IM/IV once.
- Children: Hydrocortisone 4 mg/kg IV or Dexamethasone 0.6 mg/kg IM/IV (max 16 mg) once.
Risk factors for asthma death
- Prior ICU admission or intubation.
- ≥2 hospitalizations or >3 ED visits in past year.
- 1 SABA canister/month.
- Chronic oral steroids (current/recent).
- Major psychosocial/psychiatric illness.
Approaching severe / life-threatening asthma
Adults red flags
- Words only, agitation.
- Accessory muscles.
- Pulse >120.
- O₂ sat <90%.
- PEF <50%.
- Silent chest / drowsy.
Pediatric red flags
- Unable to speak/drink, drowsy, silent chest.
- O₂ sat <92%.
- RR >60 (0–2 mo), >50 (2–12 mo), >40 (1–5 y).
- HR >200 (0–3 y), >180 (4–5 y).
Immediate actions
- Nebulized Salbutamol + Ipratropium with O₂ 6 L/min titrated as needed.
- Give systemic corticosteroids as soon as possible.
- Repeat nebs q20min until transfer.
Transfer
- Activate EMS → arrange ER transfer.
- ICU / life-threatening features → arrange it early.