1. The document provides guidelines for assessing and managing acute severe asthma exacerbations. It discusses defining exacerbations, assessing severity, pharmacological treatments including inhaled bronchodilators, systemic corticosteroids, oxygen therapy, ventilation methods, patient transfer criteria, and considerations for pregnant patients. 2. Treatment recommendations include administering inhaled short-acting beta-2 agonists, systemic corticosteroids, oxygen therapy, and adding inhaled anticholinergics if no improvement. Intubation may be needed if medical treatment fails or symptoms are severe. 3. The guidelines aim to optimize oxygen levels, ventilation pressures, sedation, and discuss transferring patients based on response and ability to be managed at home with

1. Acute severe asthma management
By
Prof Dr. Mohamed Mostafa Metwally, MD, FCCP
Assiut University, Egypt

3. Definition of acute asthma
exacerbation

4. Definition of acute severe asthma
A continual worsening of an asthmatic
condition even with the use of medications;
may cause life-threatening situations;
creates marked strain on the respiratory
and circulatory systems.

5. Assessing exacerbation severity
A brief focused history and relevant physical examination
should be conducted concurrently with the prompt
initiation of therapy, and findings documented in the
notes.
Assessment is done at first look (static) then follow up of
the patient’s response to treatment (dynamic).

6. History
Timing of onset and cause of the present exacerbation.
Severity of asthma symptoms, including any limiting exercise
or disturbing sleep.
Any symptoms of anaphylaxis.
Any risk factors for asthma-related death
All current reliever and controller medications, including doses
and devices prescribed, adherence pattern, any recent dose
changes, and response to current therapy.

8. Physical examination
Signs of exacerbation severity and vital signs
(e.g. level of consciousness, temperature, pulse rate, respiratory
rate, blood pressure, ability to complete sentences, use of
accessory muscles, wheeze).
Complicating factors (e.g. anaphylaxis, pneumonia,
pneumothorax).

9. Signs of alternative conditions that could explain acute
breathlessness (e.g. cardiac failure, inducible laryngeal
obstruction, inhaled foreign body or pulmonary embolism).
Objective measurements
Pulse oximetry. Saturation levels <90% in children or
adults signal the need for aggressive therapy.
PEF in patients older than 5 years.

10. © Global Initiative for Asthma
Managing exacerbations in primary care
GINA 2017, Box 4-3 (1/7)
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENT
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATE
Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
LIFE-THREATENING
Drowsy, confused
or silent chest
START TREATMENT
SABA 4 10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1 2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93 95% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled
SABA and ipratropium bromide,
O2, systemic corticosteroid
URGENT
WORSENING
ARRANGE at DISCHARGE
Reliever: continue as needed
Controller: start, or step up. Check inhaler
technique, adherence
Prednisolone: continue, usually for 5 7 days
(3-5 days for children)
Follow up: within 2 7 days
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1 2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
IMPROVING
WORSENING
SEVERE
Talks in words, sits hunched
forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF≤50% predictedorbest

24. Severity of asthma exacerbation
Mild Moderate Severe Respiratory Arrest
emminent
Breathless Walking Talking At rest
Talks in Sentence Phrases Words
Alertness My be Agitated Usually agitated Usually agitated Drowsy or
confused
R.R Increased Increased >30/min
Wheezes Moderate &exp. Loud Loud Absent
Pulse/min <100 100-120 >120 Bradycardia
PaO2
PaCO2
Normal
<45mmHg
>60mmHg
<45mmHg
<60mmHg
>45mmHg
SaO2 >95% 91-95% <90%

26. Management of acute asthma attack
Initial
assessment
• O2 to achieve SaO2 ≥ 95%
• Inhaled rapid acting 2 agonist for one hour
• Systemic steroid
Reassess
• If PEF 60-80%&moderate symptoms
• O2 +Inhaled rapid acting 2 agonist +anticholinergic every one hour
• +Oral glucocorticoids (Continue for 3 hours if there is improvement)
• If PEF<60% & severe symp.& no improvement on ttt 
• O2 +Inhaled rapid acting 2 agonist +anticholinergic +Systemic steroids
• Consider IV magnesium sulfate
Reassess
•Good responseDischarge Inhaled 2 agonist+Oral glucocorticoids or combination
inhaler +Follow up
•Incomplete response within 1-2h  O2 +Inhaled rapid acting 2 agonist +anticholinergic +
Systemic steroids +IV magnesium
•Poor response O2 + Inhaled rapid acting 2 agonist &anticholinergic + IV steroids
• Consider IV 2 agonist
• Consider IV theophylline
• If no improvement: admit to ICU for mechanical ventilation

27. When to start Mechanical ventilation
27

28. Treatment of acute severe asthma
1- for mild to moderate attacks, β2 agonist 2-4 puffs/20 min
or by nebulizer in the first hour.
2- Systemic corticosteroids
3- Oxygen therapy and hydration
4- Sedation is contraindicated.
If no response add:
5- Inhaled anticholinergic Ipraropium bromide
6- Magnesium sulphate I.V. drip.

29. If no response, admit to ICU and
7- consider IV β2 agonist
8- consider IV theophylline
9- consider Intubation and Mechanical ventilation.

30. Case history
A 34 year old asthmatic female came to
emergency room with progressive dyspnea and
dry cough in the last 3 day. Her PEFR is 60%
and her SaO2 is 90%.
She stopped taking her inhaled corticosteroid
because she is 27 week pregnant and does not
feel comfortable receiving medication while
pregnant.
The symptoms are now getting worse with night
awakening in the last 10 days. She feels
breathless although using relief inhaler daily and
3 times in the last hour and doesn’t feel better.
What is the INITIAL treatment for this patient?

31. Choose one answer
1- High dose ICS + Inhaled short acting B2
agonist
2- Oxygen +High dose ICS + short acting B
agonist
3- Oral and Inhaled corticosteroids and
Oxygen
4- Oxygen + Systemic Steroids+ short
acting B agonist

32. Correct Answer
4- Oxygen + Systemic Steroids+ short acting
B agonist
This patient shows uncontrolled asthma and
have more than 2 criteria of uncontrolled asthma
as daytime symptoms more than twice/week,
limitation of activity nocturnal awakening, need
reliever more than twice a week and PEFR less
than 80%. So, ICS is not enough for this
pregnant woman who has been uncontrolled for
days. Oxygen should be used to reach a
maternal saturation of at least 95% together with
systemic steroids and inhaled short acting B
agonist

34. Areas of recommendations
Five areas were defined:
1- Diagnosis and evaluation
2- Pharmacological treatment,
3- Methods of oxygen therapy and ventilation,
4- Transfer of patients,
5- Specific considerations regarding pregnant women.

35. First area: diagnosis and elements of
the diagnosis
1- From first contact with patients with asthma
exacerbation, the following severity criteria should be
sought:
History of hospital admission for asthma or need for
mechanical ventilation, recent use of oral corticosteroids,
considerable or increasing use of beta-2 agonists, age > 70
years, difficulty speaking, altered consciousness, shock,
respiratory rate > 30 breaths/min, arguments in favor of an
underlying pneumonia.

36. 2- In SAE, chest radiography and blood gas measurements
(venous or arterial) should probably be done if there is a
diagnostic doubt or non-response to treatment.

37. Second area: pharmacological treatment
1- Beta-2 agonists should not be administered
intravenously first line in adult or pediatric patients with
SAE even in mechanically ventilated patients.
2- Beta-2 agonists should probably be administered by
continuous rather than discontinuous nebulization during
the first hour in adult and pediatric patients with SAE.

38. 3- Inhaled anticholinergic drugs should be combined with
beta-2 agonists in adult and pediatric patients with SAE.
4- The experts suggest administering a 0.5-mg dose of
ipratropium bromide every 8 h in adults.

39. 5- Systemic corticosteroid therapy should be administered
early intravenously or orally (1 mg/kg of
methylprednisolone equivalent, maximum 80 mg per day)
to all adult patients with SAE.
6- Magnesium sulfate should probably not be
administered routinely to adult patients with SAE except in
the most severely ill patients.

40. 7- Antibiotic therapy should probably not be administered
routinely during SAE in adult and pediatric patients except
for cases of suspected bacterial pneumonia, based on
usual clinical, radiological, and laboratory signs.

41. Third area: methods of oxygen therapy
and ventilation
1- Oxygen therapy titrated to a pulse oxygen saturation of
94%–98% should probably be administered to adult and
pediatric patients with SAE.
2- The experts were unable to recommend the use of NIV
in SAE. High-flow nasal oxygen therapy has yet to be
assessed in this setting.

42. 3- The experts suggest resorting to intubation in adult and
pediatric SAE patients if well-conducted medical
treatment fails or if the first clinical presentation is severe
(altered consciousness, bradypnea).
Intubation should be performed using the orotracheal
route, after rapid sequence induction including ketamine
in first line hypnotic agent and succinylcholine or
rocuronium, by an experienced physician.

43. 4- The experts suggest prevention of lung overdistension
by reducing tidal volume, respiratory rate, and positive
end-expiratory pressure (PEEP), and by increasing
inspiratory flow, to limit plateau pressure in mechanically
ventilated adult and pediatric patients with SAE.

44. 5- The experts suggest deep sedation (Richmond
Agitation-Sedation Scale (RASS) of −4 to −5) at the initial
phase of invasive mechanical ventilation, as well as
neuromuscular blockers in the most severely ill patients.
The experts are not able to recommend continuous
administration of ketamine or halogenated agents.
6- Helium should probably not be used as carrier gas in
nebulizers in adult and pediatric patients with SAE.

45. 7- The experts suggest that aerosols of salbutamol should
be administered to spontaneously breathing patients with
SAE using a nebulizer.
The experts are unable to recommend a particular
method of aerosol administration for patients with SAE
receiving mechanical ventilation.

46. 8- In the absence of compelling data in adult and pediatric
patients with SAE, the experts suggest discussing with an
expert center the use of extracorporeal life support-
venovenous ECMO or extracorporeal CO2 removal
(ECCO2R) in the case of respiratory acidosis and/or
severe hypoxemia refractory to optimal medical treatment
and to well-conducted mechanical ventilation.

47. Fourth area: transfer of patients
1- The experts suggest that the decision to send patients
with SAE home should be based on an assessment
taking into account the patient’s characteristics, the
frequency of exacerbations, the severity of the initial
clinical presentation, the response to treatment, including
the progression of PEF, and the patient’s ability to be
managed at home (referral to the primary care physician).

48. 2- The experts suggest that the discharge prescription for
patients treated for SAE in the ER should at least include
a short-acting beta-2 agonist, oral corticosteroid therapy
for a short period, and inhaled corticosteroid therapy if it
has not been prescribed before.

49. 3- The experts suggest that admission to intensive care of
adult and pediatric patients with SAE should be discussed
early, on a case-by-case basis, because there are no
specific criteria on this subject.

50. Fifth area: specificities of the pregnant
woman
Pregnant women with SAE should probably be treated in
the same way as the general population, by intensifying
their controlling therapy upon admission to the emergency
room if necessary.

51. 51