Asthma Exacerbation: ED to Home Plan

Exacerbations are driven by airway inflammation plus bronchospasm. A reliable pathway covers severity triage, rapid bronchodilation, early steroids, oxygen targets, adjuncts for non-responders, and a clear discharge plan that prevents bounce-backs.

Rapid Triage (first 5 minutes)

• Vitals: RR, HR, BP, SpO₂; mental status; ability to speak in sentences vs. words.
• Oxygen: target SpO₂ 92–96% (higher for pregnancy/children per local protocol).
• Peak flow (PEF) or FEV₁ if feasible: >=70% predicted = mild; 40–69% = moderate; <40% = severe.
• Red flags: silent chest, exhaustion, altered mental status, cyanosis, PaCO₂ normalizing/rising—consider ICU and early escalation.

First-Line Treatment

• SABA: Albuterol (salbutamol) via MDI + spacer 4–8 puffs q20 min × 3 in first hour or nebulized 2.5–5 mg q20 min × 3.
• SAMA: Add ipratropium for moderate–severe attacks (MDI 2–4 puffs or neb 0.5 mg) in first hour.
• Systemic steroids: Start early. Prednisone 40–50 mg PO (adult) once daily × 5–7 days; IV methylpred if unable to take PO.
• Oxygen: titrate to 92–96%; avoid hyperoxia. Monitor continuously if severe.

If Inadequate Response After First Hour

• Repeat SABA (continuous nebulization for severe cases per protocol).
• IV Magnesium sulfate 2 g over 20 minutes (adults) for severe exacerbations or poor response.
• Epinephrine IM (anaphylaxis phenotype or life-threatening bronchospasm) per weight-based dosing.
• Consider NIV (experienced settings) in impending fatigue without contraindications.
• Arterial/Venous blood gas if severe; rising/normal PaCO₂ in a distressed patient suggests fatigue → escalate.

Discharge Criteria (Safe to go home)

• Symptoms improved; speaking in full sentences; minimal/no accessory muscle use.
• PEF/FEV₁ ≥ 70% predicted or personal best (or clear clinical improvement if spirometry not feasible).
• SpO₂ ≥ 94% on room air (institutional thresholds vary).
• Understands inhaler technique and has access to meds and follow-up.

Discharge Medications & Plan

• Systemic steroid to complete a 5–7 day total course (no taper usually needed for short course).
• Reliever: SABA as needed (with spacer); emphasize technique and dose limits.
• Controller optimization:
  • SMART approach (where available): budesonide–formoterol as both maintenance and reliever.
  • Otherwise: ensure daily inhaled corticosteroid (ICS) ± LABA; step up temporarily after an exacerbation.
• Action plan: green/yellow/red zones with symptoms/PEF thresholds and when to start steroids or seek urgent care.
• Follow-up in 24–72 hours, sooner for high-risk patients.

Technique & Adherence Pearls

• Demonstrate MDI + spacer; check seal and breath timing. Rinse mouth after ICS to reduce thrush/dysphonia.
• Identify triggers: viral infections, allergens, smoke, NSAIDs (AERD), occupational exposures.
• Vaccinations, peak-flow diary for frequent exacerbators, and written plan in the home language.

Special Populations

• Pediatrics: weight-based SABA/steroid dosing; spacer with mask for younger children; careful hydration.
• Pregnancy: uncontrolled asthma is riskier than meds—treat exacerbations aggressively; coordinate with obstetrics.
• ACO (asthma–COPD overlap): ensure ICS-containing regimen; smoking cessation; consider LAMA add-on.

Red Flags (Escalate/Admit)

• PEF <40% predicted/personal best after treatment, persistent hypoxemia, rising PaCO₂, drowsiness, silent chest, or hemodynamic instability.

Patient FAQs

“How many puffs is too many?” If needing SABA more than every 3–4 hours or >8 puffs in a short period without relief, follow the red-zone plan and seek care.

“Do I need antibiotics?” Not routinely—most exacerbations are viral/inflammatory.

References & Notes

Practical ED-to-home pathway emphasizing rapid bronchodilation, early steroids, oxygen targets, magnesium for severe attacks, and SMART or optimized ICS/LABA on discharge. Local protocols vary—follow institutional guidance. Educational only.