1. ER Management of Acute
Asthma Attack
Ahmed Al Gahtani, BSRC, RRT
Associate Director, Clinical Education
Respiratory Therapy Program
Inaya Medical College

2. Asthma exacerbations consist of acute or sub-acute
episodes of:
Coughing Wheezing
Progressively worsening
SOB
Chest Tightness
Combination

3. Impending or Actual
Respiratory Arrest
Classification of Asthma Exacerbations
SevereMild to Moderate
Mild to Moderate Exacerbation
Symptoms: SOB while at rest, prefers sitting, talk in phrases,
and/or usually agitated.
Signs: PEF of ≥ 40%, Increased RR, HR 100 to 120 , use of
accessory muscles, loud wheezes throughout exhalation, PaO2 ≥
60 mm Hg and/or PaCO2 < 42 mm Hg, SpO2 90 to 95 %
Severe Exacerbation
Symptoms: SOB while at rest, Sits upright, talk in wards, and
usually agitated.
Signs: PEF of < 40%, Increased RR often > 30, HR > 120 , usually
uses accessory muscles, loud wheezes throughout inhalation &
exhalation, PaO2 < 60 mm Hg and/or PaCO2 ≥ 42 mm Hg, SpO2 <
90 %
Impending or Actual Respiratory Arrest
Symptoms: Drowsy or confused
Signs: PEF of < 25%, Bradypnea , Bradycardia, Paradoxical
thoracoabdominal movement, and Absence of wheezes
(Note: PEF testing may not be needed in very severe attacks)

4. Early treatment of asthma
exacerbations is the best
strategy for management.
Important elements of early
treatment at the patient’s
home include a written
asthma action plan;
recognition of early signs and
symptoms of worsening
The NAEPP Expert Panel recommends
that all clinicians treating asthmatic
patients should be prepared to treat an
asthma exacerbation, recognize the signs
and symptoms of severe and life-
threatening exacerbations, and be
familiar with the risk factors for asthma-
related death. Because infants are at
greater risk for respiratory failure,
clinicians should also be familiar with
special considerations in the assessment
and treatment of infants experiencing
asthma exacerbations.

5. Principles and Primary Goals of Care
• Relieve airflow limitation
• Treat airway inflammation
• Treat hypoxemia or hypercapnia if present.
• Non-invasive ventilation / mechanical ventilation in
severe cases (clinical judgment).
• Selected therapies: magnesium sulphate and heliox.
• Limited or no role for antibiotics and
methylxanthines (aminophylline/theophylline).

6. Management
Pre-Hospital Management
EMSAt Home
All EMS personnel should receive
training in how to respond to the signs and
symptoms of severe
airway obstruction and impending respiratory
failure

7. ED Management

8. ED Management

9. ED Management

10. Expert Panel Report 3: National Heart Lung and Blood Institute 2007
https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

11. Noninvasive Mechanical Ventilation

12. Invasive Mechanical Ventilation

13. Invasive Mechanical Ventilation

14. Invasive Mechanical Ventilation

15. Invasive Mechanical Ventilation

16. Invasive Mechanical Ventilation

17. • Heliox
• Antibiotics
• Systemic Aminophylline
• Magnesium Sulfate
• Bronchial Thermoplasty
Adjunct Therapies
Am J Respir Crit Care Med. 2012 Apr 1;185(7):709-14

18. Adjunct Therapies

19. References
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