← Diagnosis and Management Guides
Asthma Exacerbation
Key considerations: Status asthmaticus, Pneumothorax, Anaphylaxis
Cannot miss
- Status asthmaticus
- Pneumothorax
- Anaphylaxis
Likely diagnoses
- Viral-triggered exacerbation
- Allergen exposure
- Exercise-induced bronchospasm
Red flags
- Inability to speak in full sentences
- Silent chest
- Altered mental status
- Peak flow <25% predicted
Workup
- history: Trigger identification, prior ICU admissions, intubation history; exam: Respiratory rate, accessory muscle use, wheezing, air entry; labs: ABG if severe (respiratory acidosis = impending failure); Peak flow pre/post treatment; imaging: CXR if first episode, fever, or poor response to treatment; bedside: Continuous SpO2
Management
- immediate: Albuterol nebs q20min x3, ipratropium; Systemic steroids: prednisone 40-60mg or methylprednisolone 125mg IV; general: Magnesium 2g IV for severe exacerbation; Consider IV epinephrine if critical; Avoid sedation
Disposition
- admit: Persistent distress after ED treatment; Peak flow <40% predicted; Prior ICU admission for asthma; discharge: Good response to treatment, peak flow >70%; Prescribe 5-day prednisone burst + rescue inhaler; consults: Pulmonology if ICU-level care needed
Clinical pearls
- A normal pCO2 in an asthmatic in distress is ominous — they should be hyperventilating
- Silent chest = critical airway obstruction
Source and review
- GINA 2024. Last reviewed: 2024-11-01