Asthma exacerbation — Frequently asked questions (FAQ)
1) What does this algorithm cover?
The algorithm guides the management of asthma exacerbations in the acute setting, including initial assessment, severity stratification, identification of risk factors, bronchodilator treatment, systemic corticosteroids, hospital admission criteria, and recommendations for discharge and follow-up.
2) What are the main signs of severity in an asthma exacerbation?
The main signs include SpO₂ <90–92%, difficulty completing sentences, marked use of accessory respiratory muscles, a silent chest on auscultation, altered level of consciousness, respiratory fatigue, bradycardia or progressive deterioration despite initial treatment.
3) Which factors increase the risk of asthma-related mortality?
Relevant risk factors include a previous intensive care unit admission or intubation, frequent exacerbations, excessive SABA use, poor treatment adherence, absence of a written asthma action plan, psychiatric illness, food allergy and recent discontinuation of corticosteroid therapy.
4) What is the recommended initial bronchodilator treatment?
Initial treatment is based on inhaled salbutamol, preferably administered using a pressurised metered-dose inhaler with a spacer. In moderate or severe exacerbations, ipratropium bromide may be added, particularly during the first hour of treatment.
5) When should systemic corticosteroids be started?
Systemic corticosteroids should be started early in moderate or severe exacerbations, or when the response to initial bronchodilator treatment is insufficient. Oral prednisolone may be used, or intravenous corticosteroids in more severe situations.
6) When should magnesium sulfate be used?
Intravenous magnesium sulfate may be considered in severe exacerbations, particularly when there is a poor initial response to bronchodilator treatment and corticosteroids or persistent severe airflow obstruction.
7) What is the target of oxygen therapy?
Oxygen therapy should maintain an SpO₂ of 93–95% in adults and 94–98% in children, avoiding significant hypoxaemia without causing unnecessary hyperoxia.
8) When should hospital admission be considered?
Hospital admission should be considered in cases of an incomplete response, persistent need for frequent bronchodilator treatment, hypoxaemia, severe exacerbation, a history of severe exacerbations, social difficulties or poor treatment adherence.
9) What should be included in discharge planning after an exacerbation?
Discharge planning should include optimisation of controller therapy, a written asthma action plan, review of inhaler technique, a short course of oral corticosteroids when indicated, guidance on reliever therapy and arrangement of a follow-up appointment.
10) What is the role of inhaled corticosteroids after an exacerbation?
An asthma exacerbation is a marker of inadequate disease control. Treatment with an ICS should be optimised, frequently in combination with formoterol, to reduce the risk of future exacerbations.
11) When should reassessment take place?
Reassessment should take place promptly, usually within 2–7 days in adults and 1–2 days in children, to confirm clinical resolution, review inhaler technique and treatment adherence, and assess the need for treatment adjustment.
