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Acute Asthma in Adults and Adolescents (ED, GINA 2026)

Acute Asthma in Adults and Adolescents (ED, GINA 2026): Acute asthma: adult or adolescent 12 years and over → Initial assessment: is it asthma? → Anaphy...

Pathway Overview

19 steps

Algorithm Steps

19 total

  1. 01Start

    Acute asthma: adult or adolescent 12 years and over

    Acute asthma or exacerbation in the ED or other acute care.

  2. 02Action

    Initial assessment: is it asthma?

    Adult or adolescent 12 years and over only; child under 12: use the paediatric asthma pathway. Assess while you prepare salbutamol. Consider other causes: anaphylaxis, pneumothorax, inducible laryngeal obstruction, pneumonia, acute heart failure, pulmonary embolism.

    • SpO2 on room air, respiratory rate, accessory muscle use, air entry, ability to speak
    • PEF or FEV1 before treatment if this does not delay treatment
    • Treatment already given: SABA doses in the last hours; current or recent oral steroid
    • Red flags for fatal asthma: past intubation or ICU; hospital or ED visits in the past year; current or recent oral steroid; no ICS; SABA over-use; food allergy; psychosocial problems
    • Pregnant: treat as for other adults (SABA, oxygen, steroid, magnesium); keep SpO2 94-98%; severe: continuous fetal monitoring, early obstetric and ICU input; PaCO2 is normally lower in pregnancy
    • Pulse oximetry can overestimate SpO2 in people with dark skin
  3. 03Warning

    Anaphylaxis features? Give IM adrenaline first

    Sudden wheeze or breathing difficulty after possible allergen exposure (food, insect, drug), with or without skin signs or hypotension: treat as anaphylaxis, then give salbutamol.

    • Adrenaline 1 mg/mL IM, outer mid-thigh: 0.01 mg/kg, max 0.5 mg (adult: 0.5 mg = 0.5 mL)
    • No or poor response: repeat adrenaline after 5 min
    • Use the anaphylaxis pathway; do not let the patient stand or walk
  4. 04Decision

    Life-threatening features?

    Any of: drowsy, confused or agitated; cyanosis; quiet or silent chest; exhausted, collapsed or poor respiratory effort; bradycardia, arrhythmia or hypotension; blood gas with low PaO2 and normal or rising PaCO2

  5. If Yes
    1. 05Warning

      Life-threatening: call ICU and anaesthesia now

      Start treatment at once (next step). Do not give sedatives.

      • Signs: drowsy, confused, cyanosis, silent chest, exhaustion or poor respiratory effort, bradycardia, arrhythmia or hypotension
      • Blood gas: PaO2 <60 mmHg (8 kPa) with normal or rising PaCO2 (>45 mmHg, 6 kPa) = respiratory failure
      • Sedatives are linked to avoidable asthma deaths
    2. 06Action

      Life-threatening: immediate treatment

      Give all of these together while ICU and anaesthesia come. Monitor continuously.

      • Nebulised salbutamol 5 mg + ipratropium 0.25 mg (oxygen-driven); repeat or give continuously
      • Oxygen 100% by non-rebreather mask at first, then titrate to SpO2 92-95% (88-92% if risk of hypercapnia)
      • Systemic steroid now: prednisolone 40-50 mg PO, or IV hydrocortisone 200 mg/day in divided doses if unable to swallow
      • IV magnesium sulfate over 20 min, single dose: 0.2 mmol/kg (about 50 mg/kg), max 8 mmol (2 g)
      • IV access, blood gas, chest X-ray; check potassium and lactate (SABA toxicity)
      • Not recommended: IV aminophylline; routine IV salbutamol
      • Not improving: intubation by a senior airway clinician. NIV only in a calm patient, never with sedation
    3. 07Outcome

      Life-threatening or not responding: ICU admission

      Needs ICU or HDU care. After ICU, refer for expert asthma review.

      • Needs or may need ventilatory support
      • Rising PaCO2, severe hypoxaemia, drowsiness or exhaustion
      • Worsening despite full treatment
    If No
    1. 08Decision

      Severity of the presentation?

      Severe if any severe feature. Mild only if all mild features.

      • Mild (all of): talks in sentences, can lie down; RR normal or mildly raised; no or mild accessory muscle use; SpO2 on air 94% or more; PEF or FEV1 >70%
      • Moderate: talks in phrases, prefers to sit, not agitated; RR raised; accessory muscle use; reduced air entry; SpO2 on air 92% or more; PEF or FEV1 50-70%
      • Severe (any of): cannot speak, drink or lie down; SpO2 on air <92%; RR >30/min; silent or quiet chest; PEF or FEV1 <50%
      • PEF or FEV1 as % of personal best or predicted
    2. Severe
    3. 09Action

      Severe: start treatment now, monitor continuously

      Any of: cannot speak, drink or lie down; SpO2 on air <92%; RR >30/min; silent or quiet chest; PEF or FEV1 <50%. Review response within 1 hour.

      • Salbutamol 6-10 puffs + ipratropium 4 puffs (20 mcg/puff) by pMDI + spacer, or nebulised salbutamol 5 mg + ipratropium 0.25 mg
      • If needed, repeat up to 3 times, 20-30 min apart
      • Prednisolone 40-50 mg PO now (adolescent: 1 mg/kg, max 50 mg); if unable to swallow: IV hydrocortisone 200 mg/day in divided doses
      • Oxygen to SpO2 92-95% (88-92% if risk of hypercapnia)
      • Consider IV magnesium sulfate over 20 min, single dose: 0.2 mmol/kg (about 50 mg/kg), max 8 mmol (2 g)
      • Blood gas if PEF or FEV1 <50% or no response
    4. 10Decision

      Response at 1 hour (or earlier)?

      Reassess SpO2, RR, accessory muscle use, air entry and PEF or FEV1. If needed, give extra bronchodilator.

      • Marked improvement and no further SABA needed
      • Partial improvement
      • Worsening
    5. Marked improvement
    6. 11Decision

      Marked improvement: meets all discharge criteria?

      No further SABA needed. All of: mild criteria for 1-2 hours after last salbutamol; SpO2 92% or more on room air; PEF or FEV1 >70%; adequate support at home. Not met: admit.

      • Meets mild criteria for at least 1-2 hours after the last salbutamol
      • SpO2 92% or more on room air
      • PEF or FEV1 >70% of personal best or predicted (measure again before discharge)
      • Adequate resources and support at home
    7. If Yes
      1. 12Outcome

        Discharge: start ICS-containing treatment, steroid course, review in 2-7 days

        Every patient leaves on ICS-containing treatment; SABA-only treatment is not recommended. Prednisolone 40-50 mg daily for 5-7 days.

        • Preferred: ICS-formoterol maintenance-and-reliever (MART), e.g. budesonide-formoterol 200/6 mcg 2 inhalations twice daily + 1 as needed, max 12 per day; not as reliever if maintenance is ICS with a non-formoterol LABA
        • If ICS or ICS-LABA with SABA reliever: increase the ICS dose for 2-4 weeks
        • Prednisolone 40-50 mg once daily for 5-7 days (adolescent: 1 mg/kg, max 50 mg, 3-5 days); no taper; diabetes: monitor blood glucose
        • Reliever as needed, not regularly; check inhaler technique and adherence
        • Written asthma action plan
        • GP review in 2-7 days; refer for expert advice if ICU was needed or another attack needed oral steroid or urgent care in the past 12 months
      If No
      1. 13Outcome

        Not ready for discharge: admit to hospital

        Admit if not improving, SpO2 <92% on room air, SABA needed more often than every 1-2 hours, or red flags for fatal asthma. Worsening at any time: senior and ICU review. Continue or start ICS-containing treatment.

        • SpO2 <92% on room air
        • Needs SABA more often than every 1-2 hours
        • Breathless 4-6 hours after systemic steroid
        • Adherence or follow-up problems, or red flags for fatal asthma
        • Also consider: FEV1 <60% predicted at 1 hour; past ICU for asthma; ED visit for asthma in past 4 weeks
    8. Partial improvement
    9. 14Action

      Partial improvement: continue treatment, review hourly

      Review at least every hour: SpO2, RR, accessory muscle use, air entry, PEF or FEV1.

      • Extra salbutamol if needed; watch for SABA toxicity (rising heart rate, low potassium, lactic acidosis)
      • Consider more ipratropium
      • Start systemic steroid if not yet given
      • Consider IV magnesium if no response and SpO2 stays <92%
    10. 15Decision

      Improved to mild criteria on hourly review?

      Yes: go to discharge criteria. No: admit. Worsening at any review: escalate now (senior and ICU), as in the Worsening step.

    11. If Yes
      1. Path rejoins step 11Shared downstream outcome
      If No
      1. Path rejoins step 13Shared downstream outcome
    12. Worsening
    13. 16Action

      Worsening: escalate now

      Call senior and ICU help. Think of other causes (pneumothorax, anaphylaxis) and of SABA toxicity: lactic acidosis causes fast breathing that can look like worse asthma.

      • Extra salbutamol + ipratropium if needed; check potassium, lactate and heart rhythm
      • Systemic steroid if not yet given
      • IV magnesium sulfate over 20 min, single dose: 0.2 mmol/kg (about 50 mg/kg), max 8 mmol (2 g), if not given
      • Blood gas; chest X-ray if pneumothorax or another cause is possible
      • Not recommended: IV aminophylline; routine IV salbutamol
    14. 17Decision

      Responding to escalation?

      Yes: admit to hospital. No: ICU.

    15. If Yes
      1. Path rejoins step 13Shared downstream outcome
      If No
      1. Path rejoins step 07Shared downstream outcome
    16. Moderate
    17. 18Action

      Moderate: salbutamol + ipratropium, start steroid

      Talks in phrases, prefers to sit, not agitated; accessory muscle use; SpO2 on air 92% or more; PEF or FEV1 50-70%. Review response within 1 hour.

      • Salbutamol 4-6 puffs + ipratropium 4 puffs (20 mcg/puff) by pMDI + spacer
      • Or nebulised salbutamol 2.5 mg + ipratropium 0.25 mg
      • If needed, repeat up to 3 times, 20-30 min apart
      • Prednisolone 40-50 mg PO within 1 hour (adolescent: 1 mg/kg, max 50 mg)
      • Oxygen only if SpO2 <92%; target 92-95%
    18. Path rejoins step 10Shared downstream outcome
    19. Mild
    20. 19Action

      Mild: salbutamol 4 puffs, then review

      All of: talks in sentences, can lie down; no or mild accessory muscle use; SpO2 on air 94% or more; PEF or FEV1 >70%. Review response before more doses.

      • Salbutamol 100 mcg/puff: 4 puffs by pMDI + spacer, 1 puff at a time; shake before each puff
      • Or budesonide-formoterol 200/6 mcg (metered; 160/4.5 mcg delivered): 2 inhalations
      • If needed, repeat once after 30-60 min
      • Oxygen only if SpO2 <92%
      • Systemic steroid if no lasting improvement, if the attack began on oral steroid, or if past attacks needed oral steroid
    21. Path rejoins step 10Shared downstream outcome

Guideline Source

Global Initiative for Asthma (GINA) 2026 Strategy Report

View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults and adolescents 12 years and over only; children 6-11 years: use the paediatric asthma pathway
  • Doses follow GINA 2026; Australian Asthma Handbook doses differ slightly (see regional note)
  • Does not cover ventilation in ICU or long-term asthma management

Contraindicated Populations

Children under 12 years (use the paediatric asthma pathway)

Applicable Regions

AUEUUSGlobal

AU: Australian Asthma Handbook v3.0 (2025), ED adults and adolescents: salbutamol 4-12 puffs (mild-moderate) or 12 puffs (severe) via spacer; ipratropium 8 puffs (21 mcg/puff) or 500 mcg nebulised every 20 min in the first hour; IV magnesium sulfate 0.2 mmol/kg, max 10 mmol, over 20 min; SpO2 target 92-96% (88-92% if hypercapnia risk, TSANZ 2022); IV salbutamol not recommended; GP review within 3 days.

US: Albuterol = salbutamol. US budesonide-formoterol inhalers are labelled by delivered dose (160/4.5 mcg).

Global: GINA 2026 Box 9-6 and Box 9-7. Follow local protocols where they differ.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Acute Asthma in Adults and Adolescents (ED, GINA 2026)?

The Acute Asthma in Adults and Adolescents (ED, GINA 2026) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on Global Initiative for Asthma (GINA) 2026 Strategy Report.

What guideline is the Acute Asthma in Adults and Adolescents (ED, GINA 2026) based on?

This algorithm is based on Global Initiative for Asthma (GINA) 2026 Strategy Report.

What are the limitations of the Acute Asthma in Adults and Adolescents (ED, GINA 2026)?

Known limitations include: Adults and adolescents 12 years and over only; children 6-11 years: use the paediatric asthma pathway; Doses follow GINA 2026; Australian Asthma Handbook doses differ slightly (see regional note); Does not cover ventilation in ICU or long-term asthma management. Individual patient factors may require deviation from these recommendations.

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