Acute Asthma Exacerbation (GINA 2025)

Algorithm Steps

1. ▶

   Start

   START: Acute Asthma Exacerbation

   Patient presents with acute bronchospasm/wheezing

   1. ●

      Action

      Initial Assessment

      Rapid evaluation while initiating treatment

      • ABC assessment
      • Brief history: onset, triggers, medications
      • PEF or FEV1 if possible (not mandatory)
      • SpO2, HR, RR, accessory muscle use
      • Ability to speak (sentences vs words)
      • Alert level
      1. ◆

         Decision

         Severity Classification?

         Classify severity to guide treatment intensity

         • MILD-MODERATE: Talks in phrases, prefers sitting, not agitated, RR increased, no accessory muscles, HR 100-120, SpO2 90-95%, PEF >50%
         • SEVERE: Talks in words, sits hunched, agitated, RR >30, accessory muscles, HR >120, SpO2 <90%, PEF ≤50%
         • LIFE-THREATENING: Drowsy/confused, silent chest, bradycardia, SpO2 <90%, unable to perform PEF
         1. ⚠

            Warning

            LIFE-THREATENING

            Immediate resuscitation + ICU

            • Drowsy, confused, or silent chest
            • Bradycardia or cyanosis
            • Poor respiratory effort
            • PEF not obtainable
            1. ●

               Action

               ICU/Resuscitation

               Aggressive intervention

               • High-flow O2 to maintain SpO2 93-95%
               • Continuous nebulized SABA + ipratropium
               • IV corticosteroids immediately
               • IV magnesium sulfate 2g over 20 min
               • Consider IV salbutamol or terbutaline
               • Prepare for intubation (ketamine preferred)
               • Call ICU/anesthesia early
               1. ⚠

                  Warning

                  ICU Admission

                  Critical care required

                  • Impending respiratory failure
                  • Altered consciousness
                  • Requiring non-invasive or invasive ventilation
                  • Hemodynamic instability
         2. ●

            Action

            SEVERE Exacerbation

            Aggressive treatment in ED

            • O2 to maintain SpO2 93-95%
            • SABA: 4-10 puffs q20min x 3 via spacer OR nebulized 2.5-5mg q20min
            • Ipratropium 500 mcg nebulized q20min x 3
            • Prednisolone 40-50 mg PO OR IV hydrocortisone 200 mg
            • Consider IV magnesium 2g over 20 min if poor response
            1. ◆

               Decision

               Reassess at 1 Hour

               Evaluate response to initial treatment

               • GOOD RESPONSE: PEF 60-80%, symptoms improved, SpO2 >94%
               • INCOMPLETE RESPONSE: PEF 40-60%, persistent symptoms
               • POOR RESPONSE: PEF <40%, worsening or no improvement
               1. ●

                  Action

                  Good Response

                  Prepare for discharge

                  • Continue SABA q1-4hr as needed
                  • Oral steroids: Prednisolone 40-50 mg daily x 5-7 days
                  • Review inhaler technique
                  • Assess for ICS/LABA controller need
                  • Written action plan
                  1. ✓

                     Outcome

                     Discharge with Action Plan

                     Safe for outpatient management

                     • PEF >70% predicted
                     • SpO2 >94% on room air
                     • Adequate symptom relief
                     • Adequate inhaler technique
                     • Follow-up arranged within 2-7 days
               2. ●

                  Action

                  Incomplete Response

                  Intensify treatment

                  • Continue SABA q1hr
                  • Add ipratropium if not given
                  • Consider IV magnesium 2g over 20 min
                  • Reassess in 1-2 hours
                  • Consider admission
                  1. ✓

                     Outcome

                     Admit to Hospital

                     Requires inpatient care

                     • Ongoing O2 requirement
                     • PEF <60% after treatment
                     • High risk features (previous ICU, intubation)
                     • Comorbidities
                     • Inadequate home support
               3. ●

                  Action

                  Poor Response

                  Escalate care

                  • Move to severe/life-threatening pathway
                  • IV magnesium if not given
                  • Consider IV beta-agonist
                  • ICU consultation
                  • Prepare for ventilation if deteriorating
         3. ●

            Action

            MILD-MODERATE Exacerbation

            Standard treatment

            • SABA: 4-10 puffs via spacer q20min x 1hr OR nebulized 2.5mg q20min
            • O2 if SpO2 <93% (target 93-95%)
            • Prednisolone 40-50 mg PO
            • Consider ipratropium if severe symptoms or poor response