Acute Asthma Exacerbation Management (GINA 2025)

Algorithm Steps

1. ▶

   Start

   Acute Asthma Exacerbation

   Patient presents with acute worsening of asthma symptoms (wheeze, SOB, cough, chest tightness)

   1. ◆

      Decision

      Assess Severity

      Evaluate talking, alertness, respiratory rate, accessory muscle use, pulse, SpO2, PEF

      • Mild-Moderate: Talks in phrases, prefers sitting, RR increased, no accessory muscles, HR 100-120, SpO2 90-95%
      • Severe: Talks in words, sits hunched forward, RR >30, accessory muscles, HR >120, SpO2 <90%
      • Life-threatening: Drowsy/confused, silent chest, bradycardia, SpO2 <90%
      1. ⚠

         Warning

         ⚠️ Life-Threatening

         Immediate ICU/resuscitation - prepare for intubation

         • Silent chest, cyanosis, poor respiratory effort
         • Bradycardia, hypotension, exhaustion/confusion
         • PEF <25% predicted or unmeasurable
         • Call for senior/ICU support immediately
         1. ✓

            Outcome

            ICU/HDU Admission

            For severe/life-threatening asthma

            • Requiring ventilatory support
            • Deteriorating PEF/symptoms despite treatment
            • Hypercapnia or severe hypoxia
            • Exhaustion, drowsiness, confusion
      2. ●

         Action

         Initial Treatment (First Hour)

         Start SABA + controlled oxygen + consider corticosteroids

         • SABA: Salbutamol 4-10 puffs via pMDI+spacer every 20 min x3, OR 2.5-5mg nebulized
         • Oxygen: Target SpO2 93-95% (94-98% in children)
         • Corticosteroids: Prednisolone 40-50mg PO or Hydrocortisone 100mg IV
         • If severe: Add ipratropium 500mcg nebulized every 20 min x3
         1. ◆

            Decision

            Reassess at 1 Hour

            Evaluate response to treatment

            • Good response: Symptoms improved, PEF >60-80% predicted, SpO2 >94%
            • Incomplete response: Some improvement but not resolved
            • Poor response: No improvement or worsening
            1. ●

               Action

               Good Response

               Continue monitoring, prepare for discharge

               • Observe for 1 hour after last nebulizer
               • Continue oral prednisolone 40-50mg daily x 5-7 days
               • Review inhaler technique
               • Provide written asthma action plan
               1. ✓

                  Outcome

                  Discharge with Action Plan

                  Criteria met for safe discharge

                  • PEF >75% predicted or personal best
                  • SpO2 >94% on room air
                  • Adequate inhaler technique demonstrated
                  • Oral corticosteroids for 5-7 days
                  • Follow-up appointment within 2-7 days
            2. ●

               Action

               Incomplete Response

               Intensify treatment

               • Continue SABA every 60 min
               • Add ipratropium if not already given
               • Consider IV magnesium sulfate 2g over 20 min (if severe)
               • Continue monitoring, reassess frequently
               1. ●

                  Action

                  IV Magnesium Sulfate

                  For severe exacerbation not responding to initial treatment

                  • Dose: 1.2-2g IV over 20 minutes
                  • Single dose only
                  • Monitor BP during infusion
                  • Not routinely recommended for mild-moderate
                  1. ✓

                     Outcome

                     Admit to Hospital

                     For ongoing treatment and monitoring

                     • SpO2 <92% on room air
                     • PEF <50% predicted after treatment
                     • Unable to maintain improvement
                     • High-risk features present
                     • Social/psychological factors
            3. ●

               Action

               Poor Response/Worsening

               Escalate care

               • IV magnesium sulfate 2g over 20 min if not given
               • Consider IV salbutamol 250mcg slowly
               • Urgent ICU referral if deteriorating
               • Prepare for possible intubation