Asthma is a chronic inflammatory airway disease characterized by reversible bronchoconstriction, airway hyperreactivity, and mucus production. In the emergency setting, asthma can range from mild to life-threatening, requiring rapid assessment and appropriate escalation of care.
Your uploaded chart offers a highly structured approach based on:
- Emergent assessment
- History
- Physical exam clues
- Basic treatment
- Severe (“SICK”) treatment
- Pearls & pitfalls
- Documentation essentials
This article explains these steps in a clear, academic, exam-oriented format.
Is It an Asthma Emergency?
The first question is whether the patient is in danger.
Emergent signs include:
- Speaking in single words or unable to talk
- Severe accessory muscle use
- Silent chest (no wheezing → very tight airways)
- Hypoxia or cyanosis
- Altered mental status
- Exhaustion (“tiring out”)
- Poor air movement
- History of prior intubations
- Failure to respond to initial therapy
Emergency Interventions
If emergent →
✔ Epinephrine SQ or nebulized (0.3 mg 1:1000)
✔ Consider BiPAP → may require intubation
Step 1: History
Important historical details include:
Past severity
- Prior intubations (strong marker of life-threatening asthma)
- Prior ICU admissions
- Frequent ED visits
- Recent steroid use
Home medications
- Inhalers, compliance, correct inhaler technique
- Response to prior treatments
Symptoms
- Should be a dry cough (wet cough suggests alternative diagnosis)
- Fever/chills? → Consider pneumonia
- Triggers (cold air, exercise, allergens, smoke)
A productive cough, fever, or chest pain may point toward infection or CHF, not pure asthma.
Step 2: Physical Exam
The physical exam helps determine severity:
Key findings
1. Respiratory rate (important indicator of worsening status)2. Wheezing (but may disappear when airways are critically tight!)
3. Speaking ability
- Full sentences → mild
- Phrases → moderate
- Single words → severe
Absence of wheezing is dangerous—indicates minimal airflow.
Step 3: Basic Treatment (for mild–moderate asthma)
The chart recommends:
1. Nebulizers ×3
- Albuterol
- Ipratropium (Duoneb)
Given back-to-back (“stacked neb treatments”).
2. Oral Steroids
Options:
- Prednisone 40–60 mg
- Dexamethasone 10 mg (single dose option)
Steroids reduce inflammation and prevent relapse.
3. Consider Chest X-ray
For:
- Productive cough
- Fever
- Suspected pneumonia
4. Frequent reassessments
Asthma patients can deteriorate quickly—repeat lung exams and vitals regularly.
Step 4: “SICK” Treatment (Severe Asthma)
For patients who remain hypoxic or distressed despite basic therapy:
1. Magnesium sulfate (2 g IV)
Relaxes smooth muscles, used for severe bronchospasm.
2. Epinephrine
- SQ or nebulized
- Useful in life-threatening asthma or airway swelling
3. BiPAP?
Helpful for:
- Fatigue
- Severe work of breathing
Not used if patient is vomiting or altered (aspiration risk).
4. IV Steroids
If too sick for oral steroids.
5. Ketamine
Used for:
- Analgesia/sedation before intubation
- Bronchodilation in severe refractory asthma
6. ABG / VBG
To evaluate ventilation status:
- Rising CO₂ = impending respiratory failure
- Falling pH = fatigue
7. Intubation
If needed, intubate using:
- Ketamine induction
- Low tidal volumes
- Slow respiratory rate
- Prolonged expiratory time
Why?
To prevent air trapping (auto-PEEP).
Pearls & Pitfalls
These are high-yield exam points.
✔ Wheezing may be absent when asthma is very severe.
A “silent chest” is an emergency.
✔ Asthma is not always a chief complaint
Many mimics exist:
- CHF
- COPD
- Anaphylaxis
- Upper airway obstruction (stridor)
✔ Clarify when patients use the word “asthma”
Some might mean general breathing trouble or COPD.
✔ Peak flows have questionable value in the ED
Trend monitoring is more helpful.
✔ Compliance issues
If poor compliance suspected → consider IM dexamethasone.
✔ Discharge checklist
- Ensure inhaler refill
- Check inhaler technique
- Provide access to MDI/spacer
- Consider inhaled corticosteroids
Documentation Essentials
General
- Degree of respiratory distress (mild, moderate, severe)
- Toxic appearance?
- Dry cough or nasal congestion?
- Ability to speak full sentences
- Treatments given by EMS
HEENT
- Nasal flaring
- Upper airway obstruction signs
Lung Exam
- Inspiratory/expiratory wheezing
- Tight breath sounds
- Retractions
- Abdominal breathing
Documentation is essential for tracking progression and medico-legal safety.
High-Yield Summary Table
| Category | Key Points |
|---|---|
| Emergent | Consider Epi & BiPAP → may need intubation |
| History | Prior intubations, recent steroids, triggers |
| Exam | RR, wheeze, accessory muscles, speech ability |
| Basic Tx | Duonebs ×3, oral steroids, CXR if fever/FC |
| Severe Tx | IV Mg, Epinephrine, IV steroids, Ketamine, ABG |
| Intubation | Low volumes, slow RR, prolonged expiration |
| Pitfalls | Wheeze may be absent; beware CHF/COPD mimics |
| Discharge | Refill inhalers, ensure adherence, inhaled steroids |
FAQs About Asthma Management
1. When does asthma become life-threatening?
When there is exhaustion, hypoxia, silent chest, or rising CO₂.
2. Why is epinephrine used?
It provides rapid bronchodilation and reduces airway edema.
3. Should BiPAP always be used in severe asthma?
No—avoid if altered mental status or active vomiting.
4. Why give magnesium?
It relaxes airway smooth muscle and helps break severe bronchospasm.
5. When to get a chest X-ray?
In asthma with fever, productive cough, or suspicion of pneumonia.
6. When do you consider intubation?
Fatigue, AMS, CO₂ retention, or failure to respond to aggressive therapy.
