Acute severe asthma can be fatal and must be treated promptly and energetically. All patients with acute severe asthma should be given high-flow oxygen (if available) and an inhaled short-acting beta2 agonist via a large-volume spacer or nebuliser; give 4–10 puffs of salbutamol 100 micrograms/metered inhalation, each puff inhaled separately via a large-volume spacer, and repeat at 10–20 minute intervals if necessary. If there are life-threatening features, give salbutamol or terbutaline via an oxygen-driven nebuliser every 15–30 minutes. In all cases, a systemic should be given. For adults, give prednisolone 40–50 mg by mouth for at least 5 days, or intravenous hydrocortisone 100 mg (preferably as sodium succinate) every 6 hours until conversion to oral prednisolone is possible. For children, give prednisolone 1–2 mg/kg by mouth (max. 40 mg) for 3–5 days or intravenous hydrocortisone (under 1 year 25 mg, 1–5 years 50 mg, 6–12 years 100 mg) (preferably as sodium succinate) every 6 hours until conversion to oral prednisolone is possible. If the child has been taking an oral corticosteroid for more than a few days, then give prednisolone 2 mg/kg (CHILD under 2 years max. 40 mg, over 2 years max. 50 mg). In life-threatening asthma, also consider initial treatment with ipratropium by nebuliser
Most patients do not require and do not benefit from the addition of intravenous aminophylline or of intravenous beta2 agonist; both cause more adverse effects than nebulised beta2 agonists. Nevertheless, an occasional patient who has not been taking theophylline may benefit from aminophylline infusion. Patients with severe asthma may be helped by magnesium sulphate [unlicensed indication] 1.2–2 g given by intravenous infusion over 20 minutes, but evidence of benefit is limited.
Treatment of acute severe asthma is safer in hospital where resuscitation facilities are immediately available. Treatment should never be delayed for investigations, patients should never be sedated, and the possibility of a pneumothorax should be considered.
If the patient’s condition deteriorates despite pharmacological treatment, intermittent positive pressure ventilation may be needed.
Most patients do not require and do not benefit from the addition of intravenous aminophylline or of intravenous beta2 agonist; both cause more adverse effects than nebulised beta2 agonists. Nevertheless, an occasional patient who has not been taking theophylline may benefit from aminophylline infusion. Patients with severe asthma may be helped by magnesium sulphate [unlicensed indication] 1.2–2 g given by intravenous infusion over 20 minutes, but evidence of benefit is limited.Treatment of acute severe asthma is safer in hospital where resuscitation facilities are immediately available. Treatment should never be delayed for investigations, patients should never be sedated, and the possibility of a pneumothorax should be considered.
If the patient’s condition deteriorates despite pharmacological treatment, intermittent positive pressure ventilation may be needed.
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