›Immediate stabilization workflow
›Airway positioning and suction readiness if secretions
›Continuous pulse oximetry for moderate to severe
›Cardiac monitor for moderate to severe or beta agonist escalation
›IV access for severe distress or poor response
›Oxygen targets
›SpO2 target 94 to 98 percent for most patients
›SpO2 target 88 to 92 percent if COPD or risk of hypercapnic respiratory failure
Bronchodilator and steroid pathway
›Standard acute bronchospasm treatment
›Salbutamol nebulized 5 mg
›Repeat every 20 minutes for 1 hour as needed
›MDI option salbutamol 4 to 8 puffs via spacer for mild to moderate
›Ipratropium nebulized 500 mcg for moderate to severe
›Systemic corticosteroid early for moderate to severe
›Prednisone 40 to 50 mg PO once daily
›Duration 5 to 7 days local protocol dependent
›Methylprednisolone 125 mg IV once if unable to take PO or severe
Severe and refractory pathway
›Escalation treatments
›Continuous salbutamol nebulization local protocol dependent
›Magnesium sulfate 2 g IV over 20 minutes for severe asthma with poor response
›Epinephrine IM for anaphylaxis suspected
›Adult 0.5 mg IM of 1 mg per mL solution
›Pediatric 0.01 mg per kg IM of 1 mg per mL solution
›Maximum pediatric single dose 0.5 mg
›Heliox adjunct local protocol dependent
Ventilatory support and airway
›Respiratory support escalation
›Noninvasive ventilation trial for impending fatigue with close monitoring
›Intubation preparation triggers
›Altered mental status
›Silent chest with worsening fatigue
›Persistent hypoxemia despite support
›Intubation considerations
›Avoid dynamic hyperinflation by allowing long expiratory time
›Permissive hypercapnia strategy local protocol dependent
Etiology specific treatments
›Cause directed additions
›COPD exacerbation antibiotics when bacterial features
›Increased sputum purulence
›Increased sputum volume
›Increased dyspnea
›Acute heart failure suspected
›Diuretics and vasodilators pathway per local protocol
›POCUS and CXR integration
›Foreign body aspiration suspected
›Early bronchoscopy consultation
›Avoid delaying with repeated bronchodilators if focal findings persist
Monitoring and reassessment loop
›Reassessment schedule
›Reassess every 15 to 30 minutes in moderate to severe
›Repeat lung exam and work of breathing
›Repeat SpO2 and respiratory rate trend
›Peak flow trend when feasible
›Escalate level of care if deterioration or no improvement after 1 to 2 hours
›Consult triggers
›ICU for severe refractory bronchospasm or ventilatory failure concern
›ENT for suspected upper airway obstruction
›Respirology for unclear diagnosis recurrent severe attacks
›Allergy for anaphylaxis follow up planning