›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
Consultation plan
›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
17Disposition/dispo25
ICU criteria
›ICU level care indicators
›Persistent hypoxemia despite escalating oxygen support
›Hypercapnia with acidosis
›Need for continuous nebulization with severe distress
›Altered mental status or exhaustion
›Need for NIPPV or invasive ventilation
Inpatient admission criteria
›Admission indicators
›Ongoing oxygen requirement after ED therapy
›Recurrent symptoms within hours after initial response
›Significant comorbidities
›Poor access to medications or unreliable follow up
Observation pathway criteria
›Observation candidates
›Partial response after 1 to 2 hours but improving trend
›Need for repeated bronchodilators less than hourly
›Stable vitals and improving work of breathing
Discharge criteria
›Discharge readiness
›Minimal work of breathing at rest
›SpO2 stable on room air at baseline goal
›Sustained improvement at least 60 minutes after last bronchodilator
›Peak flow improved and acceptable for baseline when available
›Access to inhalers and steroids if indicated
Follow up timing
›Follow up plan
›Primary care within 2 to 7 days
›Asthma educator or respirology for recurrent exacerbations
›Allergy referral after anaphylaxis concern
18Discharge Instructions/di13
Copy discharge instructions
›Patient instructions
›You were treated for wheezing and breathing tightness
›Use your reliever inhaler as prescribed for symptoms
›If you were given steroids take them exactly as prescribed
›Avoid triggers that worsened your symptoms today
›Follow up with your clinician within the recommended timeframe
›Return to the ER immediately for
›Trouble speaking because of shortness of breath
›Breathing getting worse despite reliever use
›Blue lips or severe sleepiness
›Chest pain or fainting
›Swelling of lips tongue or throat
›Widespread hives with breathing problems
19References/r8
Guidelines and key sources
›Key references
›Global Initiative for Asthma Global Strategy for Asthma Management and Prevention 2025
›Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Prevention Diagnosis and Management of COPD 2025 Report
›National Heart Lung and Blood Institute National Asthma Education and Prevention Program 2020 Focused Updates to the Asthma Management Guidelines 2020
›Canadian Paediatric Society Managing an acute asthma exacerbation in children statement
›NICE Quality Standard QS10 Emergency oxygen during an exacerbation of COPD 2023
›British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings 2017
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
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