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
Disposition
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
Discharge Instructions
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
References
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
World Allergy Organization Anaphylaxis Guidance 2020
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.