Asthma exacerbationMANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

⚲

632 items

☷ Legend

⚲

Cardiovascular Presentations66▾

Respiratory Presentations47▾

Acute bronchitis Acute Respiratory Distress Syndrome (ARDS)Acute respiratory failure Apparent Life-Threatening Event (ALTE-BRUE)Aspiration pneumonia Asthma exacerbation Bacterial Tracheitis Bronchiolitis Bronchiolitis (RSV)Chylothorax Community-acquired pneumonia COPD exacerbation COVID-19 pneumonia Croup Croup (laryngotracheobronchitis)Cystic Fibrosis Exacerbation Empyema Epiglottitis Epiglottitis (Pediatric)Fat Embolism Syndrome Foreign Body Aspiration Foreign Body Aspiration (Pediatric)Healthcare-Associated Pneumonia Hemothorax Hospital-acquired pneumonia Legionnaires' Disease Lung Abscess Pertussis Pleural effusion Pleurisy Pneumocystis jirovecii Pneumonia Pneumocystis Pneumonia Pneumomediastinum Pneumothorax (Simple)Pneumothorax (traumatic)Psittacosis Pulmonary Alveolar Proteinosis Pulmonary contusion Pulmonary Edema (Non-cardiogenic)Sarcoidosis Exacerbation Smoke Inhalation Injury Spontaneous pneumothorax Status Asthmaticus Sudden Infant Death Syndrome (SIDS)Tension Pneumothorax Tracheal Stenosis Viral Pneumonia

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp68

Immediate stabilization

›Airway breathing circulation priorities

›Position of comfort

›Upright

›Avoid supine if severe dyspnea

›Oxygenation targets

›SpO2 94 to 98 percent for most

›SpO2 88 to 92 percent if chronic hypercapnia risk

›Monitoring

›Continuous pulse oximetry

›Cardiac monitor for severe symptoms or high dose beta agonist

›Escalation triggers

›If silent chest or minimal air movement, resuscitation bay

›If altered mental status, resuscitation bay

›If SpO2 < 90 percent despite oxygen, resuscitation bay

›If impending exhaustion, early airway plan

›Time zero treatments

›Inhaled short acting beta agonist

›Metered dose inhaler with spacer preferred if feasible

›Continuous nebulization for severe exacerbation

›Inhaled anticholinergic

›Add for moderate to severe exacerbation

›Systemic corticosteroid

›Early administration within first hour when moderate to severe

›Reassessment interval

›Every 15 to 30 minutes until improving

›After each treatment cycle for disposition decisions

Severity stratification

›Bedside severity categories

›Mild

›Speaks full sentences

›Minimal accessory muscle use

›PEF or FEV1 at least 70 percent predicted or personal best

›Moderate

›Speaks in phrases

›Accessory muscle use

›PEF or FEV1 40 to 69 percent predicted or personal best

›Severe

›Speaks in words

›Marked work of breathing

›PEF or FEV1 < 40 percent predicted or personal best

›Life threatening

›Drowsiness confusion

›Silent chest

›Cyanosis

›Bradycardia or hypotension

›PEF < 25 percent predicted or personal best

›Objective response markers

›Dyspnea trend

›Speech improvement

›Accessory muscle reduction

›Airflow trend

›PEF improvement at least 60 to 70 percent predicted or personal best

›Reduced wheeze intensity with improved air entry

›Gas exchange trend

›SpO2 improvement to target range

›Rising PaCO2 as a fatigue marker in severe disease

Key decision points

›Alternative diagnosis triggers

›If unilateral absent breath sounds, pneumothorax consideration

›If fever focal crackles, pneumonia consideration

›If pleuritic chest pain hypoxemia, pulmonary embolism consideration

›If stridor, upper airway obstruction consideration

›Ventilatory failure risk

›If PaCO2 normal or elevated in severe attack, fatigue concern

›If worsening acidosis, imminent failure concern

›If decreasing respiratory rate with persistent distress, exhaustion concern

›Consultation triggers

›If life threatening features, critical care

›If need for noninvasive ventilation or intubation, anesthesia or ICU

›If refractory to ED maximal bronchodilators, ICU

02History/hx75

Presenting features and trajectory

›Symptom pattern and timing

›Onset time

›Minutes to hours

›Days with progressive worsening

›Peak severity time

›Current worst point

›Nocturnal symptoms

›Prior similar episodes

›Typical response to inhaler

›Prior intubation or ICU

›Triggers and exposures

›Viral upper respiratory symptoms

›Fever

›Sick contacts

›Allergen exposure

›Pets

›Dust mites

›Irritants

›Smoke vaping

›Occupational fumes

›Exercise cold air

›Recent exertion

›Cold exposure

›Medication triggers

›Nonselective beta blockers

›NSAID sensitivity history

Baseline asthma control and risk

›Baseline control markers

›Daytime symptoms frequency

›More than twice weekly

›Daily symptoms

›Night waking frequency

›Any night waking

›Frequent night waking

›Activity limitation

›School work exercise limitation

›Missed school work days

›Exacerbation risk markers

›Prior ED visit hospitalization

›Past 12 months

›Multiple ED visits

›Prior intubation or ICU

›Any history

›Recent history

›Overuse of short acting beta agonist

›Multiple canisters per month

›Frequent rescue use

›Underuse of controller therapy

›No inhaled corticosteroid

›Poor adherence

Medications and comorbidities

›Current therapies

›Rescue inhaler details

›Last dose time

›Number of puffs in last 24 hours

›Controller therapy

›Inhaled corticosteroid dose

›ICS LABA use

›Recent systemic steroid

›Within past 30 days

›Dose and duration

›Comorbid conditions

›Anaphylaxis allergy history

›Food venom medication allergy

›Urticaria angioedema symptoms

›COPD overlap or smoking history

›Long smoking history

›Chronic sputum

›Cardiac disease

›Heart failure history

›Arrhythmia history

›Gastroesophageal reflux

›Heartburn regurgitation

›Chronic cough pattern

›Mental health and anxiety

›Panic symptoms

›Hyperventilation episodes

03Physical Exam/exam51

Respiratory assessment

›Work of breathing

›Accessory muscle use

›Intercostal retractions

›Suprasternal retractions in pediatrics

›Speech limitation

›Full sentences

›Words only

›Respiratory rate

›Age adjusted tachypnea

›Declining rate with exhaustion concern

›Auscultation

›Wheeze distribution

›Diffuse expiratory

›Inspiratory component in severe

›Air entry

›Good air movement

›Reduced air movement

›Silent chest

›Focal findings

›Localized crackles

›Unilateral reduction

›Oxygenation and perfusion

›SpO2 on room air and oxygen

›< 90 percent severe marker

›Response to oxygen

›Heart rate

›Tachycardia expected with distress or beta agonist

›Bradycardia late warning

›Blood pressure

›Hypertension from catecholamine response

›Hypotension severe marker

General and high risk signs

›Mental status

›Agitation anxiety

›Early hypoxemia sign

›Hyperventilation pattern

›Drowsiness confusion

›Hypercapnia marker

›Impending failure marker

›Ability to lie flat

›Tripod posture

›Orthopnea differential consideration

›Hydration and fatigue

›Dry mucous membranes

›Exhaustion posture

PITFALLS

›False reassurance patterns

›Reduced wheeze with worsening air entry

›Silent chest as critical sign

›Minimal chest movement as critical sign

›Normal initial SpO2 in early bronchospasm

›Rapid deterioration risk

›Continuous monitoring need

04Differential Diagnosis/ddx41

Life threatening mimics

›Alternative diagnoses requiring exclusion

›Anaphylaxis

›Hypotension

›Urticaria angioedema

›Upper airway obstruction

›Stridor

›Foreign body aspiration

›Pneumothorax

›Sudden pleuritic pain

›Unilateral absent breath sounds

›Pulmonary embolism

›Pleuritic pain

›Risk factors and hypoxemia

›Heart failure pulmonary edema

›Crackles

›Peripheral edema

Common competing conditions

›Lower respiratory infections

›Pneumonia

›Fever focal crackles

›Pleuritic pain

›Acute bronchitis

›Cough predominant

›Minimal airflow limitation

›COPD exacerbation

›Older age smoking history

›Chronic sputum

›Vocal cord dysfunction

›Inspiratory wheeze or stridor

›Poor response to bronchodilator

›Anxiety hyperventilation syndrome

›Paresthesias

›Normal lung exam between episodes

Coding anchors

›ICD 10 compatible terms

›Asthma with acute exacerbation

›J45.901 unspecified asthma with acute exacerbation

›J45.21 mild intermittent asthma with acute exacerbation

›J45.31 mild persistent asthma with acute exacerbation

›J45.41 moderate persistent asthma with acute exacerbation

›J45.51 severe persistent asthma with acute exacerbation

›Status asthmaticus

›J45.902 unspecified asthma with status asthmaticus

05Laboratory Tests/lt34

Core labs by indication

›Targeted labs for severe or atypical presentations

›Arterial or venous blood gas for ventilatory failure concern

›Rising PaCO2 marker

›Normalization or elevation in severe attack as fatigue marker

›Worsening acidosis as imminent failure marker

›PaO2 assessment if severe hypoxemia

›PaO2 in mmHg

›A a gradient interpretation when needed

›Electrolytes for high dose beta agonist

›Potassium

›Hypokalemia risk from beta agonist shift

›Repletion planning when symptomatic or significant

›Glucose

›Hyperglycemia risk from beta agonist and steroids

›Diabetes management consideration

›CBC for infection concern

›Leukocytosis interpretation caution

›Steroid related demargination

›Stress leukocytosis

Point of care testing

›ED rapid tests when clinically indicated

›Viral testing based on local policy

›Influenza or SARS CoV 2 when it changes management

›Outbreak context

›Lactate for shock concern

›Alternative causes of elevated lactate

›Beta agonist associated lactate elevation

›Sepsis physiology differentiation

PITFALLS

›Lab limitations

›ABG or VBG not routine in mild to moderate

›Clinical response as primary guide

›Over testing risk

›Leukocytosis not equal bacterial infection

›Clinical and imaging correlation

›Antibiotic stewardship

06Diagnostic Tests/dt59

Scoring Systems

›Structured severity tools

›Peak expiratory flow based stratification

›PEF percent predicted or personal best

›At least 70 percent mild

›40 to 69 percent moderate

›< 40 percent severe

›< 25 percent life threatening

›Response categories

›PEF at least 60 to 70 percent after treatment supports discharge consideration

›PEF < 40 percent after treatment supports admission consideration

›Pediatric asthma scores

›PRAM Pediatric Respiratory Assessment Measure

›Suprasternal indrawing

›Scalene muscle use

›Air entry

›Wheeze

›Oxygen saturation

›Use cases

›Serial reassessment for response

›Communication between teams

MRI

›Role of MRI

›Not routine for acute exacerbation

›Time constraints

›Limited acute utility

›Alternative diagnoses evaluation

›If mediastinal mass suspicion

›If complex congenital airway considerations in pediatrics

›Role of CT

›Not routine for acute exacerbation

›Radiation and time

›Reserve for alternative diagnosis

›Indications for CT chest consideration

›If suspected pulmonary embolism

›Persistent hypoxemia disproportionate to wheeze

›Pleuritic pain and risk factors

›If suspected complications

›Pneumomediastinum with chest pain and subcutaneous emphysema

›Atypical focal findings with non diagnostic radiograph

Ultrasound

›POCUS adjuncts

›Lung ultrasound for alternative diagnoses

›Pneumothorax evaluation

›Absent lung sliding

›Lung point

›Pulmonary edema evaluation

›B lines pattern

›Pleural effusions

›Cardiac ultrasound when indicated

›Right heart strain with PE concern

›Global function in shock

›Chest radiograph role

›Indications

›First presentation or uncertain diagnosis

›Fever focal findings

›Suspected pneumothorax pneumomediastinum

›Poor response to therapy

›Typical findings

›Hyperinflation

›Peribronchial thickening

›Normal radiograph common

07Disposition/dispo39

Admission and ICU criteria

›Level of care decisions

›ICU indications

›Life threatening features

›Silent chest

›Altered mental status

›Persistent hypoxemia

›SpO2 < 90 percent despite oxygen

›PaO2 persistently low in mmHg

›Hypercapnia or acidosis

›Rising PaCO2

›Worsening pH

›Need for ventilatory support

›Noninvasive ventilation

›Intubation

›Ward admission indications

›Persistent moderate to severe symptoms after ED therapy

›Need for frequent bronchodilator

›PEF < 40 to 50 percent predicted or personal best after treatment

›Social or access barriers

›Poor follow up reliability

›Inability to obtain medications

ED discharge criteria

›Discharge readiness

›Clinical stability

›Minimal work of breathing

›Speaks in full sentences or age appropriate baseline

›Objective measures

›PEF at least 60 to 70 percent predicted or personal best

›SpO2 at target on room air or baseline oxygen

›Treatment spacing

›Short acting beta agonist no more frequent than every 4 hours

›Sustained response at least 60 minutes after last bronchodilator

›Plan completeness

›Systemic steroid course started

›Controller plan provided

›Follow up arranged

Transfer considerations

›Interfacility transfer triggers

›No ICU capability locally with severe attack

›Need for continuous nebulization with close monitoring beyond local capacity

›Pediatric critical care requirement

08Treatment/t128

Bronchodilators and steroids

›Inhaled short acting beta agonist

›Albuterol salbutamol dosing

›Adults MDI spacer

›4 to 8 puffs every 20 minutes for 1 hour then reassess

›4 to 8 puffs every 1 to 4 hours as needed

›Adults nebulized

›2.5 to 5 mg every 20 minutes for 3 doses

›Continuous 10 to 15 mg per hour for severe

›Pediatrics nebulized

›0.15 mg per kg per dose

›Minimum 2.5 mg per dose

›Maximum 5 mg per dose

›Every 20 minutes for 3 doses then reassess

›Monitoring with high dose therapy

›Tachycardia tremor

›Hypokalemia surveillance

›Levalbuterol option

›Similar efficacy

›Consider if significant tachyarrhythmia concern

›Inhaled anticholinergic

›Ipratropium dosing

›Adults nebulized

›0.5 mg every 20 minutes for 3 doses

›Pediatrics nebulized

›0.25 to 0.5 mg every 20 minutes for 3 doses

›Combination therapy

›Add to SABA for moderate to severe in first hour

›Reduced hospitalization in severe presentations

›Systemic corticosteroid

›Prednisone or prednisolone oral

›Adults

›40 to 60 mg daily for 5 to 7 days

›No taper for short course in most

›Pediatrics

›1 to 2 mg per kg per day

›Maximum 60 mg per day

›3 to 5 days typical

›Methylprednisolone IV

›Indications

›Unable to tolerate oral

›Severe exacerbation with vomiting or impending failure

›Adults dosing

›60 to 125 mg IV initial

›Pediatrics dosing

›1 mg per kg IV

›Maximum 60 mg per dose

Adjunct therapies for severe or refractory

›Magnesium sulfate IV

›Indications

›Severe exacerbation with poor response to initial bronchodilators

›PEF or FEV1 < 25 to 30 percent predicted or personal best

›Adults dosing

›2 g IV over 20 minutes

›Hypotension monitoring

›Pediatrics dosing

›25 to 50 mg per kg IV over 20 to 30 minutes

›Maximum 2 g

›Evidence

›Reduced hospitalization in severe exacerbations in multiple trials and meta analyses

›Epinephrine

›Indications

›Anaphylaxis with bronchospasm

›Life threatening asthma with poor inhaled delivery and impending arrest as rescue consideration

›IM dosing for anaphylaxis

›Adults

›0.5 mg IM of 1 mg per mL

›Pediatrics

›0.01 mg per kg IM of 1 mg per mL

›Maximum 0.3 mg per dose prepubertal

›Maximum 0.5 mg per dose adolescent

›Nebulized epinephrine

›Role limited

›Consider primarily for upper airway edema not typical asthma

›Noninvasive ventilation

›Indications

›Severe work of breathing with hypercapnia risk

›Cooperative patient without immediate intubation need

›Contraindications

›Altered mental status inability to protect airway

›Hemodynamic instability

›Monitoring needs

›Continuous monitoring

›Early reassessment for failure

›Ketamine

›Role

›Induction agent with bronchodilatory properties during intubation

›Analgosedation option in ventilated severe asthma

›Dosing examples

›RSI induction 1 to 2 mg per kg IV

›Analgosedation infusion 0.5 to 2 mg per kg per hour titrated

›Heliox

›Consideration

›Severe airflow obstruction with poor aerosol delivery

›Availability dependent

›Limitations

›Requires high helium fraction

›Reduced effectiveness if high oxygen requirement

Therapies generally not recommended

›Antibiotics

›Not routine

›Reserve for clear bacterial infection evidence

›Stewardship emphasis

›Mucolytics

›Not recommended in acute asthma

›Sedatives without airway plan

›Avoid due to hypoventilation risk

Airway and ventilation

›Intubation indications

›Respiratory arrest or peri arrest

›Altered mental status with inability to protect airway

›Refractory hypoxemia or hypercapnia with acidosis

›Exhaustion with impending failure

›Ventilation strategy for intubated severe asthma

›Dynamic hyperinflation mitigation

›Low respiratory rate

›Prolonged expiratory time

›Permissive hypercapnia with pH target individualized

›Barotrauma monitoring

›High peak pressures

›Pneumothorax surveillance

›Auto PEEP recognition

›Hypotension after ventilation initiation

›Ventilator flow not returning to baseline

›Evidence and guideline anchors

›Inhaled SABA and systemic corticosteroid as first line standard of care

›Broad guideline consensus

›Early steroid reduces relapse and admission risk

›Add ipratropium for moderate to severe in ED

›Evidence supports reduced admissions in severe presentations

›IV magnesium for severe refractory cases

›Evidence supports reduced hospital admission in severe attacks

09Special Populations/sp40

Pregnancy

›Pregnancy specific considerations

›Maternal oxygenation priority

›SpO2 target at least 95 percent commonly used to support fetal oxygenation

›Early escalation when hypoxemic

›Medication safety

›Inhaled SABA preferred rescue

›Inhaled corticosteroid continuation

›Systemic corticosteroid when indicated

›Obstetric collaboration triggers

›Severe exacerbation

›Reduced fetal movement or bleeding

›Differential emphasis

›Pulmonary embolism risk increased in pregnancy

›Preeclampsia pulmonary edema consideration

Geriatric

›Older adult considerations

›Cardiac comorbidity and beta agonist effects

›Tachyarrhythmia risk

›Ischemia risk in coronary disease

›COPD overlap

›Baseline hypercapnia possibility

›Oxygen targets individualized

›Medication interactions

›Beta blocker use

›Polypharmacy review

›Frailty and disposition

›Lower threshold for observation or admission

›Home support assessment

Pediatrics

›Pediatric specific considerations

›Weight based dosing

›SABA nebulized 0.15 mg per kg per dose

›Magnesium 25 to 50 mg per kg IV

›Clinical markers

›Suprasternal retractions

›Poor feeding or lethargy

›Delivery method

›MDI spacer effectiveness

›Mask fit importance

›Admission threshold lower in young children

›History of severe attack

›Persistent need for frequent bronchodilator

10Background/b43

Epidemiology

›Burden and patterns

›Common ED presentation across age groups

›Seasonal viral peaks

›Allergen related peaks

›Exacerbation relapse risk after ED visit

›Higher with prior severe history

›Higher with poor controller adherence

›Mortality concentrated in high risk groups

›Prior ICU or intubation history

›High SABA use and low ICS use

Pathophysiology

›Core mechanisms

›Bronchial smooth muscle constriction

›Rapid onset component

›Reversibility with bronchodilator

›Airway inflammation and edema

›Slower response component

›Steroid responsive component

›Mucus plugging

›Ventilation perfusion mismatch

›Atelectasis risk

›Dynamic hyperinflation in severe attack

›Increased work of breathing

›Auto PEEP and hemodynamic compromise

Therapeutic Considerations

›Rationale for first line therapies

›SABA mechanism

›Beta 2 receptor mediated bronchodilation

›Rapid symptom relief

›Anticholinergic add on

›Reduced vagal bronchoconstriction

›Additive bronchodilation with SABA

›Systemic corticosteroid

›Reduced airway inflammation

›Reduced relapse after discharge

›Magnesium sulfate

›Smooth muscle relaxation

›Greatest benefit in severe obstruction

›Controller therapy after exacerbation

›Inhaled corticosteroid foundation

›Reduced future exacerbations

›Reduced need for systemic steroids

›Follow up and action plan reduces recurrence

›Trigger avoidance strategies

›Inhaler technique correction

11Patient Discharge Instructions/pdi31

copy discharge instructions

›Discharge plan

›Medications

›Rescue inhaler use

›2 to 4 puffs every 4 hours as needed

›Spacer use if available

›Oral steroid course completion

›Take daily until finished

›Take with food if stomach upset

›Controller therapy

›Continue daily inhaled steroid if prescribed

›Start inhaled steroid if newly prescribed

›Trigger control

›Avoid smoke vaping exposure

›Avoid known allergens when possible

›Viral infection precautions

›Follow up timing

›Primary care or asthma clinic within 1 to 3 days for moderate to severe ED visit

›Within 7 days for mild ED visit

›Return immediately for

›Trouble speaking due to breathing

›Lips or face turning blue or gray

›Severe chest tightness not improving after rescue inhaler

›Need for rescue inhaler more often than every 4 hours

›Fainting confusion extreme sleepiness

›Chest pain or one sided decreased breath sounds

›Device technique

›Spacer technique review

›Nebulizer cleaning instructions if used

›Written asthma action plan

›Green yellow red zone guidance

›Peak flow use if available

12References/r23

Clinical guidelines and evidence sources

›Guideline sources

›Global Initiative for Asthma

›GINA strategy for asthma management and prevention

›ED acute exacerbation principles and discharge planning

›NHLBI NAEPP focused updates

›Controller strategies and risk reduction concepts

›Stepwise therapy framework

›British Thoracic Society SIGN guideline

›Acute asthma assessment and management framework

›Severity features and escalation triggers

›Evidence base for key ED therapies

›Ipratropium plus SABA in acute severe asthma

›Reduced hospitalization in severe attacks in multiple trials

›Greatest benefit in first hour treatment bundles

›Early systemic corticosteroid in ED

›Reduced relapse and admission in meta analyses

›Benefit greatest when given early

›IV magnesium sulfate for severe exacerbation

›Reduced hospitalization in severe exacerbations in meta analyses

›Benefit most consistent in severe obstruction

›Ventilation strategies for status asthmaticus

›Low minute ventilation approach for hyperinflation avoidance

›Barotrauma risk mitigation principles

Learn More: Asthma exacerbation→

Comprehensive Clinical Review

Structured, evidence-informed, long-form analysis for deeper understanding.

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.