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