⚠️ Prevention is key: All patients at risk of severe exacerbations should have an individualised plan 📋 to manage deterioration early with short-acting beta-agonists (SABA), oral steroids, and clear instructions to seek urgent medical help.

🚨 Initial Status Asthmaticus Management Summary
🫁 ABC, Oxygen 15 L/min via non-rebreather, establish IV access. Slow IV fluids 💨 Nebulised Beta agonists Salbutamol (5 mg) every 15–30 min with high-flow O₂. Terbutaline (10 mg) every 15–30 min with high-flow O₂. Watch for tachycardia and lactic acidosis 💨 Oxygen target is 94–98% in all patients (titrate to avoid hyperoxia) 💨 Steroids 💉 Hydrocortisone 100 mg IV stat and then 100 mg IV 6 hrly OR 💉 Prednisolone 40 mg OD (may be given with single dose of Hydrocortisone initially) 🚨 Reassess after 5-10 mins and if not improving take senior advice 🚨 Monitor for tachycardia, hypokalaemia, hypoxia, acidosis, exhaustion ➕ Add Ipratropium Bromide 0.5 mg every 4–6 hrs via Nebs. ⚡ Consider IV Magnesium Sulphate 2.0 g over 20 min. ⚡ Consider IV Aminophylline 5 mg/kg Loading dose over 20 min. (Not if on Oral Aminophylline) ⚡ Followed by IV Aminophylline 0.5 mg/kg/hr Infusion. 💉 Consider IV Salbutamol infusion (5–20 mcg/min) or 250 mcg IV bolus. 👩‍⚕️ No Improvement Get early senior/ITU input if not responding. 🩻 Portable CXR & ABG. Look for small PTX. Escalate to ITU if fails to improve. ⚠️ Warning signs of deterioration: seek ITU help long before Cyanosis Worsening Hypoxia with PO₂Acidosis Progressive exhaustion pCO₂ changes from low to normal Wheeze quieter as less air moving Reduced GCS

🚨 Initial Status Asthmaticus Management Summary

🫁 ABC, Oxygen 15 L/min via non-rebreather, establish IV access. Slow IV fluids
💨 Nebulised Beta agonists
- Salbutamol (5 mg) every 15–30 min with high-flow O₂.
- Terbutaline (10 mg) every 15–30 min with high-flow O₂.
- Watch for tachycardia and lactic acidosis
💨 Oxygen target is 94–98% in all patients (titrate to avoid hyperoxia)
💨 Steroids
- 💉 Hydrocortisone 100 mg IV stat and then 100 mg IV 6 hrly OR
- 💉 Prednisolone 40 mg OD (may be given with single dose of Hydrocortisone initially)
🚨 Reassess after 5-10 mins and if not improving take senior advice
🚨 Monitor for tachycardia, hypokalaemia, hypoxia, acidosis, exhaustion
➕ Add Ipratropium Bromide 0.5 mg every 4–6 hrs via Nebs.
⚡ Consider IV Magnesium Sulphate 2.0 g over 20 min.
⚡ Consider IV Aminophylline 5 mg/kg Loading dose over 20 min. (Not if on Oral Aminophylline)
⚡ Followed by IV Aminophylline 0.5 mg/kg/hr Infusion.
💉 Consider IV Salbutamol infusion (5–20 mcg/min) or 250 mcg IV bolus.
👩‍⚕️ No Improvement Get early senior/ITU input if not responding.
🩻 Portable CXR & ABG. Look for small PTX. Escalate to ITU if fails to improve.
⚠️ Warning signs of deterioration: seek ITU help long before
- Cyanosis
- Worsening Hypoxia with PO₂Acidosis
- Progressive exhaustion
- pCO₂ changes from low to normal
- Wheeze quieter as less air moving
- Reduced GCS

📊 Assessing Severity in Adults (BTS/SIGN SIGN 158)

Severity	Key Clinical Features	PEF (% best or predicted)	SpO₂ on air
Moderate exacerbation	Talking in sentences • No features of acute severe asthma	>50%	≥92%
Acute severe asthma	Any one of: RR ≥25/min • HR ≥110/min • Unable to complete sentences in one breath	33–50%	≥92%
Life-threatening asthma	Any one of: SpO₂ <92% • PEF <33% • Silent chest • Cyanosis • Poor respiratory effort • Arrhythmia • Hypotension • Exhaustion • Confusion • Coma	<33%	<92%
Near-fatal asthma	Raised PaCO₂ and/or requiring mechanical ventilation	Variable	Variable

👶 Children – Severity (same principles, age-adjusted)

Use paediatric early warning score (PEWS) + BTS traffic-light system
Life-threatening signs in children: SpO₂ <92%, silent chest, poor effort, hypotension, exhaustion, altered consciousness
Clinical advice: Children can decompensate faster – involve senior paediatrician/anaesthetist early

🩻 Investigations & Monitoring – Clinical Advice

PEF (if able) and continuous SpO₂, RR, HR
ABG only if life-threatening features or not responding after 1 hour of treatment. A “normal” PaCO₂ (4.6–6.0 kPa) in a tachypnoeic distressed patient is ominous (indicates fatigue and impending failure). Rising PaCO₂ or acidosis = immediate senior/ICU discussion.
CXR NOT routine – only if suspected pneumothorax, consolidation, pneumomediastinum, or life-threatening asthma
U&E (watch potassium – salbutamol drives it down)

🚑 Initial Management – All Patients (Clinical Pearls)

ABC approach • Sit upright • High-flow oxygen titrated to SpO₂ 94–98% (use Venturi if COPD overlap suspected)
Continuous monitoring – never leave the patient unattended (even during transfer)
Reassure calmly – anxiety worsens symptoms
Clinical advice: If the patient cannot speak or is exhausted, prepare for advanced airway support immediately

💊 Pharmacological Management (BTS/SIGN SIGN 158)

Moderate exacerbation (PEF >50%)

Salbutamol 4–10 puffs via spacer (or nebuliser 5 mg) – repeat every 15–30 min as needed
Prednisolone 40–50 mg PO daily for at least 5 days (continue usual preventer ICS)
Clinical advice: Good response = PEF >75% after 1 hour + stable → consider discharge with clear plan

Acute severe or life-threatening asthma

Oxygen titrated to SpO₂ 94–98%
Nebulised salbutamol 5 mg – give back-to-back (every 15 min) or continuous nebuliser until improvement or side effects appear
Add nebulised ipratropium 500 mcg (every 4–6 hours in severe cases)
Systemic steroids: prednisolone 40–50 mg PO OR hydrocortisone 100 mg IV stat, then 100 mg IV 6-hourly if unable to swallow
IV magnesium sulphate 2 g over 20 minutes (first-line add-on – give early in life-threatening cases)
Senior/ICU review within 15–30 minutes for life-threatening features

🔴 Escalation if Poor Response – Practical Advice

Repeat nebulisers + magnesium (already given)
IV salbutamol infusion only on specialist advice (monitor lactate and potassium)
Aminophylline infusion NOT routine – only if consultant decision
Clinical advice: Prepare for intubation if: exhaustion, drowsiness, rising PaCO₂, respiratory arrest, or SpO₂ falling despite maximal therapy

Special Populations – Important Clinical Advice

Pregnancy: Treat aggressively – uncontrolled asthma is more dangerous than medicines. Steroids and salbutamol are safe. Continue usual preventer. Involve obstetric team early.
Obese patients: May need higher doses or longer nebuliser time; consider vocal cord dysfunction as differential.
Smokers/vapers: Higher risk of poor response – give smoking cessation advice and nicotine replacement in hospital.

🏡 Discharge Criteria & Planning – Practical Checklist

PEF >75% best/predicted • No acute severe features • Stable on usual therapy for 1–2 hours
Continue Prednisolone 40–50 mg for 5 days total (no taper needed)
Check and correct inhaler technique BEFORE discharge (critical step – most readmissions are technique-related)
Prescribe regular preventer ICS-based therapy (no SABA monotherapy)
Provide written Personalised Asthma Action Plan (PAAP) + PEF meter if appropriate
Arrange follow-up: GP/asthma nurse within 48 hours (after ED attendance) or 2 weeks (after admission)
Safety-netting advice: Return immediately if worsening, unable to speak, or PEF falling
Review triggers (viral, allergens, occupational, NSAIDs) and offer smoking cessation support

📚 Official References (2026)

BTS/SIGN British Guideline on the Management of Asthma – SIGN 158 (2019 with 2024/2025 pathway updates)
NICE NG244 Asthma: diagnosis, monitoring and chronic asthma management (2024)
NICE NG245 Acute asthma management summary
BTS Acute Asthma Audit recommendations 2025

This is an educational summary only. Always follow your local hospital protocol, trust guidelines and obtain senior advice. Early escalation saves lives. Last updated March 2026.

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Acute Severe Asthma (Status Asthmaticus)✅