Acute Asthma Exacerbation — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Severity assessment
   How severe is the exacerbation? (GINA: speaks in full sentences / prefers sitting / not agitated / SpO2 90–95% / PEF >50% = mild–moderate; speaks in words only / sits hunched / agitated / RR >30 / accessory muscle use / HR >120 / SpO2 <90% / PEF ≤50% = severe; drowsy, confused, silent chest, bradycardia = life-threatening.)
   • Mild–moderate → Mild–moderate
   • Severe → Severe
   • Life-threatening → Life-threatening
2. [End] Mild–moderate
   Repeated inhaled SABA (salbutamol, MDI with spacer or nebulizer); controlled oxygen targeting SpO2 93–95%; oral systemic steroid (prednisolone 40–50 mg); reassess PEF/symptoms at 1 h. If improved, continue and make a discharge control plan; if not, escalate as severe. Do not routinely order chest X-ray or blood gas.
3. [End] Severe
   Frequent/continuous nebulized SABA + ipratropium (SAMA); controlled oxygen SpO2 93–95%; early systemic steroid (prednisolone 40–50 mg orally, or IV hydrocortisone/methylprednisolone); add magnesium sulfate 2 g IV (over 20 min) if poor response. Close monitoring in ED/inpatient, reassess at 1 h, escalate if worsening.
4. [End] Life-threatening
   Life-threatening (silent chest / altered consciousness / signs of respiratory failure): ICU; continuous nebulized SABA + ipratropium, IV steroid, magnesium sulfate; non-invasive ventilation or early intubation (use an obstructive-lung ventilation strategy — low rate, long expiration, permissive hypercapnia). (Note: Marked respiratory distress without wheeze suggests impending respiratory failure. Differentiate anaphylaxis, pneumonia, PE, heart failure.)

Source guidelines & references

• GINA 2025 Global Strategy for Asthma Management and Prevention · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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