Skip to content

Acute Asthma Exacerbation

Rafael J. Fernandez III, Stacy McIntyre


  • Sub-acute to acute progressive worsening of dyspnea, chest tightness, wheezing, and cough

  • Important historical cues: Prior hx of asthma, adherence to controller medications, triggers (exercise, allergens, cold)

  • Risk stratifying: Hx of intubations/ exacerbations, recent steroid course for exacerbation

  • Physical exam: wheezing, poor air movement, tachypnea, ↑ work of breathing, hypoxemia

  • Peak flows can help and are often cited in literature but do not change management acutely, can be useful as baseline for assessing response to therapy.

  • PEF <200 L/min or PEF <50% predicted indicates severe obstruction, PEF <70% predicted indicates moderate exacerbation)


  • Generally aimed at ruling out causes for exacerbation and other diagnoses; these are not required but should be considered in pts being admitted for inpatient management:

    • EKG, trop, BNP, D-dimer to assess for cardiac cause (ACS, CHF, PE)

    • CXR to rule out underlying process (PNA, PTX, atelectasis)

    • ABG/VBG not routinely needed unless ill-appearing, tachypneic, or lethargic/altered

  • Dangerous signs and possible ICU if:

    • Tachypnea >30 and/or significantly increased work-of-breathing

    • Hypercapnia or even normocapnia (these pts are usually hyperventilating; a normal CO2 in a severe asthma exacerbation could indicate impending respiratory failure)

    • Altered mental status

    • Requiring continuous nebulizers


  • Good asthma care requires frequent re-evaluation. Generally, reassess q1h after treatment initiation. If deteriorating, step up the ladder of management

  • ABC: if not protecting airway, intubate and admit to ICU

  • Peak expiratory flow (Order in EPIC “Peak Flow Measurement”). If pt cannot do it, consider A/VBG if ill-appearing, tachypneic, lethargic/AMS, or thinking about engaging ICU

  • SpO2 goal 93-95%. Avoid hyperoxia

  • Further work-up: Not required, but aimed at ruling out causes of exacerbation and other dx

  • CBC w/ diff (looking at eosinophils)

  • CXR to rule out underlying process (PNA, PTX, atelectasis)

  • Corticosteroids: dosing based on severity of illness

    • Oral equivalent to IV (Lancet 1986;1:181-184)
    • Transition to PO and lower dose after improving air movement, work of breathing and gas exchange
    • Will need minimum of 5-7 days of oral corticosteroids.
    • Good data for no need to taper in general population, sometimes considered in someone with multiple severe exacerbations.
  • Step down SABA-Nebulizer treatments based on wheezing

  • Inspiratory/Expiratory wheezing q2 -> q3; Mostly Expiratory wheezing q3 -> q4; Minimal Wheezing q4 -> q6 or PRN. (Pediatrics 2000; 106 (5): 1006–12)

  • No need for empiric antibiotics unless there is concern for bacterial infection, then treat as Pneumonia (see Pneumonia chapters)

Prior to discharge:

  • Ensure that pt is on appropriate controller medications (see outpatient management)

  • See outpt management section but consider starting an ICS/LABA as part of SMART (JAMA 2018; 319(14):1485–1496)

  • Evaluate for causes of acute exacerbation to prevent future events (noncompliance, resp viruses, allergies, exposures, etc.). Evaluate for asthma inflammatory phenotype after recovery (IgE, peripheral eos, ABPA)

  • Can consider writing a simple asthma action plan ( content/uploads/2021/05/GINA-Pt-Guide-2021-copy.pdf)

  • Consider follow up with PCP vs. pulmonologist for evaluation of outpt regimen