Acute severe asthma in the emergency department: next steps after initial bronchodilators
A 9-year-old girl with known asthma presents to the emergency department with a 2-day history of coryza and worsening wheeze. She has been using her salbutamol inhaler every 2 hours overnight. On arrival she is sitting upright, respiratory rate 34, heart rate 130, oxygen saturation 91% in air, and she can speak only in single words. Chest examination shows widespread expiratory wheeze and mild subcostal recession. Peak expiratory flow is 45% of her personal best. She has received three back-to-back salbutamol nebulisers with ipratropium and oral prednisolone 40 mg. An hour later she is still tachycardic at 125, saturation 93% in air, speaking in short phrases, and peak flow is 55% of best. She has no fever and is not drowsy. There is no intensive care bed available at your hospital.
1. Classify the severity and justify your next interventions.
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This is acute severe asthma, not life-threatening: she is speaking in phrases, not drowsy, and has no silent chest, cyanosis, or exhaustion. The persistence of hypoxia and tachycardia after three nebulisers and ipratropium means I would give oxygen to target 94–98%, continue salbutamol nebulisers every 20–30 minutes or consider intravenous salbutamol, and add intravenous magnesium sulfate 40 mg/kg over 20 minutes with cardiac monitoring. She has already had oral prednisolone; if she cannot swallow or vomits, give intravenous hydrocortisone. I would avoid sedatives and routine antibiotics. A blood gas is not mandatory if she is improving, but I would monitor for fatigue, rising carbon dioxide, and altered consciousness. The absence of an intensive care bed does not change the treatment she needs; it changes the urgency of retrieval, so I would contact the regional retrieval service early rather than wait for deterioration.
2. What criteria would you use to decide discharge versus admission?
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Discharge after acute severe asthma requires a sustained response, not a single good number. I would admit her because she remains hypoxic at 93% in air and tachycardic after appropriate initial therapy. For discharge I would want oxygen saturation above 94% in air for at least 1 hour, peak flow above 70% of personal best, no distress, ability to speak normally, and reliable observation at home.
She also needs a written action plan, a course of oral prednisolone, a review within 48–72 hours, and an asthma nurse appointment; a preventer should be reviewed because severe exacerbations signal inadequate control. Before discharge I would check inhaler technique and trigger avoidance. If she improves rapidly, a short period of observation in an assessment unit is acceptable, but she should not be sent home from the emergency department directly after a severe attack.