if > 5years old

• able to talk in sentences
• SpO2 ≥92%
• PEF ≥50% best or predicted
• heart rate - ≤125/min
• respiratory rate - ≤30/min

acute severe asthma

• too breathless to talk
• SpO2 <92%
• PEF 33–50% best or predicted
• heart rate >125/min
• respiratory rate >30/min
• use of accessory neck muscles

life threatening asthma

SpO2 <92% and any one of the following:

• silent chest
• cyanosis
• poor respiratory effort
• agitation
• confusion
• PEF <33% best or predicted

immediate management

• β2 agonist 2–10 puffs via spacer and mouthpiece  (given one puff at a time inhaled separately using tidal breathing)
• give one puff of β2 agonist every 30–60 seconds up to 10 puffs according to response
• consider oral prednisolone 30-40 mg

immediate management

• oxygen via face mask
• 10 puffs of β2 agonist or nebulised salbutamol 5 mg
• oral prednisolone 30-40 mg

assess response to treatment 15 mins after β2 agonist

immediate management

• oxygen via face mask
• nebulise every 20 minutes with: salbutamol 5 mg +  ipratropium 0.25 mg
• oral prednisolone 30-40 mg or IV hydrocortisone 100 mg if vomiting

if poor response arrange admission

if poor response repeat β2 agonist and arrange admission

repeat β2 agonist via oxygen driven nebuliser whilst arranging immediate hospital admission

GOOD RESPONSE

• continue up to 10 puffs of nebulised beta2 agonistas needed, not exceeding 4 hourly
• if symptoms are not controlled repeat beta2 agonist and refer to hospital
• continue prednisolone for up to 3 days
• arrange follow-up clinic visit within 48 hours
• consider to referral to secondary care asthma clinic if 2nd attack within 12 months

POOR RESPONSE

• stay with patient until ambulance arrives
• send written assessment and referral details
• repeat beta2 agonist via oxygen-driven nebuliser in ambulance