Paul E. Marik, MD

abstract: The mainstay of therapy for acute severe asthma includes ß2-agonists, anticholinergics, and corticosteroids. Other agents, such as leukotriene modifiers and magnesium sulfate, can be used in patients who have responded poorly to conventional therapy. Noninvasive positive pressure ventilation (NPPV) should be tried before intubation in alert, cooperative patients who have not improved with aggressive medical therapy. However, NPPV should not be attempted in patients who are rapidly deteriorating or in those who are somnolent or confused. Endotracheal intubation is recommended for airway protection or for patients who present with altered mental status or circulatory shock. Patients should be admitted to the ICU if they have difficulty in talking because of breathlessness, altered mental status, a forced expiratory volume in 1 second or peak expiratory flow rate of less than 25% of predicted, or a PaCO2 greater than 40 mm Hg after aggressive treatment in the emergency department. (J Respir Dis. 2007;28(3):113-117)

The initial assessment of acute severe asthma includes confirmation of the diagnosis and rapid assessment of mental status and degree of respiratory distress. The severity of airflow obstruction is best determined by forced expiratory volume in 1 second or peak expiratory flow rate. While inhaled ß2-agonists are the initial therapy, the combination of ipratropium and a ß2-agonist can enhance results in some patients. There also is evidence that inhaled corticosteroids can lead to a more rapid improvement in pulmonary function. (J Respir Dis. 2007;28(2):57-64)