Initial Assessment
Brief history, physical examination (auscultation, use of accessory muscle, heart rate, respiratory rate), PEF or FEV₁, oxygen saturation, and other tests as indicated

End

Repeat Assessment^* 
Symptoms, physical examination, PEF, oxygen saturation, other tests as needed

Admit to Hospital Intensive Care (see box below)

FEV₁ or PEF 40% (mild-to-moderate)

FEV₁ or PEF 40% (mild-to-moderate)

Oxygen to achieve Sao₂ 90%
Inhaled SABA by nebulizer or MDI with valved holding chamber, up to 3 doses in first hour
Oral systemic corticosteroids if no immediate response or if patient recently took oral systemic corticosteroid

FEV₁ or PEF < 40% (severe)

Oxygen to achieve Sao₂ 90%
High-dose inhaled SABA plus ipratropium by nebulizer or MDI plus valved holding chamber, every 20 minutes or continuously for 1 hour
Oral systemic corticosteroids

Impending or Actual Respiratory Arrest

Intubation and mechanical ventilation with 100% oxygen
Nebulized SABA and ipratropium
Intravenous corticosteroids
Consider adjunct therapies

End

Moderate Exacerbation
FEV₁ or PEF 40–69% predicted/personal best
Physical examination: moderate symptoms

Inhaled SABA every 60 minutes
Continue treatment every 1–3 hours, provided there is improvement; make admit decision in <4 hours

Severe Exacerbation
FEV₁ or PEF <40% predicted/personal best
Physical examination: severe symptoms at rest, accessory muscle use, chest retraction
History: high-risk patient
No improvement after initial treatment

Oxygen
Nebulized SABA + ipratropium, hourly or continuous
Consider adjunct therapies

Admit to Hospital Intensive Care

Oxygen
Inhaled SABA hourly or continuously
Intravenous corticosteroid
Consider adjunct therapies
Possible intubation and mechanical ventilation

Discharge Home

Continue treatment with inhaled SABA
Continue course of oral systemic corticosteroid
Consider initiation of an ICS
Patient education

Review medications, including inhaler technique
Review/initiate action plan
Recommend close medical follow-up

Review medications, including inhaler technique
Review/initiate action plan
Recommend close medical follow-up

Good Response

FEV₁ or PEF 70%
Response sustained 60 minutes after last treatment
No distress
Physical examination: normal

Incomplete Response

FEV₁ or PEF 40–69%
Mild-to-moderate symptoms

Poor Response

FEV₁ or PEF <40%
PCO₂ 42 mm Hg
Physical examination: symptoms severe, drowsiness, confusion

Improve

Admit to Hospital Ward

Oxygen
Inhaled SABA
Systemic (oral or intravenous) corticosteroid
Consider adjunct therapies
Monitor vital signs, FEV₁ or PEF, Sao₂

Improve

Discharge Home

Continue treatment with inhaled SABAs
Continue course of oral systemic corticosteroid
Continue on ICS, For those not on long-term control therapy, consider initiation of an ICS
Patient education (eg, review medications, including inhaler technique and whenever possible, environmental control measures; review/initiate action plan; recommend close medical follow-up)
Before discharge, schedule follow-up appointment with primary care provider and/or asthma specialist in 1–4 weeks

Individualized decision re: hospitalization (see text)

Discharge Home

Continue treatment with inhaled SABA
Continue course of oral systemic corticosteroid
Consider initiation of an ICS
Patient education

Review medications, including inhaler technique
Review/initiate action plan
Recommend close medical follow-up

Review medications, including inhaler technique
Review/initiate action plan
Recommend close medical follow-up

Admit to Hospital Ward

Oxygen
Inhaled SABA
Systemic (oral or intravenous) corticosteroid
Consider adjunct therapies
Monitor vital signs, FEV₁ or PEF, Sao₂

^* Patients who have achieved 70% PEF or FEV₁ should go to the “Good Response” category.