Acute Severe Asthma & COPD Exacerbation
Emergency management of life-threatening obstructive lung disease: continuous beta-agonist nebulization, systemic corticosteroids, intravenous magnesium, terbutaline, and mechanical ventilation traps.
Resuscitation Quick Ribbon (First 2 Minutes)
Bottom-Line Clinical Pearl
The 'silent chest' in a severe asthmatic is an ominous sign of impending respiratory arrest due to air trapping, not improvement. Initiate continuous albuterol (10–20 mg/h) and ipratropium immediately, give early IV/PO steroids (Methylprednisolone 60–120 mg or Dexamethasone 10–16 mg), and infuse Magnesium Sulfate 2g IV over 20 minutes. For acute COPD with respiratory acidosis (pH < 7.35, pCO2 > 45), early BiPAP reduces intubation rates by 60% and mortality by 40%.
1. Escalation Ladder for Severe Asthma / Status Asthmaticus
| Tier | Therapeutic Intervention | Dose / Delivery | Clinical Goal |
|---|---|---|---|
| Tier 1 (Immediate) | Continuous Inhaled Bronchodilators | Albuterol 10–20 mg/h + Ipratropium 0.5 mg x 3 | Overcome acute bronchospasm via beta-2 agonism and anticholinergic vagal block |
| Tier 1 (Immediate) | Systemic Corticosteroids | Dexamethasone 12 mg IV/PO or Methylprednisolone 60 mg IV | Blunt inflammatory cascade and prevent rebound airway edema |
| Tier 2 (Severe) | Intravenous Magnesium Sulfate | 2g IV infused over 20 minutes | Direct bronchial smooth muscle relaxation via calcium channel inhibition |
| Tier 2 (Severe) | Subcutaneous Beta-Agonist | Terbutaline 0.25 mg SC or Epinephrine 0.3 mg IM | Systemic delivery when severe bronchospasm blocks aerosolized drug penetration |
| Tier 3 (Impending Arrest) | Intravenous Ketamine | 0.5–1.0 mg/kg sub-dissociative IV or 1.5–2 mg/kg RSI | Potent direct bronchodilator and sympathomimetic; facilitates BiPAP tolerance |
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