• Procalcitonin instead of ABX


  • Oxygen to sats 90-95%
  • Albuterol q1-4 hours
  • Ipratropium
    • Nebulization: 0.5 mg (500 mcg) every 20 minutes for 3 doses, then as needed (NAEPP 2007)
    • MDI: 8 inhalations every 20 minutes as needed for up to 3 hours (NAEPP 2007)
  • Steroids
    • A higher initial dose of methylprednisolone 60 to 80 mg every 6 to 12 hours (ICU)
    • A lower initial dose of 40 to 60 mg every 12 to 24 hours is likely adequate for patients who are admitted to wards
    • A massive initial dose (eg, methylprednisolone 500 mg intravenous bolus) is no more effective than a large initial dose (125 mg)
    • Glucocorticoids can be given intramuscularly if intravenous and oral access is not available.
    • Patients can stop their oral glucocorticoids sooner based on resolution of their symptoms and self-monitored peak flow values (eg, when peak expiratory flow is greater than 70 percent of baseline)
  • Magnesium Sulfate
    • 2 gram infused over 20 minutes
    • life-threatening exacerbation or whose exacerbation remains severe (peak expiratory flow <40 percent of baseline) after one hour
    • Avoid in renal insufficiency
  • Nonstandard therapies without sufficiency evidence
    • Ketamine for status asthmaticus
      • an initial dose of ketamine 0.5 to 1 mg/kg is usually infused over two to four minutes, followed by a continuous infusion of 0.5 to 2 mg/kg per hour
    • Parenteral Beta-agonist (risk of tachycardia/MI)
      • Anaphylaxis: epinephrine 0.3 to 0.5 mg of 1:1000 may be given intramuscularly
      • Impeding respiratory failure w/o anaphylaxis: rare reports of response to parenteral epinephrine 0.3 to 0.5 mg subcutaneously 1:1000 solution
      • terbutaline is 0.25 mg by subcutaneous injection every 20 minutes up to three doses. Terbutaline OR epinephrine may be used, but NOT both
    • Heliox
    • Leukotriene receptor antagonist (singulair or zafirukast) if ASA or NSAID exacerbation

Airway Managemtn

  • Indications for Intubation
    • Slowing of the respiratory rate
    • Depressed mental status
    • Inability to maintain respiratory effort
    • Worsening hypercapnia and associated respiratory acidosis
    • Inability to maintain an oxygen saturation >95 percent despite high-flow supplemental oxygen
  • Intubation
    • Rapid sequence intubation is preferred.
    • Nasal intubation is not recommended
  • Mechanical Ventilator Strategies
    • Goal: maintain adequate oxygenation and ventilation while minimizing elevated airway pressures.
    • low tidal volumes (6 to 8 mL/kg)
    • low respiratory rates (10 to 12 breaths/minute)
    • The initial inspiratory flow is usually 60 to 80 L/min, but may need to be increased to prolong time for exhalation in patients with more severe obstruction.
    • Permissive Hypercapnea: elevations in PaCO2 must be tolerated to avoid barotrauma



The Mandatory Disclaimer: All information on this website is purely for educational and training purposes. Use best clinical judgement, the most current reference articles, medical standards of care, and specialist consultations when making clinical decisions for your patients.

Last Updated August 25, 2015