• Although bronchial asthma is the most common cause of acute shortness of breath accompanied by wheezing, other causes should also be considered, especially in elderly patients or in the absence of a positive treatment effect.
• The severity of the attack can easily be underestimated.
Provide 40-60% oxygen and administer 5 mg of salbutamol or 10 mg of terbutaline through a nebulizer filled with oxygen. Quickly assess the severity of the attack. Is the patient conscious? Can he / she speak in full sentences or only with difficulty in separate words? Estimate peak expiratory flow rate, respiratory rate, saturation, heart rate, and blood pressure. Listen to the lungs.
Does an attack pose a threat to life? Any of the following signs indicates a threat to the life of a patient with an attack of bronchial asthma:
• Silent chest, cyanosis, weak breathing efforts.
• Bradycardia or arterial hypotension.
• Exhaustion, confusion, or coma.
• Peak expiratory flow rate <30% of the predicted or previous best result.
If one or more of these symptoms is observed, catheterize the peripheral vein, connect an ECG monitor, and:
• Invite an anesthetist in case emergency mechanical ventilation is needed.
• Add 0.5 mg of ipratropium to the nebulizer mixture.
• Intravenously inject 200 mg of hydrocortisone.
• Intravenously administer 250 mg of aminophylline for 20 minutes (if the patient has not already taken theophylline by mouth) or 250 μg of salbutamol for 10 minutes, then switch to intravenous drip.
If there are signs of a life threat or saturation <92%, check the arterial gas composition. Other patients do not need to evaluate arterial blood gases (performing this procedure without indications can distract attention from finding a solution to stop the attack). To exclude pneumonia or pneumothorax, organize a chest x-ray.
If the patient’s condition does not improve after 15-30 minutes:
• Provide more frequent administration of salbutamol through a nebulizer (up to every 15-30 minutes).
• Add 0.5 mg of ipratropium to the nebulizer mixture and repeat it every 6 hours.
• Introduce 200 mg of hydrocortisone intravenously.
• Eliminate obstruction of the upper respiratory tract (stridor, laryngeal edema, elevated PaCO2) and other causes of dyspnea.
If the patient’s condition still does not improve:
• Start an infusion of aminophylline (unless the patient is taking theophylline by mouth) or salbutamol.
• Transfer the patient to the intensive care unit, if there are: a deterioration in peak expiratory flow rates, hypoxia and hypercapnia intensify or persist, or severe patient fatigue is noted.