Asthma and COPD Exacerbations Guide

Initial Evaluation

  • Assess airway, breathing, circulation
  • Check vital signs: RR, HR, SpO₂, BP, Temp
  • Rapid focused history:
    • For asthma: known diagnosis, triggers, prior hospitalizations/intubations, home medications
    • For COPD: smoking history, baseline function, oxygen use, prior exacerbations, home nebulizer use
  • Focused physical exam:
    • Wheezing, accessory muscle use, tripod positioning
    • Signs of respiratory fatigue or altered mental status

Diagnostics

  • Asthma (mild to moderate): Typically does not require labs or imaging
  • COPD Exacerbation:
    • Chest X-ray: rule out pneumonia or pneumothorax
    • Basic labs: CBC, BMP if indicated
    • ABG for moderate/severe cases or altered mental status
    • ECG and troponin if chest pain or concern for cardiac disease

Treatment

  • Bronchodilators (Mainstay for Both):
    • Albuterol via nebulizer (minimum 5 mg for adults in the ED)
      • Note: Duonebs often only provide 2.5 mg of albuterol – ED patients often need higher doses and have often being using their own duonebs at home
    • May repeat every 20 minutes x 3 as needed
    • For severe cases: Continuous albuterol neb can be ran at 20mg/hr or 40mg/hr (careful at 40mg/hr if elderly or prone to arrhythmias)
    • Add Ipratropium (Atrovent) for moderate/severe cases
  • Steroids:
    • Dexamethasone 10 mg IV/PO (equivalent to 5-day prednisone course)
      • Krishnan JA, Davis SQ, Naureckas ET, et al. Chest. 2009;135(3):804-823.
    • Repeat dose of dexamethasone in 48–72 hrs reduces relapse
      • Alangari AA, et al. Respir Med. 2006;100(5):882-888.
    • Alternative: Solu-Medrol 125 mg IV
  • Antibiotics for COPD Exacerbation (GOLD Standard):
    • Indicated if: increased sputum volume, purulence, or need for admission
    • Options: Azithromycin, Doxycycline, or Augmentin
  • Additional Interventions:
    • Oxygen to maintain SpO₂ > 90%
    • BiPAP for respiratory fatigue or hypercapnia (esp. in COPD)
    • Magnesium sulfate 2 g IV over 20 min for severe symptoms
    • Intubation for respiratory failure, altered mental status or increasing PCO2 on ABG
      • Keep respiratory rate low (10-12) to increase the expiration time (I:E Ratio), TV 450-550mL for adult males, TV 350-450mL for adult females based on ideal body weight.
      • May allow for permissive hypercapnia as long as pH is above 7.2 while giving additional treatments

Disposition

  • Asthma:
    • Majority improve with ED treatment and can be discharged
    • Discharge meds: Albuterol inhaler, oral steroids or second dose dexamethasone (optional)
  • COPD:
    • More likely to require admission
    • Admit if ongoing dyspnea, hypoxia, or poor response to ED treatment

✅Discharge Checklist

  • Albuterol MDI with spacer (if needed) or nebulizer refill
  • Oral steroid prescription (or confirm dexamethasone dose given)
  • Antibiotics if applicable (COPD)
  • Home oxygen reassessment (COPD)
  • Clear return precautions (e.g., worsening dyspnea, fevers, chest pain)
  • Follow-up with primary care or pulmonologist within 3–5 days

References

  1. Krishnan JA, Davis SQ, Naureckas ET, et al. Acute asthma exacerbations: Management strategies and performance measures. Chest. 2009;135(3):804-823.
  2. Alangari AA, et al. Repeat dose of dexamethasone reduces relapse in adult asthma. Respir Med. 2006;100(5):882-888.
  3. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of COPD. 2024 Report.