Assess severity

Measure PEF:<50% Personal best or predicted suggests severe

exacerbation.
Note signs and symptomps:degrees of cough,breathlessness,wheeze
and chest tightness correlate imperfectly with severity of
exacerbation.accessory muscle use and suprasternal retractions
suggest severe exacerbation.
Initial treatment
Inhaled short-acting 2-agonist:
Up to three treatments of 2-4 puffs by MDI at 20 min intervals
or single nebulizer treatment.
Good respon
Mild exacerbation:
PEF>80% predicted or personal best no wheezing or shortness
of breath response to 2-agonist sustained for 4h.
May continue 2-agonist every 3-4for 24-48h.
For patients on inhaled corticosteroids,double dose of 7-10 day.
Contact clinician for follow up instructions.
Incomplete response
Moderate exacerbation:
PEF 50%-80% predicted or personal best.presistent wheezing
and shortness of breath.
Add oral corticosteroids
Continue 2-agonist.
Contact clinician urgently(this day)for instructions.
Poor response
Severe exacerbation:

PEF <50% predicted or personal best marked wheezing

and shortness of breath.
Add oral corticosteroids.
Repeat 2-agonist immediately.
If distress is severe and non responsive,call your
doctor and proceed to emergency
department,consider calling ambulance or 9-1-1
Produceed to emegency department.

Initial assessment
History,physical examination(auscuttation,use of accessory
muscles,heart rate,respiratory rate)PEF or FEV,oxygen saturation,and
other tests as indicated.
FEV1 or PEF >50%
Inhaled 2-agonist by metered-dose inhaler or nebulizer,up to
three doses in first h
Oxygen to achieve O2 saturation 90%

 Oral systemic corticosteroids if no immediate response or

patient recently took oral systemic corticosteroid.
FEV1 or PEF <50%(severe exacerbation)
Inhaled high-dose 2-agonist and anticholinergic by nebulization
every 20 min or continuously for 1h
Oxygen to achieve O2 saturation 90%
Oral systemic corticosteroid
Repeat assessment
Symptoms,physical examination,PEF,O2 saturation,other test as
needed.
Impending or actual respiratory arrest
Intubation and mechanical ventilation with 100% O2
Nebulized 2-agonist and anticholinergic
Intravenous corticosteroid
Admit to hospital intensive care(see box below)
Moderate exacerbation
FEV1 or PEF 50%-80% predicted or personal best physical
exam:moderate symptoms.
Inhaled short-acting 2-agonist every 60 min
Systemic corticosteroid
Continue treatment 1-3h,provided there is improvement.
Severe exacerbation
FEV1 or PEF <50% predicted or personal best physical
exam:severe symptoms at rest,accessory muscle use,chest
retrection.
History:high-risk patient
No improvement after initial treatment.

 Inhaled short-acting 2-agonist,hourly or continuous

+ inhaled anticholinergic
Oxygen
Systemic corticosteroid
Good response
FEV1 or PEF 70%
Response sustained 60 min after last treatment
No distress
Physical exam:normal
Incompelete response
FEV1 or PEF 50% but <70%
Mild to moderate symptoms
Individualization decision re:hospitalization(see text)
Admit to hospital ward:
Inhaled 2-agonist + inhaled anticholinergic
Systemic (oral or intravenous)corticosteroid
Oxygen
Monitor FEV1 or PEF,O2
IMPROVE
Discharge home
Continue treatment with inhaled 2-agonist
Continue course of oral systemic corticosteroid
Patient education
i. Review medicine use.
ii. Review /initiate action plan
iii. Recommend close medical follow-up
Poor respond
FEV1 Or PEF <50%
Pco242 mmhg
Physical exam:symptoms severe,drowsiness,confusion.
Admit to hospital intensive care.

 Inhaled 2-agonist hourty or continuosly + inhaled

anticholinergic
Intravenous corticosteroid
Oxygen
Possible intubation and mechanical ventilation
discharge home
Continue treatment with inhaled 2-agonist
Continue course of oral systemic corticosteroid
Patient education
i. Review medicine use.
ii. Review /initiate action plan
iii. Recommend close medical follow-up