Additional treatment for persistent life-threatening acute asthma

Adrenaline (epinephrine)

If the patient is unresponsive, has poor respiratory effort, and cannot inhale bronchodilators, or is considered to be peri-arrest, consider adrenaline (epinephrine). Give:

In life-threatening situations adrenaline (epinephrine) can also be administered intravenously or by continuous infusion—seek expert advice before administration.

Intravenous salbutamol

Intravenous salbutamol is reserved for the sickest patients with life-threatening acute asthma and for those in whom nebulisation is impractical. The potential harm versus benefit is not favourable compared to nebulised salbutamol, and there is no evidence of increased efficacy. Comprehensive monitoring (blood electrolytes, heart rate, blood lactate) in a critical care or high-dependency environment is required. Seek expert advice before administration.

Intravenous aminophylline

The potential harms of aminophylline outweigh the expected benefits in most situations.

The occasional patient with life-threatening acute asthma who is not responding to other therapy, may respond to aminophylline. Comprehensive monitoring in a critical care or high-dependency environment is required. Seek expert advice before administration.

Ventilatory support

Ventilatory support may be required for patients with persistent life-threatening acute asthma.

Consider noninvasive positive pressure ventilation for patients who continue to show no improvement with treatment and are starting to tire or show signs of respiratory failure. Evidence for its use is limited, particularly in children; however, it may avoid the need for intubation. High-flow nasal cannula oxygen therapy is used in some centres, but evidence is limited. Adequately trained staff are needed to administer and monitor acute noninvasive ventilation, usually in a critical care environment or a high-dependency unit; seek expert advice before administration.

If the patient doesn’t improve with noninvasive ventilation, intubate and start mechanical ventilation. Intubation and ventilation of these patients is difficult and has significant associated risks. Ideally, it should only be undertaken by an experienced critical care or emergency physician.