Patients can present to the hospital in imminent arrest that needs rapid treatment within a few minutes. Providers should work to avert respiratory and cardiac arrest

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Initial treatment

The initial steps include: 

• Provide oxygen supplementation with high-flow oxygen with a non-rebreather mask or using bag-mask ventilation.
• Provide short-acting inhaled beta 2 agonists via metered-dose inhalation (MDI) or nebulizer. Deliver at 20-minute intervals or for one hour continuously.
• Mix 0.5mg ipratropium bromide at 20-minute intervals three times. This will augment the bronchodilation from the beta 2 agonist and is a useful adjunct in emergent asthma in the ED. Typically, this is not used if the patient is admitted, rather corticosteroids are used if beta2 agonists are not effective.
• Beta 2 agonist systemically if inhaled beta 2 agonists are not available or cannot be used. Treatment is with SC 0.3-0.5 mg epinephrine or 0.25 mg terbutaline at 20-minute intervals three times. 
• Provide heliox or magnesium sulfate in conjunction with primary therapy if symptoms persist.

Patients should be evaluated in the initial 10-20 minutes following treatment. Clear improvement should be easily demonstrated with increase oxygenation, improved clinical signs and symptoms as well as increased PEF to at least 150-200L/min. If the patient progresses, rapid intubation is called for while continuing to support ventilations.