Management of severe acute asthma in the

emergency department
Brian H. Rowea,b, William Sevcika and Cristina Villa-Roela,b
a

Department of Emergency Medicine and bSchool of

Public Health, University of Alberta, Edmonton, Alberta,
Canada
Correspondence to Brian H. Rowe, MD, MSc,
CCFP(EM), FCCP, Associate Dean (Clinical Research),
Faculty of Medicine & Dentistry, Canada Research
Chair in Emergency Airway Diseases, Research
Director, Department of Emergency Medicine,
Professor, University of Alberta, 1G1.43 Walter C.
Mackenzie Centre, 8440112 Street NW, Edmonton,
AB T6G 2B7, Canada
Tel: +1 780 407 6707; fax: +1 780 407 3982;
e-mail: [email protected]
Current Opinion in Critical Care 2011,
17:335341

Purpose of review
Asthma is one of the most common chronic diseases in most developed countries and
control may be elusive. Deterioration in asthma control is common when patients are
exposed to airway irritants, viruses, and/or when adherence to chronic anti-inflammatory
medications is suboptimal. Acute asthma exacerbations are common, important reasons
for presentations to emergency departments, and severe cases may result in
hospitalization. Important knowledge gaps exist in what is known and what care is
delivered at the bedside.
Recent findings
The literature in asthma is rapidly expanding and recent advances in the care are
important to summarize. Systematic reviews, especially high-quality syntheses
performed using Cochrane methods, provide the best evidence for busy clinicians to
remain current. Management of asthma is based on early recognition of severe disease
with aggressive therapy using multimodal interventions that focus on both
bronchoconstriction and inflammatory mechanisms.
Summary
Treatment of severe acute asthma can effectively and safely reduce hospitalizations,
airway interventions, and even death. Using the approach outlined herein will enable
clinicians to assist patients to rapidly regain asthma control, return to normal activities,
and improve their quality of life in the follow-up period.
Keywords
asthma, bronchodilators, corticosteroids, magnesium sulfate, prevention
Curr Opin Crit Care 17:335341
2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295

Introduction
Asthma is one of the most common chronic conditions
and is characterized by intermittent exacerbations
followed by variable degrees of stability. Asthma is an
inflammatory disease of the airways, with many symptoms resulting from the secondary bronchoconstriction.
This multifactorial disease is influenced by genetics,
early environmental influences, demographic factors
(e.g., age, sex, and ethnicity), geography (regional variation
is often noted), BMI, and socioeconomic status. Not
surprisingly, the prevalence of asthma varies widely
within and among countries.
Control of asthma has proven to be elusive. Deterioration
in asthma control is common when patients are exposed
to airway irritants, viruses, and/or when adherence
to chronic anti-inflammatory medications is suboptimal.
The hallmark of exacerbation includes a history of
asthma, increasing symptoms of dyspnea, wheeze and/
or cough, and increasing need for short-acting b-agonists.
Asthma exacerbations are common presentations to the
1070-5295 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

emergency department (ED) in many parts of the world

[1] and the costs associated with the care of asthma are
significant [24]. For example, in the United States
approximately 14 billion dollars per year is spent on
asthma [5]; nearly a quarter of all asthma expenses are
related to acute exacerbations (ED visits, hospitalizations) [4]. Severe acute asthma is a potentially lifethreatening medical emergency that usually involves
symptoms such as shortness of breath, cough, and wheeze
and signs such as accessory muscles use, tachypnea and
tachycardia, airway outflow measures [peak expiratory
flow (PEF) or forced expiratory volume in one second
(FEV1) less than 50% of predicted], and arterial
saturation less than 90%.
Given this major economic and health burden, it is
not surprising that a number of guidelines have been
developed to guide the management of asthma and its
severe exacerbations [6,7

,8

,9,10]. Despite the availability of these guidelines, there is a care gap between
what is known and what is practiced and the dissemination of evidence often does not reach the patient in
DOI:10.1097/MCC.0b013e328348bf09

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336 Emergencies

the ED or other acute care settings. This is due, in part, to

the rapidly changing literature and the introduction
of new management strategies in this field. Moreover,
disparities in terms of healthcare access (patients often
cannot afford the appropriate medicines) and education
(some patients do not know that it is possible to live
a normal life with asthma) continue to complicate the
management of asthma.

Key points

The use of short-acting b2-agonist (SABA) inhaler
with spacer device is safe and effective for most
patients.

Early treatment of acute asthma with systemic
corticosteroids and SABA agents combined with
short-acting anticholinergic agents may be required.

In more severe presentations, adjuncts such as i.v.
magnesium sulfate, inhaled corticosteroid, and
epinephrine may reduce the need for intubation.

When patients remain distressed, noninvasive
ventilation may be an option.

If all treatments fail, securing the airway using rapid
sequence intubation, experienced personnel with
intubation skills, and experience in mechanical
ventilation is critical.

This article focuses on summarizing the evidence for the

management of severe acute asthma. Using the approach
outlined herein will enable clinicians to assist patients
to avoid hospitalizations, limit airway interventions, and
reduce mortality.

Asthma frequency
The frequency of acute asthma can be measured through
patient self-report and health services use (e.g., clinic
visits, hospital services). More severe cases often require
acute care services only available at EDs or hospital
inpatient units.
Emergency department visits: hospitalization

Several large-scale studies have examined the presentations of patients with asthma to EDs. Using the National
Hospital Ambulatory Medical Care Survey (NHAMCS),
investigators in the United States have demonstrated
stable ED presentations [11

], although Canadian studies have shown a decreasing rate of asthma presentations
to the ED [12]. In addition, investigator groups have
demonstrated various factors associated with hospitalization. Clearly, patients and treatment factors are associated with admissions, and following the summary below
should reduce the need for hospitalization.

Asthma assessment
Acute asthma assessment involves a thorough history of
past and present asthma control, a physical examination
including mental status assessment, review of medication
use and adherence, and assessment of routine vital
signs including pulse oximetry and airflow obstruction
(e.g., PEF/FEV1).
Severity

Estimates of exacerbation severity, response to therapy,

and risk of relapse following discharge by physicians
are often inaccurate in acute asthma. The assessment
of asthma severity is recommended by all major acute
asthma guidelines [6,7

]; however, the method of assessing severity is debated. Some guidelines recommend
that severity be determined objectively using spirometry,
PEF, or both [7

]. Although there is conflicting evidence

Table 1 Summary of drug class, agents, and dosing used in severe acute asthma
Class

Most common agent

Most common dose

Short-acting b-agonists

Salbutamol inhaler

48 puffs through spacer device every 20 min 

3 doses; continue every hour thereafter
2.55.0 mg nebulizer every 20 min  3 doses;
continue every hour thereafter
48 puffs through spacer device every 20 min 
3 doses; continue every 46 hours thereafter.
0.1250.25 mg nebulizer every 20 min  3 doses;
continue every 46 hours thereafter
4060 mg p.o.
80125 mg i.v.
250500 mg i.v.
Variable dosing
250500 mg inhaler administered in variable doses
2 mg nebulizer or 400800 mg inhaler administered
in variable doses
2 g i.v. over 20 min
NA
0.3 ml i.m. once (1 : 1000 concentration); may be repeated
To maintain SaO2 > 92%

Salbutamol nebulizer
Short-acting anticholinergics

Ipratropium bromide (Atrovent) inhaler

Ipratropium bromide (Atrovent) nebulizer

Systemic corticosteroids

Inhaled corticosteroids
Adjuncts

Prednisone
Methyl-prednisolone (Solumedrol)
Hydrocortisone (Solucortef)
Dexamethasone (Decadron)
Fluticasone (Flovent)
Budesonide (Pulmicort)
Magnesium sulfate
Noninvasive ventilation
Epinephrine
Oxygen

i.m., intramuscular; i.v., intravenous; NA, not applicable; p.o., oral.

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Severe acute asthma Rowe et al. 337

regarding the psychometric properties of each of these

measures [13], many EDs measure PEF, rather than
FEV1, and follow this marker over the course of treatment. The cut-points for severity vary among the
different guidelines; however, all suggest less than 40
50% predicted of either PEF or FEV1 indicates severe
disease. A more important consideration for ED clinicians
relates to the change in pulmonary function over the
acute treatment period. Finally, most guidelines suggest
the ED target for discharge be 70% predicted [6,7

].
Vital signs (temperature, pulse rate, respiratory rate, and
blood pressure) may be helpful in assessing severe acute
asthma. Pulse oximetry (SaO2), often called the fifth vital
sign, should also be recorded. Although vital signs are
considered helpful and contribute to decisions to admit
patients, they may also be deceiving in adults. For example, normal or near normal vitals do not exclude severe
asthma or the possibility of post-ED relapse. Measurement
of SaO2 may help to guide treatment in adult patients;
however, no studies have clearly demonstrated SaO2
predicted admission or relapse in adult asthmatic patients.
In summary, assessment of severity in acute asthma
requires a multifactorial approach. The use of pulse
oximetry, pulmonary function tests, vital signs, history,
physical examination, response to therapy, and current
medications, all are required to determine the need for
hospitalization and the risk of relapse after discharge.

nebulizers, especially in children. Economic evaluations

of these competing approaches demonstrate an advantage
favoring SABA delivery by MDI with holding chamber
compared with nebulizer [15].
An important caveat is that these data do not include
patients with status asthmaticus or near-fatal asthma.
The benefits of continuous SABA nebulization [16],
and the need to focus on other management issues,
may make nebulization a more attractive choice in
patients with severe acute asthma. Attempts to identify
optimal doses or treatment intervals to achieve maximal
bronchodilation or symptom relief have not been successful [17]. In addition, lower SABA doses appear to be
equivalent to higher (up to 510 mg per nebulization
dose) with regard to maximizing clinical outcomes [18].
The clinical observation of a plateau in bronchodilation
suggests that additional SABA therapy may only contribute to more side-effects. In addition, this likely explains
why intravenous (i.v.) SABA agents have not proven to
be effective in adult patients with severe asthma [19].
Some guidelines now recommend titrating SABA use to
a plateau using objective assessment of airway obstruction with pulmonary function measures [10].
Finally, the worldwide severe acute respiratory syndrome
and H1N1 influenza outbreaks and their apparent
spread following nebulization [20] have discouraged
routine treatment by nebulizer. In some settings, these
recent events have facilitated conversion to MDI with
holding chamber.

Management of severe acute asthma

There are a variety of interventions designed to alleviate bronchospasm, address airway inflammation, and
reduce symptoms in patients with severe acute asthma
(See Table 1). The following summarizes the common
treatments and highlights their effectiveness.
b2-Agonist bronchodilators

Early treatment of acute asthma has generally focused

on the use of inhaled short-acting b2-agonists (SABAs)
because of their undisputed and generally rapid bronchodilation effect. The most effective delivery method
[e.g., nebulizer or a metered dose inhaler (MDI) with
holding chamber or spacer device] has been an area of
intense research. A Cochrane Library systematic review,
updated in 2008, involving 614 adults from 27 trials
from EDs and community settings suggested that the
use of either delivery method yields similar outcomes
[14]. In adults, the relative risk (RR) of admission or poor
outcome for holding chamber versus nebulizer was 0.97
[95% confidence interval (CI) 0.631.49]. The ED length
of stay for adults and FEV1 or PEF measures were also
similar for the two delivery methods (Fig. 1) [14]. Finally,
use of MDI with holding chamber was associated
with fewer side-effects (e.g., tachycardia, tremor) than

Anticholinergic bronchodilators

There is support for adding short-acting anticholinergic

(SAAC) agents in the form of ipratropium bromide to b2agonist therapy in moderate-to-severe acute asthma [21].
The systematic review of adult asthma patients identified
a modest beneficial effect of adding ipratropium bromide
to inhaled b2-agonists. After 4590 min of treatment,
the absolute increase in FEV1 and PEF was 7.3 (95%
CI 411%) and 22.1% (95% CI 1133%), respectively.
The risk of admission was decreased by 27% (RR 0.73,
95% CI 0.530.99). A large randomized controlled trial
(RCT) has since been completed, confirming the
systematic review evidence [22]. The study observed
a 21% (95% CI 338%) improvement in PEF and
a 48.1% (95% CI 2076%) improvement in FEV1 over
the control group. Multiple doses of ipratropium bromide
reduced the risk of hospital admission by 49% (RR 0.51,
95% CI 0.310.83); the number needed to treat (NNT)
to prevent a single admission was 5 (95% CI 317%).
Although several questions regarding SAAC in the
acute asthma still need to be resolved (such as the
doseresponse relationship), evidence supports adding
ipratropium bromide to SABA for patients with severe
acute asthma.

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338 Emergencies
Figure 1 The effectiveness of short-acting b-agonist delivery by inhaler with spacer device compared with nebulizer (admission
outcome)

Review: holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma
Comparison: 1 spacer (chamber) versus nebulizer (multiple treatment studies)
Outcome: 1 hospital admission
Study or subgroup
Holding chamber
Nebulizer
Risk Ratio
n/N
n/N
M-H, fixed, 95% Cl

1 Adults
Colacone 1993
Idris 1993
Raimondi 1997
Rao 2002
Rodrigo 1993

Risk Ratio
M-H, fixed, 95% Cl

1/40

0/40

3.00 [0.13, 71.51]

1/15

1/20

1.33 [0.09, 19.64]

0/9

0/9

0.0 [0.0, 0.0]

0/25

1/25

0.33 [0.01, 7.81]

5/49

4/48

1.22 [0.35, 4.29]

14/36

17/33

0.75 [0.45, 1.28]

Turner 1988

4/27

5/26

0.77 [0.23, 2.56]

Vivek 2003

5/68

1/54

3.97 [0.48, 32.98]

269

255

0.97 [0.63, 1.49]

Rodriguez 1999

Subtotal (95% Cl)

Total events: 30 (holding chamber), 29 (nebulizer)

2
Heterogeneity: 2 = 3.82, df = 6 (P = 0.70); l = 0.0%
Test for overall effect: Z= 0.15 (P=0.88)
2 Children
Chong-Neto 2005
Chou 1995

0/20

0/10

0.0 [0.0, 0.0]

4/71

5/81

0.91 [0.25, 3.27]

Jamalvi 2006

4/84

7/66

0.45 [0.14, 1.47]

Leversha 2000

10/30

18/30

0.56 [0.31, 1.00]

Ploin 2000

3/31

3/32

1.03 [0.23, 4.73]

Sannier 2007

6/39

3/40

2.05 [0.55, 7.63]

Vazquez 1992

0/9

0/9

0.0 [0.0, 0.0]

Williams 1996

2/42

2/18

0.43 [0.07, 2.81]

Subtotal (95% Cl)

326
Total events: 29 (holding chamber), 38 (nebulizer)
Heterogeneity: 2 = 4.43, df = 5 (P = 0.49); l 2 = 0.0%
Test for overall effect: Z = 1.55 (P = 0.12)

286

0.72 [0.47, 1.09]

595
Total (95% Cl)
Total events: 59 (holding chamber), 67 (nebulizer)
Heterogeneity: 2 = 8.90, df = 12 (P = 0.71); l 2 = 0.0%
Test for overall effect: Z = 0.24 (P = 0.22)

541

0.83 [0.61, 1.12]

0.01
Chamber better

0.1

10

100

Nebulizer better

CI, confidence interval. Reproduced with permission from [14].

Corticosteroids

The airway edema and increased secretions associated

with acute asthma are the result of inflammation and
warrant early aggressive anti-inflammatory treatments.
For example, systemic corticosteroids delivered early
(i.e., within 2 h of arrival) is a first-line treatment in
most current and previous published asthma guidelines
[8

,9,10,23,24]. A Cochrane meta-analysis identified 12
RCTs involving a total of 863 patients with acute asthma
and concluded systemic corticosteroids significantly
reduced admissions [odds ratio (OR) 0.50, 95% CI
0.310.81) compared with placebo or standard care;
the NNT was 8 (95% CI 520%) [25]. This benefit
was more pronounced for corticosteroid naive patients
(OR 0.37, 95% CI 0.190.70) and those experiencing
a severe attack (OR 0.35, 95% CI 0.210.59). Given the

limited follow-up periods for many of these studies, sideeffect profiles were similar among all corticosteroid
treatment routes, suggesting treatment with corticosteroid
is safe in the short term.
Current treatment options for physicians include using i.v.,
intramuscular (i.m.), and/or oral corticosteroids in severe
disease. Although most evidence-based clinicians use oral
agents (e.g., prednisone or dexamethasone), in severe
asthma an i.v. route of administration may be preferable.
Until further evidence is available, it seems appropriate to
provide systemic corticosteroids to all patients as follows:
mild-to-moderate asthma, oral systemic corticosteroids;
i.v. corticosteroids should be reserved for patients
who have severe asthma, are too dyspneic to swallow,
have decreased level of consciousness, are intubated or

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Severe acute asthma Rowe et al. 339

in the process of being intubated, and/or are unable to

tolerate oral medications (e.g., vomiting). Furthermore,
systematic reviews in hospitalized patients are underpowered to conclude superiority or equivalence regarding
high doses.
The agent and dose of systemic corticosteroids
administered should be based on familiarity, availability,
and patient factors. Most importantly, clinicians need to
start systemic corticosteroids early and consistently for
patients with severe acute asthma.
Magnesium sulfate

Intravenous magnesium sulfate (MgSO4) is a treatment

option for a variety of acute severe diseases such as
eclampsia, cardiac arrhythmias, and asthma. In asthma,
it has both a direct effect on smooth muscles, through its
influence on cellular calcium homeostasis, and a proposed
airway anti-inflammatory effect. The use of i.v. MgSO4 in
unresponsive acute asthma has gained support over the
past decade. There have been a number of systematic
reviews that all conclude that i.v. magnesium is not
only safe but also effective in those patients with
severe disease [26,27]. Overall, 13 studies (eight adults,
five children) involving 965 patients have examined the
addition of i.v. MgSO4 to SABA and systemic corticosteroids. Considering all studies, the addition of MgSO4

reduced hospitalization; however, significant heterogeneity was identified (I2 47.6%; Fig. 2). When the
analysis was restricted to only adults the treatment did
not appear to reduce admissions (RR 0.91, 95% CI 0.77
1.09). In the severe asthma subgroup, MgSO4 did reduce
hospitalization when all studies were considered (RR
0.60, 95% CI 0.480.74), and also improved pulmonary
function (PEF 26.8 l/min, 95% CI 7.345%). Overall,
adverse effects and side-effects with this treatment
were rare or minor, although these outcomes are poorly
reported in most clinical trials.
Adult patients with clinically severe asthma (e.g.,
pulmonary function testing less than 30% predicted
and/or those patients with severe symptoms who exhibit
a poor response to initial bronchodilator therapy) appear
to benefit most from i.v. MgSO4 treatment. As this agent
has been shown to be easy to use, extremely safe and
inexpensive, its early use in severe acute asthma should
be considered. Currently, the recommended dose is 2 g
i.v. over 20 min in adults, and this approach has been
widely accepted by emergency physicians surveyed in
North America [28].
Inhaled corticosteroids

Although inhaled corticosteroids (ICSs) are considered

treatment for chronic asthma, there is ample evidence

Figure 2 The effectiveness of intravenous magnesium sulfate compared with placebo in severe acute asthma (admission outcome)

Study
or sub-category

MgSO4
n/N

Placebo
n/N

01 High admission rate

Skobeloff 1989
Bloch 1995
Ciarallo 1997
Devi 1997
Ciarallo 2000
Subtotal (95% Cl)

7/19
7/21
11/15
9/15
8/16

15/19
11/14
16/16
15/16
14/14

86

79

RR (random)
95% Cl

RR (random)
95% Cl

0.47 (0.25, 0.88)

0.42 (0.22, 0.82)
0.73 (0.54, 1.00)
0.64 (0.42, 0.99)
0.50 (0.31, 0.82)
0.60 (0.48, 0.74)

Total events: 42 (MgSO4), 71 (Placebo)

2
2
Test for heterogeneity: = 4.66, df = 4 (P = 0.32), I = 14.2%
Test for overall effect: Z=4.55 (P< 0.00001)
02 Low admission rate
Green 1992
Matusiewicz 1994
Bloch 1995
Boonyavorakul 2000
Scarfone 2000
Porter 2001
Silverman 2002
Subtotal (95% Cl)

13/58
45/64
14/46
3/17
11/24
5/18
39/122

349
Total events: 130 (MgSO4), 137 (Placebo)
2
2
Test for heterogeneity: = 1.76, df = 6 (P= 0.94), I = 0%
Test for overall effect: Z=0.15 (P= 0.88)
435
Total (95% Cl)
Total events: 172 (MgSO4), 208 (Placebo)
2
2
Test for heterogeneity: = 20.99, df = 11 (P = 0.03), I = 47.6%
Test for overall effect: Z=2.37 (P= 0.02)

11/62
47/67
13/54
4/16
16/30
5/24
41/126

1.26 (0.62, 2.59)

1.00 (0.80, 1.25)
1.26 (0.66, 2.41)
0.71 (0.19, 2.67)
0.86 (0.50, 1.49)
1.33 (0.45, 3.92)
0.98 (0.68, 1.41)
1.01 (0.86, 1.19)

349

458

0.79 (0.64, 0.96)

0.1

0.2

0.5

Favours MgSO4

10

Favours placebo

CI, confidence interval; RR, relative risk.

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340 Emergencies

that ICS may influence outcomes in the acute setting

[29]. Their ability to do so is linked to the vasoconstrictive properties of these agents, rather than the antiinflammatory properties. Systematic review evidence
from the Cochrane identified 10 trials (five in adults) that
involved 587 patients [29]. Overall, patients treated with
a variety of ICS agents were less likely to be hospitalized
(OR 0.32, 95% CI 0.180.54) and the treatment was
well tolerated. Although ICS agents should not be
primary treatment, they may assist in more severe
asthma, especially if patients have not previously been
on systemic corticosteroids prior to ED presentation. The
dose, frequency, and agents used in this review varied
widely; however, there appears to be evidence of effect
despite this heterogeneity.
Adjuvant agents

Intramuscular epinephrine injections have been recommended in acute allergic reactions and may benefit
patients in whom acute asthma is known or suspected
to be due to anaphylaxis [30]. Both long-acting b2agonists (LABAs) and leukotriene receptor antagonists
(LTRAs) are recommended as add-on therapy in
chronic, poorly controlled asthma; however, research in
acute asthma is limited. A RCT of 201 patients treated
with placebo, 7 or 14 mg of intravenous montelukast,
suggested a clinically significant improvement in FEV1
within 10 min of administration [31]; however, other
evidence-based treatments were not administered to
all patients. Another study examined treatments in the
ED and after discharge [32]. Overall, the evidence in
this treatment is limited and whether their use should
be encouraged in addition to systemic corticosteroids
remains uncertain. As the evidence regarding the use
of both LTRA and LABA agents accumulates, clinicians
are encouraged to search for systematic review updates.

Airway interventions
Despite the use of aggressive management outlined
above, in rare cases some patients will continue to
deteriorate and decisions regarding the need for assisted
ventilation will be required.

sparse. In fact, a systematic review published in 2005

identified only one trial and although this evidence is
positive [35], recent reviews have generated neutral
recommendations [36]. The authors believe that the
benefits of NIV in this setting, the success in similar
respiratory failure cases due to other common acute
conditions, suggest a trial of NIV may be warranted in
certain cases. The ultimate goal is to avoid intubation and
NIV may be the last resort.

Intubation

If all else fails to improve, intubation may be required.

The decision to intubate patients with asthma should
not be taken lightly, given the potential barotrauma
and complications associated with the intervention.
Limited comparative research has been performed in
this setting and fortunately the need for intubation is
rare. A decreasing level of consciousness and respiratory
fatigue are clear signs of the need for airway control.
Although rapid sequence intubation with ketamine is
recommended, it must be stressed that preparation
and airway expertise is essential for a successful, nontraumatic intubation. The airway settings, techniques
of mechanical ventilation, use of heliox, timing of extubation, and other airway considerations are covered more
comprehensively by other reports [37

].

Conclusion
Asthma is a common, chronic, and often debilitating
disease and exacerbations of this disease are frequent
in EDs in most countries. In severe acute cases, the
early, aggressive, multimodal interventions treatment
approaches to treat bronchoconstriction and control airway inflammation summarized herein provide guidance
for avoiding hospitalization and intubation as well as early
return to activities, reduced symptoms, and improved
quality of life in the post-ED period. Combining SABA
bronchodilators and corticosteroids are sufficient for
most patients (Table 1); however, adjuncts such as SAAC,
i.v. MgSO4, ICS, and NIV provide patients with the
best opportunity to avoid hospitalization and maintain
excellent health status in the future.

Noninvasive ventilation

Many clinicians in the acute care setting have become

adept at the use of noninvasive ventilation (NIV, also
referred to as noninvasive positive pressure ventilation)
for patients with respiratory failure, especially in the
setting of heart failure and chronic obstructive pulmonary
disease (COPD) [33,34]. NIV is usually applied by partial
or full-face mask, in the form of biphasic respiratory
support. Although the evidence to support these interventions in COPD and heart failure is based on pooling
of multiple small RCTs demonstrating homogeneous
efficacious outcomes, the evidence in acute asthma is

Despite the advancements in evidence-based asthma,

additional research is required to improve the care
of these important patients. Future research should
examine methods to disseminate and implement
evidence-based treatments in the acute care setting,
the role of innovative health service delivery options
(e.g., observation units, short-stay units), identification
of markers of airway infection/inflammation in order to
personalize treatments, and identification of additional
management strategies. Finally, there is a need for
pragmatic, multicenter trials to resolve these issues.

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Severe acute asthma Rowe et al. 341

Acknowledgements
No funding was received for this work.
The authors would like to thank Ms Melissa Andersen (Department
of Emergency Medicine) for her assistance with the production of
this manuscript. C.V.R. is supported by CIHR in partnership with the
Knowledge Translation branch. B.H.R. is supported by the 21st
Century Canada Research Chairs program through the Canadian
Institutes of Health Research and the Government of Canada (Ottawa,
Ontario, Canada). B.H.R. has received funding for investigator-initiated
asthma and COPD research in the past 2 years from GlaxoSmithKline
(Mississauga, Ontario, Canada) and for an industry-initiated asthma and
COPD studies from MedImmune Inc. (Gaithersburg, Maryland, USA);
however, B.H.R. is not a paid employee or consultant to either
respiratory company.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:


of special interest


of outstanding interest
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World Literature section in this issue (p. 403).

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