Asthma is one of the quintessential Obs protocols

Inclusion Criteria

  • Alert and oriented, acceptable VS
  • Intermediate response to therapy - improving but still wheezing
  • PEFR (peak flow) 40-70% predicted (or personal best) after β2 agonists
  • β2 agonist nebs (2 treatments or 10 mg albuterol) + steroids given in ED
  • Minimum ED treatment time > 2 hours
  • Chest X-ray with no acute findings (pneumonia, pneumothorax, CHF)

Exclusion Criteria

  • Unstable VS or clinical condition - severe dyspnea, confusion, drowsiness
  • Poor response to initial ED treatment:
  • Persistent use of accessory muscles, RR>40, or excessive effort
  • Elevated pCO2 (>50) plus decreased pH if ABG done
  • O2Sat < 92% on room air, unless documented chronic hypoxia
  • PEFR* < 40% predicted or personal best
  • Suspicion of ACS, new onset CHF, pneumonia

Potential Interventions

  • Serial treatments with nebulized β2 agonist and ipratropium
  • IV Magnesium Sulfate as needed.
  • Frequent reassessment. BNP if needed.
  • Systemic steroids (PO or IV)
  • Pulse oximetry, ABG, and oxygen with cardiac monitoring as needed

Discharge Criteria


(Patient to be discharged on steroids, nebs, with follow-up and smoking cessation)
    • Acceptable VS – HR <100, RR <20 after ambulation (if able)
    • Pulse Ox >95% on RA (or return to baseline)
    • Resolution of bronchospasm or return to baseline status
    • PEFR > 70% predicted (or 70% personal best) – if reliable reading


    • Progressive deterioration in clinical status or VS
    • Failure to resolve bronchospasm within 15 hours
    • Persistent PEFR < 70% of predicted (if reliable)
    • Hypoxic despite therapy, if not chronic state


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