1. Administer oxygen (see page 431) by face mask at a rate of 10 liters per minute. If cold weather precipitated the attack, try to get the victim into a warmer climate.

2. Administer an inhaled (aerosol or “micronized”) bronchodilator. Bronchodilators (airway openers) are drugs that carry the advantages of minimal side effects and direct delivery to the site of action. They are available in metered-dose handheld nebulizers (“mistometers”) from which the victim inhales therapeutic puffs. An excellent drug for an acute attack is albuterol (Ventolin). The dose for an adult is two to six puffs initially, followed by two to four puffs every 3 to 6 hours. A mild to moderate asthma episode in an adult can frequently be controlled with an inhaled bronchodilator alone. Young children have difficulty using the inhaler, and therefore may require administration of the drug orally in pill or liquid form. The most effective technique for metered-dose inhalation appears to be discharging the aerosol through a spacer clamped between the lips. The drug should be released (canister pressed down or “triggered”) at the beginning of a deep inspiration. After inhalation, the recipient should attempt to hold his breath for 10 seconds.

3. Administer epinephrine if the victim remains in severe distress after inhalation of a bronchodilator. Epinephrine is a powerful bronchodilator that is injected subcutaneously (see page 474) as an aqueous solution of 1:1,000 concentration in a dose of 0.3 to 0.5 mL for an adult and 0.01 mL/kg of body weight for a child (not to exceed 0.3 mL). For weight estimation, 1 kg equals 2.2 lb. The drug is not recommended for those known to have coronary artery heart disease (angina or recent heart attack) or older than 45 years. Epinephrine is the treatment of choice for a severe asthma attack in a child. When administering an injection, never share needles between people. Epinephrine is available in autoinjectors (EpiPen and Twinject: see page 67) for administration to both adults and children.

4. Administer a corticosteroid. Asthma is often accompanied by inflammation of the airways. The victim should be dosed with prednisone tablets at the earliest possible opportunity, because the onset of their action is delayed by 4 to 6 hours. The dose for an adult is 50 to 80 mg, tapered over 10 days (for example, give 80 mg on days 1 and 2; 60 mg on days 3 and 4; 40 mg on days 5 and 6; 20 mg on days 7 and 8; and 10 mg on days 9 and 10). The initial dose for a child is 1 mg/kg (1 kg = 2.2 lb) of body weight, also tapered over 10 days. If a person with asthma improves greatly (e.g., feels completely normal) after using epinephrine or an inhaled bronchodilator (or both), steroid administration is not absolutely necessary, but in general, it is a highly helpful intervention. If a victim is carrying his own steroid inhaler, have him use it. Similarly, if he is carrying his own ipratropium, this can be self-administered.

5. A person with asthma who is in more than minimal distress or who does not achieve great improvement with these basic pharmacological maneuvers should be transported rapidly to the nearest medical facility. Great care should be taken to keep him well supplied with oxygen and as exertion-free as possible.