Wheeze/asthma exacerbation workflow

Scope

Use for

Outpatient initial management of wheeze/asthma symptoms in patients without immediate respiratory failure signs.

Not for

• Severe respiratory distress, hypoxia, or exhaustion requiring emergency pathway.
• Inpatient-level acute asthma management.

Immediate actions

• Record respiratory rate, pulse, oxygen saturation, speech, work of breathing and air entry; repeat after treatment. Assess prior ICU care, recent steroid courses and reliever response.
• Consider anaphylaxis, foreign body and other causes of wheeze. Infant bronchiolitis needs a separate age-specific pathway.

Red flags: escalate now

If any of these are present, stop routine steps and follow the urgency stated. Activate emergency care for instability or findings that need immediate transfer.

• Call emergency services for silent chest, exhaustion, impaired consciousness, cyanosis or marked distress; begin stabilization while transfer is arranged.
• Persistent hypoxemia or poor bronchodilator response requires emergency assessment. In children, SpO2 below 92% needs urgent oxygen and acute-care management; a reassuring saturation alone does not establish mild disease.

First-line plan

• Give inhaled rapid bronchodilator treatment using the age-specific acute asthma protocol; MDI with spacer is preferred when feasible. Do not substitute routine as-needed dosing for an exacerbation protocol.
• Moderate or severe attacks need early systemic corticosteroid assessment and monitored care; do not delay transfer for office investigations.
• Review technique and adherence. Before discharge, prescribe or optimize an inhaled corticosteroid-containing plan appropriate to age and prior treatment; daily low-dose ICS plus as-needed SABA is the CTS first-line approach to mild asthma. Other regimens require age-specific selection.

Follow-up and monitoring

• Discharge only after sustained clinical improvement with a feasible reliever schedule and reliable access to care.
• Provide a written action plan, arrange early reassessment for residual symptoms and complete a control review within 4 weeks in children. Children needing reliever more often than every 4 hours after discharge require reassessment.
• Review persistent symptoms or more than 2 reliever doses per week for inadequate control.

Before the patient leaves

Return precautions you can say as written:

“If symptoms get worse, new warning signs appear, or you cannot follow the plan from this visit, seek urgent care now.”

• Point to the red flags above that apply to this patient.
• Confirm follow-up timing and where to go after hours.
• Attach a relevant handout to reinforce the plan.
• Document disposition, rationale, unresolved uncertainty, and that precautions were understood.

About this workflow

Clinical owner

Family Medicine Editorial Team

Risk tier

High

Review cadence

Every 3 months

Last reviewed

September 4, 2026AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.

Review status

Evidence current. Next review due December 4, 2026.

References

• CPS Managing an acute asthma exacerbation in children (opens in a new tab)
• CTS Very mild and mild asthma guideline (2021) (opens in a new tab)