Protocol 2: Severe Asthma

Asthma is an inflammatory disease of the airways which results in more than 450,000 hospital admissions and 5,000 fatalities a year. Every patient with asthma is at risk for a severe, acute exacerbation that requires aggressive management. This protocol outlines the treatment of an asthma attack causing persistent respiratory distress not responding to the patient’s use of a prescribed rescue inhaler. This is a high-risk problem that can cause respiratory failure and death from respiratory arrest. Early recognition and prompt treatment is essential.


Patients who have progressed to severe asthma may experience a combination of the following:

Shortness of Breath (<8 or >30 respirations /min)
Mental status changes (anxious, confused, combative, drowsy, etc.)
Inability to speak in complete sentences
Diaphoretic (unusually sweaty)
Unable or unwilling to lie down


If the patient is not responding to or is unable to properly use an MDI (metered dose inhaler), proceed to the following:

Inject 0.01 mg/kilogram (up to 0.5 mg) of 1 mg/ml solution of epinephrine intramuscularly (IM) into the lateral mid-thigh. A dose of 0.3 to 0.5 mg is appropriate for the average adult.
Maintain an open airway and position of comfort. Initiate either positive pressure ventilations (PPV; rescue breathing) or cardiopulmonary resuscitation (CPR) as indicated.
Repeat epinephrine injections as soon as every 5 minutes if needed.
Prednisone 60 mg/day for an average adult.**
Have the patient self-administer 6-10 puffs from their Metered Dose Inhaler (MDI). This may be repeated every 20 minutes for a total of three doses.
Evacuate to definitive care as quickly as possible. Consider an advanced life support intercept en route (ALS).
If evacuation is not possible, monitor carefully and repeat treatment per protocols necessary.


** There is 1 mg of epinephrine in 1 ml of epinephrine 1/1000; there is 0.3 mg in 0.3 ml of 1/1000. Pre-loaded commercially available injectors deliver either 0.3 mg (standard adult dose) or 0.15 mg (standard pediatric dose). If the person weighs less than 66 lbs (30 kg), the doses are: epinephrine is 0.01 mg/kg; prednisone is 1 - 2 mg/kg. When using lbs, multiply the weight times 0.45 to get the weight/mass in kilograms.



Special Note: The preferred concentration of epinephrine for IM injection is 1 mg/1 ml. Although the lateral mid-thigh is preferred, an injection into the deltoid may be the only practical option. Commercially available auto-injectors such as the EpiPen deliver 0.3 mg as a standard adult dose or a 0.15 mg or 0.1 mg for a smaller person (less than 55 lbs; 25 kg), depending on body mass. The auto-injector is the most user-friendly device, but also the most expensive. Epinephrine is also supplied in 1 ml ampules, and vials of various sizes, for a fraction of the cost from CVS pharmacies. Manual Injection Kits (everything but the prescription epinephrine) are available at for under $5.


CWS graduates at the WEMT and WFR level are trained in the use of syringes, needles, vials, and ampules for this purpose. For patients weighing less than 55 lbs (25 kg), the doses are: epinephrine 0.01 mg/kg or the appropriate auto-injector and prednisone 1 mg/kg. Multiply the weight in pounds times 0.45 to get the weight in kilograms. The organization may need a prescription from a medical advisor to obtain the injectable epinephrine, syringes and prednisone used in the protocol. It is essential for prescribers and organizations to be familiar with state, provincial or national regulations that may address the prescribing of medication and the acceptable means of injecting epinephrine.


Last Updated: Nov. 2019

These protocols were written by Jeffrey Isaac, PA-C (of Wilderness Medical Associates International) and have been edited and authorized by the executive medical and curriculum directors Kathryn Vaughn, MD, FAWM & Jennifer Kay, RN, BNS, CCRC, CCRP, WALS, for use by Center for Wilderness Safety, Inc.


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