Prescribe oxygen to a target range, use high-flow nasal oxygen early in hypoxaemic respiratory failure and track the ROX index, apply NIV correctly in hypercapnic COPD and cardiogenic pulmonary oedema, recognise NIV failure early, and treat acute severe asthma stepwise.
5 topics
- 01
Oxygen prescription and SpO2 targets
Prescribe oxygen like a drug: SpO2 94-98% for most acutely ill patients (92-96% is a reasonable ICU range), 88-92% if at risk of hypercapnia. Avoid both hypoxaemia and hyperoxia; choose the right device.
6 stepsAlgorithmNew - 02
High-flow nasal oxygen and the ROX index
HFNC is the first-line non-invasive support for acute hypoxaemic respiratory failure. Start at 50-60 L/min, titrate FiO2 to target, and use the ROX index at 2, 6 and 12 h to avoid delayed intubation.
5 stepsAlgorithmNew - 03
NIV in acute hypercapnic COPD exacerbation
Start NIV when pH < 7.35 and PaCO2 > 45 mmHg (6.5 kPa) persist after initial treatment. Titrate IPAP quickly, target SpO2 88-92%, recheck the gas at 1-2 h, and decide early whether NIV is working.
6 stepsAlgorithm3 dosesNew - 04
NIV and CPAP beyond COPD
CPAP or bilevel NIV is strongly indicated for cardiogenic pulmonary oedema, useful in immunocompromised and post-operative respiratory failure, can prevent post-extubation failure in high-risk patients, but should not be used to rescue established post-extubation failure.
7 stepsAlgorithmNew - 05
Acute severe and life-threatening asthma
Grade severity quickly (PEF, speech, RR, HR, SpO2, PaCO2). Give oxygen-driven salbutamol, ipratropium and steroids at once; add IV magnesium; a normal or rising PaCO2 is a danger sign; intubate early and ventilate to avoid breath stacking.
8 stepsAlgorithm5 dosesNew
Drugs in this module
Doses written for this module's context. The same drug may read differently in another module.
Salbutamol (albuterol)
Short-acting beta-2 agonist
Salbutamol (albuterol)
Short-acting beta-2 agonist
- Indications
- Acute asthma and COPD exacerbation; hyperkalaemia (adjunct).
- Adult dose
- Nebulised 5 mg (oxygen-driven in asthma, air-driven in hypercapnic COPD) repeated every 15-30 min, or continuous 5-10 mg/h in severe asthma. MDI with spacer 4-10 puffs (100 mcg/puff) every 20 min is equivalent in less severe attacks. IV 5 mcg/min up to 20 mcg/min only if inhaled route is not possible (senior decision).
- Preparation (India)
- Respules 2.5 mg/2.5 mL and 5 mg/2.5 mL; nebuliser solution 5 mg/mL; MDI 100 mcg/puff.
- Cautions
- Tachycardia, hypokalaemia, lactic acidosis (type B), tremor.
- Monitoring
- Potassium and lactate when giving repeated or continuous doses.
Ipratropium bromide
Short-acting antimuscarinic
Ipratropium bromide
Short-acting antimuscarinic
- Indications
- Acute severe or life-threatening asthma; COPD exacerbation.
- Adult dose
- 500 mcg nebulised every 4-6 h (may be given every 20 min for the first hour in severe asthma).
- Preparation (India)
- Respules 500 mcg/2 mL; often combined with salbutamol (Duolin-type respules: levosalbutamol or salbutamol + ipratropium).
- Cautions
- Glaucoma (use mouthpiece or protect eyes).
Magnesium sulfate
Bronchodilator (calcium antagonism)
Magnesium sulfate
Bronchodilator (calcium antagonism)
- Indications
- Acute severe or life-threatening asthma not responding to initial inhaled therapy.
- Adult dose
- 1.2-2 g IV over 20 min, single dose.
- Preparation (India)
- 50% w/v (500 mg/mL) 2 mL ampoules: 2 g = 4 mL, diluted in 100 mL NS.
- Cautions
- Hypotension, flushing; caution in renal failure (repeated doses).
Prednisolone / hydrocortisone
Systemic corticosteroid
Prednisolone / hydrocortisone
Systemic corticosteroid
- Indications
- All acute asthma attacks; COPD exacerbation.
- Adult dose
- Asthma: prednisolone 40-50 mg orally daily for at least 5 days, or hydrocortisone 100 mg IV every 6 h if unable to swallow. COPD: prednisolone 40 mg daily for 5 days.
- Preparation (India)
- Prednisolone 5, 10, 20, 40 mg tablets; hydrocortisone 100 mg vials. Methylprednisolone 40 mg IV is a common Indian ICU alternative.
- Cautions
- Hyperglycaemia; myopathy with high doses and neuromuscular blockers.
Aminophylline
Methylxanthine
Aminophylline
Methylxanthine
- Indications
- Life-threatening asthma not responding to inhaled therapy (senior decision only).
- Adult dose
- Load 5 mg/kg IV over 20 min (omit if on oral theophylline), then 0.5 mg/kg/h; check levels (10-20 mg/L).
- Preparation (India)
- 250 mg/10 mL ampoules.
- Cautions
- Narrow therapeutic index: arrhythmias, seizures, vomiting; interactions (ciprofloxacin, clarithromycin, erythromycin raise levels).