Severe Asthma

Asthma InhalerThis protocol outlines the treatment of an asthma attack causing persistent respiratory distress not responding to the patient’s use of a 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. Early recognition and prompt treatment, particularly in the wilderness setting may be essential to preserve life.

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

  • Shortness of Breath (>30 respirations per min)
  • Mental status changes (anxious, confused, combative, drowsy, etc.)
  • Inability to speak in sentences
  • Unable or unwilling to lie down
  • Sweaty


Recommended Treatment

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

  1. 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.
  2. Maintain an open airway and position of comfort. Initiate either positive pressure ventilations (PPV) or cardiopulmonary resuscitation (CPR) as indicated.
  3. Repeat epinephrine injections as soon as every 5 minutes if needed.
  4. Prednisone 60 mg/day for an average adult.
  5. Have the patient self-administer 6-10 puffs from the MDI/HFA. This may be repeated every 20 minutes for a total of three doses.
  6. Evacuate to definitive care if safe to do so. Consider an advanced life support intercept en route (ALS).
  7. If evacuation is not possible, monitor carefully and repeat treatment per protocol as necessary.

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 either 0.3 mg or 0.5 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. 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. (25kg), 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.



The above specified protocol has been authorized for use by Center for Wilderness Safety for WEMT, WFR, WAFA, WFAA and WFA trained employees of the employer named on page 3 of this document, provided they meet the requirements of the authorization criteria listed in this protocols packet. Only those certified as WEMT and WFR are permitted to manually administer epinephrine via syringe (as opposed to an auto-injector).

Note that prednisone is a schedule III prescription anabolic steroid, and if carried by the organization (employer), it may require a prescription from a medical advisor. It is essential for prescribers and organizations to be familiar with state, provincial or national regulations that may address the prescribing of medication.

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These protocols were written by Jeffrey Isaac, PA-C of WMA, and have been edited and authorized by the executive medical and curriculum directors Kathryn Vaughn, M.D., William Incatasciato, M.D. and Jennifer Kay, RN, BSN for use by Center for Wilderness Safety, Inc.Last Revised: February 2021