Acute exacerbation of bronchial asthma (asthma for short) refers to the sudden onset of symptoms such as shortness of breath, cough, chest tightness, or a sharp aggravation of the existing symptoms, the degree of which varies and the exacerbation can occur within hours or days, or occasionally within minutes, which can be life-threatening, so the severity of the disease should be accurately assessed and active and effective management measures should be taken. The following is a discussion of several issues of concern in the management of acute exacerbations, with reference to classic domestic and foreign research data, for the reference of our colleagues. Some patients can find allergens or other non-specific stimuli that cause asthma attacks and can be confirmed to be the cause of asthma exacerbation or persistent non-remission. Avoiding or disengaging from allergen exposure is an important part of managing an acute asthma attack, and it is important to take a history and perform the necessary tests, which are often the most overlooked by clinicians. Allergen-specific immunotherapy (SIT) has been shown to be effective in some patients, reducing the number of attacks, alleviating asthma symptoms, and improving lung function. II. Accurate determination of severity Both the Guidelines for the Management of Bronchial Asthma and the Global Initiative for Asthma Control (GINA) classify acute exacerbations as mild, moderate, severe or critical. Experienced clinicians have no difficulty in distinguishing between these classifications based on clinical signs. However, there is a line that must be clearly drawn between moderate and severe. It is very important to distinguish this line to facilitate enhanced monitoring and management of critically ill patients, timely management of complications, and reduction of morbidity and mortality. In addition to pulmonary function tests, the most objective laboratory test is arterial blood gas analysis. Often, in severe patients with significant hypoxemia or even respiratory failure, the partial pressure of arterial blood carbon dioxide (PaCO2) begins to rise and the pH value changes from elevated to normal or acidic. In addition, the severity of the condition should also be judged with reference to the medical history, which is also often overlooked by clinicians. Patients who have had previous episodes of hypercapnia and tracheal intubation should be given high priority and monitored more closely. Third, pay attention to the differentiation of dyspnea caused by other diseases, especially endotracheal tumors, foreign bodies, mediastinal tumor compression, acute pulmonary thromboembolism, etc., misdiagnosis and mismanagement cases are common. The reason for misdiagnosis and mistreatment is that other important clinical signs and timely acquisition of ancillary test results are neglected in the management process. If the symptoms of dyspnea are not relieved, the possibility of complications caused by acute asthma attacks, such as spontaneous pneumothorax and mediastinal emphysema, should be considered, instead of increasing the dose of asthma medication and leading to drug overdose. The use of glucocorticoids is the most effective anti-inflammatory drug at present. They can significantly inhibit the synthesis and release of inflammatory mediators and cytokines, reduce microvascular leakage and inhibit glandular secretion, thus reducing the congestion and edema of bronchial mucosa and improving airflow limitation. In addition, due to the effect of inhibiting inflammatory mediators and upregulating β2 receptors, it also indirectly acts as a diastolic agent for bronchial smooth muscle. Therefore, glucocorticoids play an important role in the management of acute attacks. The proper and rational use of glucocorticoids is an important topic in the treatment of asthma. To summarize, it should be “appropriate, adequate and short course”. What is “at the right time”? In other words, patients with mild or moderate acute attacks should be treated with sufficient bronchodilators (continuous nebulized inhalation of short-acting β2 agonists every 20 min in the first hour), and those with severe or critical attacks should be treated with systemic glucocorticoids as soon as possible. The so-called “adequate dose” means taking the appropriate dose according to the severity of the disease, rather than delaying the treatment by gradually increasing the dose from small doses on a trial basis. Usually, hydrocortisone succinate 200-800mg per day or methylprednisolone 40-160mg per day is used, and individual critically ill patients can also try shock therapy with methylprednisolone 250-500mg per day for 1 to 3 d. The so-called “short course” means that those without glucocorticoid-dependent tendency should stop the drug within 3 to 5 d. For those with glucocorticoid-dependent tendency, the duration of administration should be extended, and after controlling the symptoms, oral administration should be changed and the glucocorticoid dosage should be gradually reduced. In addition, when systemic glucocorticoids are needed for patients with mild or moderate acute attacks, they can be administered orally. Correct and rational use also includes the choice of drug species. Dexamethasone has a strong anti-inflammatory effect but should be avoided or not used for a longer period of time because of its long half-life in plasma and tissues and its long inhibitory effect on the pituitary-adrenal axis. Budesonide suspension is nebulized and inhaled by compressed air or high-flow oxygen, which does not require high inhalation, has a faster onset of action, is effective in patients with mild to moderate asthma attacks and some severe attacks, reduces the use of systemic glucocorticoids and decreases the rate of hospitalization, and there is more research data on children. The combined use of various bronchodilators is the most classic combined treatment plan in asthma treatment. A large number of foreign studies have shown that the combination of short-acting β2 agonists and anticholinergic drugs with continuous nebulized inhalation can enhance the bronchodilatory effect and improve the lung function more significantly than single drugs in patients with moderate exacerbations, especially those with peak expiratory flow rate (PEFR) <200 L/min, and can significantly reduce the side effects caused by increasing the dose of single drugs and decrease the hospitalization rate. It is especially effective in patients with exacerbations lasting more than 24 h or with a first second force expiratory volume (FEV1) ≤ 30%. Plasma theophylline concentration at night is more relevant to bronchodilator effect The results of the study in the 1990s showed that a higher plasma theophylline concentration was not needed to achieve better lung function improvement during the daytime, while a higher plasma theophylline concentration was needed to achieve the same bronchodilator effect at night. In daily clinical practice, however, health care providers do not pay attention to this important phenomenon, especially in the management of severe and critical exacerbations, where intravenous theophylline is administered only during the daytime or as a single dose, resulting in low theophylline concentrations at night. Therefore, in the management of critically ill patients, the drug should be administered in divided doses or 24h continuous treatment to maintain a stable theophylline concentration at night. Continuous nebulized inhalation is the best route of administration during acute exacerbations Inhalation of bronchodilators using high-flow oxygen or compressed air-driven jet nebulization devices is the preferred method for managing acute asthma exacerbations. Happily, this approach has been promoted to some extent in recent years. However, it is still far from adequate, and it is known that many large teaching hospital emergency departments are not yet equipped with such inhalation devices. From another perspective, we can also see the relative lag in the education of physicians in asthma prevention and treatment. In the management of acute asthma attacks, both GINA and our guidelines advocate the establishment of a condition assessment and a standardized treatment model, i.e., initial treatment after initial condition assessment. In the first hour of initial treatment, a standard dose of short-acting β2 agonist is inhaled every 20 min, and the condition is assessed again and treated according to the degree of the condition. If the attack is moderate or above, a combination of inhaled short-acting β2 agonist and anticholinergic drugs should be administered, and the condition should be judged after 1 to 3 h. Depending on the response to treatment, the patient should be discharged, hospitalized or admitted to the intensive care unit. The above condition assessment and treatment modalities are very important because there is a therapeutic window in the management of any acute illness, and inaccurate condition assessment and inappropriate management can lead to treatment failure. The management of asthma patients in the 1sth in hospital after acute exacerbation is crucial and is important to improve the outcome and reduce the hospitalization and morbidity and mortality rates. In practice, most hospitals in China do not adopt this assessment and standardized treatment model, and further research is needed to confirm whether this assessment and standardized treatment model is suitable for China's national conditions. The Asthma Group of the Chinese Academy of Medical Sciences is organizing a national multicenter clinical study to evaluate this model objectively.