Saudi expert consensus on the management of acute asthma and COPD exacerbations with algorithm of aerosol drug delivery device recommendations

OBJECTIVE: To develop a practical, expert consensus for the management of acute asthma and chronic obstructive pulmonary disease (COPD) exacerbations in Saudi Arabia's Emergency Departments (EDs), addressing gaps in triage, diagnostic certainty, and aerosol delivery. METHODS: A modified expert consensus process with Delphi elements was employed. Eight multidisciplinary experts in pulmonary medicine, emergency medicine, and respiratory therapy, three of whom were affiliated with the Saudi Society of Emergency Medicine (SASEM), two of whom are authors of the Saudi initiative for Asthma (SINA) Guidelines, and three of whom are authors of the Saudi COPD guidelines, reviewed evidence-based presentations and formulated structured discussion questions before the meeting. The advisory board session (Riyadh, November 19, 2025) served as the formal consensus round, addressing ten predefined clinical questions across two moderated debate sessions, with formal voting on two key device-selection statements. RESULTS: The panel adopted a dual-phase severity classification: a binary "Non-Severe vs. Severe" model for rapid ED triage, followed by the four-tier SINA classification for clinical management. Pharmacological algorithms were standardized, prioritizing early corticosteroid therapy and optimizing bronchodilator dosing to mitigate toxicity. The panel reached a unanimous consensus that aerosol delivery device selection significantly influences treatment success; A-VMN was recommended at escalating strengths across severity levels (Class IIb-I) and as a preferred option for severe and ventilated patients, based on superior lung deposition, infection control advantages, and improved discharge rates. CONCLUSION: This modified expert consensus aims to provide an up-to-date, organized, and action-oriented protocol for Saudi EDs. It advocates a stratified triage system and evidence-based selection of aerosol-delivery devices to improve patient outcomes, enhance safety, and optimize resource utilization.