What is the management of acute asthma exacerbation?

From the Guidelines

Management of acute asthma exacerbations requires prompt assessment and stepwise treatment, with the most recent and highest quality study recommending early treatment with inhaled short-acting beta-agonists, systemic corticosteroids, and oxygen therapy to maintain oxygen saturation ≥92% 1.

Key Components of Treatment

• Inhaled short-acting beta-agonists (SABA) like albuterol 2.5-5 mg via nebulizer or 4-8 puffs via metered-dose inhaler with spacer every 20 minutes for the first hour
• Systemic corticosteroids, such as prednisone 40-60 mg orally daily for 5-7 days or methylprednisolone 40-60 mg IV if the patient cannot take oral medications
• Oxygen therapy to maintain oxygen saturation ≥92% ### Severe Exacerbations
• Provide continuous albuterol nebulization (10-15 mg/hour)
• Add ipratropium bromide 0.5 mg via nebulizer every 4-6 hours for the first 24-48 hours
• Consider magnesium sulfate 2 grams IV over 20 minutes for patients not responding to initial therapy ### Monitoring and Follow-up
• Reassess the patient frequently, monitoring respiratory rate, heart rate, oxygen saturation, and work of breathing
• Prepare for possible intubation and mechanical ventilation if the patient shows signs of respiratory failure
• Before discharge, ensure the patient has improved symptoms, stable vital signs, and a clear follow-up plan including a short course of oral corticosteroids, continued bronchodilator therapy, review of inhaler technique, and a written asthma action plan 2, 3 ### Special Considerations
• Infants are at greater risk for respiratory failure and require special consideration in assessment and treatment
• Patients with 1 or more risk factors for asthma-related death require close monitoring and aggressive treatment 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.

For acute asthma exacerbation management, the drug label for albuterol (INH) 4 suggests that the medication can be used to control recurring bouts of bronchospasm. The recommended dosage is 2.5 mg administered three to four times daily by nebulization.

• Key points for management:
  • Use 2.5 mg of albuterol (one vial)
  • Administer three to four times daily
  • By nebulization If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately.

From the Research

Classification and Assessment of Acute Asthma Exacerbations

• Asthma exacerbations can be classified as mild, moderate, severe, or life threatening, based on symptoms and physical examination parameters, as well as lung function and oxygen saturation 5
• Criteria for exacerbation severity are essential in determining the appropriate management strategy

Management Strategies for Acute Asthma Exacerbations

• In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart may be safely employed at home 5
• Administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta2 agonist therapy in children and adults 5
• Multiple doses of inhaled anticholinergic medication combined with beta2 agonists improve lung function and decrease hospitalization in school-age children with severe asthma exacerbations 5
• Intravenous magnesium sulfate has been shown to significantly increase lung function and decrease the necessity of hospitalization in children 5

Role of Systemic Corticosteroids and Other Therapies

• The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization, with the most pronounced effect in patients with severe exacerbations 5
• Airway inflammation can persist for days to weeks after an acute attack; therefore, more intensive treatment should be continued after discharge until symptoms and peak expiratory flow return to baseline 5
• The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 6

Post-Exacerbation Care and Prevention of Future Exacerbations

• Post-exacerbation care is crucial in preventing future exacerbations, and includes the addition of inhaled corticosteroids, consideration of stepping up asthma maintenance therapy, close follow-up, and education on asthma action plans 6
• Asthma action plans help patients triage and manage symptoms at home, and can reduce the risk of exacerbations and need for oral corticosteroids 6