What is the best treatment regimen for a severe asthma (Acute Severe Asthma) exacerbation?

From the Guidelines

The best treatment regimen for a severe asthma exacerbation involves prompt administration of high-dose inhaled short-acting beta-agonists (SABAs), systemic corticosteroids, and supplemental oxygen. Initially, administer albuterol (salbutamol) via nebulizer at 2.5-5 mg or 4-8 puffs via metered-dose inhaler with spacer every 20 minutes for the first hour, then reassess. Simultaneously, give systemic corticosteroids such as prednisone 40-60 mg orally or methylprednisolone 60-125 mg intravenously, which should be continued for 5-7 days, as there is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1. Provide supplemental oxygen to maintain oxygen saturation ≥92%. For patients not responding adequately, add ipratropium bromide 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for the first hour, then every 2-4 hours as needed. Consider magnesium sulfate 2 grams IV over 20 minutes for patients with severe exacerbations not responding to initial therapy. Continuous monitoring of vital signs, oxygen saturation, and response to treatment is essential. If the patient shows signs of respiratory failure (decreasing consciousness, worsening hypoxemia despite oxygen, rising CO2), prepare for possible intubation and mechanical ventilation, using a strategy of "permissive hypercapnia" or "controlled hypoventilation" to provide adequate oxygenation while minimizing airway pressures and the possibility of barotrauma 1.

Some key points to consider in the management of severe asthma exacerbations include:

• The importance of early administration of systemic corticosteroids to reduce airway inflammation 1
• The use of inhaled ipratropium bromide in addition to SABAs for patients with severe exacerbations 1
• The consideration of magnesium sulfate for patients not responding to initial therapy 1
• The need for close monitoring of patients with severe asthma exacerbations and preparation for possible intubation and mechanical ventilation 1

It is also important to note that the treatment of severe asthma exacerbations should be individualized based on the patient's response to treatment and the severity of their symptoms. Consultation with or comanagement by a physician expert in ventilator management is essential for patients requiring mechanical ventilation 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 best treatment regimen for severe asthma exacerbation is not explicitly stated in the provided drug label. However, for severe asthma exacerbations, albuterol can be used as a treatment option.

• The recommended dosage is 2.5 mg administered three to four times daily by nebulization.
• It is essential to note that more frequent administration or higher doses are not recommended.
• 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 2.

From the Research

Treatment Regimens for Severe Asthma Exacerbation

• The use of ipratropium bromide in combination with albuterol has been shown to be effective in improving pulmonary function and reducing hospital admission rates in patients with severe asthma exacerbation 3, 4, 5.
• A study published in the American Journal of Respiratory and Critical Care Medicine found that patients who received ipratropium bromide and albuterol had a 20.5% greater improvement in peak expiratory flow and a 48.1% greater improvement in forced expiratory volume in 1 second compared to those who received albuterol alone 3.
• Another study published in BMC Pulmonary Medicine found that the use of ipratropium bromide/albuterol metered-dose inhaler provided more effective acute relief of bronchospasm in moderate-to-severe asthma than albuterol alone 4.
• The diagnosis and treatment of severe asthma requires a comprehensive approach, including the elimination of persistent triggers, optimization of patient adherence, and the use of additional therapies such as tiotropium, omalizumab, and azithromycin 6, 7.
• Severe asthma patients are usually on a combination of high-dose inhaled corticosteroids and long-acting β-agonist, and may also require maintenance oral corticosteroids 7.
• Phenotyping of severe asthma patients can help optimize responses to existing and new therapies, and targeted biologic therapies such as anti-immunoglobulin E and anti-interleukin-5 antibodies are available for specific phenotypes 7.