From the Guidelines
Asthma exacerbation management should prioritize prompt intervention with bronchodilators, corticosteroids, and supportive care to reduce morbidity, mortality, and improve quality of life. The most recent and highest quality study 1 recommends that all patients presenting with an asthma exacerbation should be evaluated and triaged immediately, with treatment instituted promptly based on the severity of the exacerbation.
Key Recommendations
- Primary treatment consists of administration of oxygen, inhaled b2-agonists, and systemic corticosteroids, with the dose and frequency of administration dependent on the severity of the exacerbation 1.
- For mild to moderate exacerbations, treatment may include albuterol (salbutamol) via metered-dose inhaler with spacer, and oral prednisone 40-60 mg daily for 5-7 days 1.
- For severe exacerbations, provide oxygen to maintain saturation ≥93%, continuous nebulized albuterol plus ipratropium bromide, and intravenous methylprednisolone 40-80 mg in divided doses 1.
- Monitor response with peak flow measurements, oxygen saturation, and clinical assessment, and hospitalization is indicated for patients with severe symptoms, oxygen saturation <90%, or poor response to initial treatment 1.
Considerations
- Infants are at greater risk for respiratory failure, and clinicians should be familiar with special considerations in the assessment and treatment of infants experiencing asthma exacerbations 1.
- After stabilization, review and adjust the patient's maintenance therapy, provide an asthma action plan, and schedule follow-up within 1-2 weeks to improve quality of life and reduce the risk of future exacerbations 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 asthma exacerbation management, the drug label suggests that albuterol can be used to control recurring bouts of bronchospasm. The recommended dosage is 2.5 mg administered 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 as this may indicate worsening asthma that requires reassessment of therapy 2.
From the Research
Asthma Exacerbation Management
- Asthma exacerbations are a common reason for presentation to the Emergency Department and are associated with significant morbidity and mortality 3
- The assessment of patients with severe asthma is based upon the clinical examination, and it is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation 3
- First line therapies for severe exacerbations include:
- Inhaled short-acting beta agonists
- Inhaled anticholinergics
- Intravenous steroids
- Magnesium 3
- Additional therapies for refractory cases include:
- Parenteral epinephrine or terbutaline
- Helium-oxygen mixture
- Consideration of ketamine 3
- In patients 12 years and older, home management includes an inhaled corticosteroid/formoterol combination for those who are not using an inhaled corticosteroid/long-acting beta2 agonist inhaler for maintenance, or a short-acting beta2 agonist for those using an inhaled corticosteroid/long-acting beta2 agonist inhaler that does not include formoterol 4
- In the office setting, it is important to assess exacerbation severity and begin a short-acting beta2 agonist and oxygen to maintain oxygen saturations, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 4
- Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 4
- The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 4
- Improvement in symptoms and forced expiratory volume in one second or peak expiratory flow to 60% to 80% of predicted values helps determine appropriateness for discharge 4