From the Guidelines
Asthma exacerbation requires immediate treatment with oxygen, inhaled beta-2 agonists, and systemic corticosteroids to reduce morbidity, mortality, and improve quality of life. The management of asthma exacerbations involves a step-wise approach, starting with the assessment of the severity of the exacerbation. According to the guidelines from the National Asthma Education and Prevention Program Expert Panel Report 3 1, primary treatment consists of administration of oxygen, inhaled beta-2 agonists, and systemic corticosteroids.
Key Components of Treatment
- Oxygen should be provided to maintain saturation ≥92% 1
- Inhaled beta-2 agonists, such as albuterol, should be administered via metered-dose inhaler with spacer or nebulizer for immediate bronchodilation
- Systemic corticosteroids, such as prednisone, should be started early, typically 40-60 mg daily for 5-7 days for adults or 1-2 mg/kg/day (maximum 60 mg) for children 1
- For moderate to severe exacerbations, add ipratropium bromide to enhance bronchodilation
Monitoring and Follow-up
- Patients should be monitored for improvement in symptoms, oxygen saturation, and peak flow measurements
- If symptoms persist or worsen despite initial treatment, or if the patient has severe respiratory distress, low oxygen saturation (<90%), or poor response to therapy, immediate medical attention in an emergency department is necessary 1
- Following an exacerbation, review and adjust the long-term asthma management plan, ensure proper inhaler technique, identify and address triggers, and schedule follow-up within 1-2 weeks 1
The British Thoracic Society guidelines 1 also provide recommendations for the management of severe asthma attacks, including the use of intravenous hydrocortisone, high flow oxygen, and salbutamol or terbutaline via an oxygen-driven nebulizer. However, the more recent guidelines from the National Asthma Education and Prevention Program Expert Panel Report 3 1 take precedence in guiding clinical practice.
From the Research
Asthma Exacerbation Management
- Asthma exacerbations are defined as a deterioration in baseline symptoms or lung function, causing significant morbidity and mortality 2
- Management strategies include the use of asthma action plans, inhaled corticosteroids, and short-acting beta2 agonists
Treatment Options
- In patients 12 years and older, home management includes an inhaled corticosteroid/formoterol combination or a short-acting beta2 agonist 2
- In children four to 11 years of age, an inhaled corticosteroid/formoterol inhaler can be used to reduce the risk of exacerbations and need for oral corticosteroids 2
- Continuous nebulization of albuterol is a relatively new administration technique for treating patients with unresponsive asthma, offering advantages such as greater penetration of drug into the lung and reduced bronchospasm 3
Severe Exacerbations
- 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 2
- The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 2
Comparison of Treatment Methods
- A randomized controlled clinical trial found that nebulized albuterol with heliox versus albuterol nebulization in acute asthma exacerbation resulted in significantly better control of asthma attacks in the short term 4
- A systematic review with meta-analysis found no significant differences between metered-dose inhalers with a spacer and nebulization for the delivery of albuterol in pediatric patients with asthma exacerbations, but a significant reduction in the pulmonary index score and a smaller increase in heart rate were found with metered-dose inhalers 5
Combination Therapy
- Combination of inhaled corticosteroids plus other medications, such as long-acting beta2 agonists, leukotriene receptor antagonists, and theophylline, can be used in the management of moderate to severe persistent asthma 6