What is the treatment for asthma exacerbation?

From the Guidelines

Treatment for an asthma exacerbation should prioritize the administration of systemic corticosteroids, such as prednisone 40-60 mg orally daily for 5-7 days, alongside bronchodilators like albuterol, to address both inflammation and airway constriction. The most recent and highest quality study 1 supports the use of systemic corticosteroids as the cornerstone of treatment for acute asthma exacerbations, with the goal of reducing airway inflammation and preventing further exacerbations.

Key Components of Treatment

• Systemic corticosteroids: Prednisone 40-60 mg orally daily for 5-7 days for adults (1-2 mg/kg/day for children, maximum 60 mg) to reduce airway inflammation 1.
• Bronchodilators: Albuterol, administered via metered-dose inhaler with spacer (2-4 puffs every 20 minutes for up to 1 hour) or nebulizer (2.5-5 mg every 20 minutes for up to 1 hour) for immediate relief.
• Supplemental oxygen: To maintain oxygen saturation ≥92%.
• Ipratropium bromide: Consider adding for moderate to severe exacerbations to enhance bronchodilation (0.5 mg by nebulizer or 4-8 puffs by MDI every 20 minutes for 1-2 hours).

Monitoring and Adjustment

Continuous monitoring of respiratory status, heart rate, and oxygen levels is essential. If symptoms do not improve or worsen despite treatment, seek emergency care immediately as mechanical ventilation may be needed. After the acute episode resolves, review and adjust the patient's maintenance therapy to prevent future exacerbations, considering the addition of inhaled corticosteroids (ICSs) if not already part of the treatment regimen 1.

From the FDA Drug Label

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 the treatment of asthma exacerbation, the drug label suggests that albuterol sulfate inhalation solution can be used to control recurring bouts of bronchospasm.

• The label recommends seeking medical advice if a previously effective dosage regimen fails to provide the usual relief, as this may indicate worsening asthma that requires reassessment of therapy 2.
• Key points to consider are:
  • Continuing use of albuterol sulfate inhalation solution as medically indicated
  • Monitoring for signs of worsening asthma
  • Seeking medical advice if symptoms persist or worsen

From the Research

Treatment for Asthma Exacerbation

• Asthma exacerbation is defined as a progressive increase in symptoms of shortness of breath, cough, or wheezing sufficient to require a change in therapy 3
• Short-acting β2 agonists and short-acting muscarinic antagonists are effective as bronchodilators for asthma in the acute setting 3, 4
• Systemic corticosteroids to reduce airway inflammation continue to be the mainstay therapy for asthma exacerbations, and, unless there is a contraindication, the oral route is favored 3, 4, 5

Management Strategies

• Asthma action plans help patients triage and manage symptoms at home 5
• 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 5
• 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 5

Adjunct Treatments

• The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 5
• Nebulized magnesium should not be routinely used in acute asthma, but intravenous magnesium sulfate may be considered in selected cases, particularly in severe exacerbations 3, 4
• Methylxanthines have a minimum role as therapy for asthma exacerbations but may be considered in refractory cases of status asthmaticus with careful monitoring of toxicity 3

Hospital Management

• Patients needing admission to the hospital require continued monitoring and systemic therapy similar to treatments used in the emergency department 5
• 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 5
• The use of adjunct interventions for patients with severe asthma exacerbations varies widely across U.S. hospitals, but hospitals generally fall into two clusters differentiated primarily by the use of invasive or noninvasive mechanical ventilation 6