From the Guidelines
Asthma exacerbation requires prompt treatment with short-acting beta-agonists (SABAs) like 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 1 hour) as first-line therapy, as recommended by the most recent guidelines 1.
Key Components of Treatment
- Oral corticosteroids should be started early for moderate to severe exacerbations, typically prednisone 40-60 mg daily for 5-7 days for adults (1-2 mg/kg/day for children, maximum 60 mg) 1.
- Oxygen should be provided to maintain saturation ≥92% 1.
- For severe exacerbations not responding to initial treatment, consider adding ipratropium bromide (0.5 mg by nebulizer or 4-8 puffs by MDI every 20 minutes for 1-2 hours), and in hospital settings, intravenous magnesium sulfate (2 g infused over 20 minutes) may help 1.
Discharge Plan
- After stabilization, patients need a discharge plan including continued controller medications, proper inhaler technique education, and a follow-up appointment within 1-2 weeks 1.
- Patients should be instructed on how to use a written asthma action plan, recognize early indicators of an exacerbation, and adjust their medications accordingly 1.
Risk Factors for Poor Asthma Outcomes
- Assess risk factors at diagnosis and periodically, at least every 1–2 years, particularly for patients experiencing exacerbations 1.
- Risk factors for poor asthma outcomes include uncontrolled asthma symptoms, medications, comorbidities, exposures, and lung function 1.
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 for asthma exacerbations include the use of inhaled corticosteroids, short-acting beta2 agonists, and long-acting beta2 agonists 2, 3, 4.
- 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.
Treatment Options
- Short-acting beta2 agonists (SABAs) are no longer recommended as the preferred reliever for patients with symptomatic asthma, due to significant safety concerns and poor outcomes 3.
- Instead, the use of a combined inhaled corticosteroid-fast acting beta agonist as a reliever is recommended 3.
- Ipratropium bromide, a quaternary anticholinergic bronchodilator, can be used as adjunctive therapy for the emergency treatment of acute asthma exacerbation 5.
- As-needed use of albuterol-budesonide has been shown to result in a significantly lower risk of severe asthma exacerbation than as-needed use of albuterol alone among patients with mild asthma 6.
Severe Asthma 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.
- 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 2.