What is the best treatment for a patient experiencing a severe asthma attack?

From the Guidelines

The best way to treat a severe asthma attack is to administer high-dose inhaled short-acting beta-agonists (SABAs) immediately, along with systemic corticosteroids. Start with 4-8 puffs of albuterol (salbutamol) via a metered-dose inhaler with a spacer, or 2.5-5 mg via nebulizer, repeated every 20 minutes for the first hour, as recommended by the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations 1. Simultaneously, give oral prednisone 40-60 mg or intravenous methylprednisolone 60-80 mg, as suggested by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. Provide supplemental oxygen to maintain oxygen saturation above 92%, and monitor the patient closely for improvement in symptoms and peak expiratory flow rate. Some key points to consider in the management of severe asthma attacks include:

• The use of ipratropium bromide (0.5 mg nebulized or 4-8 puffs via MDI) as an adjunct therapy, especially in patients with severe exacerbations, as indicated by the Journal of Allergy and Clinical Immunology 1.
• The potential benefits of continuous nebulized albuterol, intravenous magnesium sulfate (2 g over 20 minutes), and intramuscular epinephrine (0.3-0.5 mg) in life-threatening attacks, as discussed in the Journal of Allergy and Clinical Immunology 1.
• The importance of close monitoring to assess response and escalate treatment if needed, as emphasized by the British Thoracic Society and other organizations 1. It is essential to prioritize the patient's safety and well-being, and to be prepared to transfer them to an intensive care unit if necessary, as recommended by the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma 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.

The best treatment for a patient experiencing a severe asthma attack is to administer 2.5 mg of albuterol by nebulization as indicated in the dosage instructions. If the patient's symptoms do not improve or worsen, medical advice should be sought immediately 2.

From the Research

Treatment Options for Severe Asthma Attack

• The first treatment for a patient experiencing a severe asthma attack is oxygen to overcome hypoxemia 3
• Beta-2 agonists should always be given with oxygen to prevent a decrease in oxygen saturation due to increased blood flow in relatively poor ventilated areas of the lung 3
• Oral prednisolone is the treatment of choice for the most severe asthma exacerbations, given together with oxygen and beta-2 agonists 3
• High-dose inhaled corticosteroids are at least as effective as oral corticosteroids in controlling moderate-to-severe asthma attacks, especially in children, and are associated with less cortisol suppression 3

Medications for Acute Asthma

• Beta agonists and systemic corticosteroids are the cornerstones of initial treatment for acute asthma 4
• Delivery of beta agonists via nebulizer or metered-dose inhaler with spacer device appear to be similarly efficacious 4
• Addition of ipratropium bromide to early beta agonist treatments may reduce airway obstruction and reduce hospital admissions, especially for more severe asthma 4
• Intravenous magnesium sulfate may provide similar benefits in severe asthma 4

Management of Acute Severe Asthma

• Close observation plus aggressive administration of bronchodilators (SABAs plus ipratropium bromide via a nebulizer driven by oxygen) and oral or intravenous corticosteroids are necessary to arrest the progression to severe hypercapnic respiratory failure 5
• Adjunctive therapies (intravenous magnesium sulfate and/or others) should be considered in order to avoid intubation 5
• The decision to intubate is essentially based on clinical judgement, with factors such as exhaustion, deteriorating mental status, refractory hypoxaemia, and increasing hypercapnia indicating a higher likelihood of intubation 5

Role of Beta-Agonists in Asthma Treatment

• Short acting beta-agonists provide symptom relief with a rapid onset of bronchodilation, and protect against exercise-induced asthma and the early asthmatic response to allergen 6
• High doses of short acting beta-agonist in combination with oxygen and corticosteroid therapy remains the most appropriate treatment for acute severe asthma in the emergency room situation 6
• Long acting beta-agonists provide more prolonged bronchodilation, greater reduction of symptoms, increased lung function and reduced need for short acting beta-agonists 6

Inhaled Therapy for Acute Adult Asthma

• High-flow oxygen can be associated with hypercarbia, and full humidification of the inspired gases should be recommended 7
• Specific short-acting inhaled beta(2)-agonists are the drugs of choice, with a more rapid and profound bronchodilatation achieved when sufficient doses are given using pressurized meter dose inhalers and large-volume valved-spacers 7
• High and repetitive doses of ipratropium bromide in combination with beta(2)-agonists are indicated as first line treatment of severe acute asthma 7