What is the immediate treatment for a patient with asthma exacerbation and peribronchial thickening on Chest X-ray (CXR)?

From the Guidelines

The immediate treatment for a patient with asthma exacerbation and peribronchial thickening on CXR involves administering a short-acting beta-agonist (SABA) such as albuterol via nebulizer (2.5-5 mg) or metered-dose inhaler with spacer (4-8 puffs) every 20 minutes for the first hour, accompanied by systemic corticosteroids like prednisone (40-60 mg orally) or methylprednisolone (60-125 mg IV) if the patient is unable to take oral medications, as recommended by the National Asthma Education and Prevention Program Expert Panel report 3 guidelines for the management of asthma exacerbations 1.

The treatment approach should be based on the severity of the exacerbation, with the dose and frequency of administration, along with the frequency of patient monitoring, dependent on the severity of the exacerbation.

• Key considerations include:
  • Supplemental oxygen to maintain oxygen saturation above 92%
  • Addition of ipratropium bromide (0.5 mg via nebulizer or 4-8 puffs via MDI) to the albuterol treatments for moderate to severe exacerbations
  • Continuous monitoring of vital signs, oxygen saturation, and response to therapy
  • Peribronchial thickening on CXR indicates airway inflammation, supporting the diagnosis of asthma exacerbation and the need for anti-inflammatory treatment with corticosteroids

After initial stabilization, a step-down approach with continued bronchodilators, oral corticosteroids (typically prednisone 40-60 mg daily for 5-7 days), and arrangement of follow-up care within 1-2 weeks is recommended to prevent relapse, as suggested by the guidelines 1.

It is essential to note that the British Thoracic Society guidelines also emphasize the importance of immediate treatment for severe asthma, including oxygen therapy, salbutamol via nebulizer, and prednisolone tablets or intravenous hydrocortisone 1. However, the most recent and highest quality study, which is the National Asthma Education and Prevention Program Expert Panel report 3 guidelines for the management of asthma exacerbations 1, should be prioritized in guiding the treatment approach.

From the FDA Drug Label

The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm 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. Ipratropium Bromide Inhalation Solution can be mixed in the nebulizer with albuterol or metaproterenol if used within one hour

The immediate treatment for a patient with asthma exacerbation and peribronchial thickening on Chest X-ray (CXR) may include the use of albuterol and ipratropium via nebulization, as these medications can help control bronchospasm.

• Albuterol can be administered at a dosage of 2.5 mg three to four times daily by nebulization 2.
• Ipratropium can be mixed with albuterol in the nebulizer if used within one hour 3. If a previously effective dosage regimen fails to provide relief, medical advice should be sought immediately, as this may indicate worsening asthma 2.

From the Research

Immediate Treatment for Asthma Exacerbation with Peribronchial Thickening on CXR

• The immediate treatment for a patient with asthma exacerbation and peribronchial thickening on Chest X-ray (CXR) involves the use of inhaled corticosteroids (ICS) and long-acting beta-agonists (LABAs) as combination therapy 4.
• According to the study by 5, home management of asthma exacerbations includes the use of an inhaled corticosteroid/formoterol combination for patients not using an inhaled corticosteroid/long-acting beta2 agonist inhaler for maintenance.
• In the office setting, assessment of exacerbation severity and initiation of a short-acting beta2 agonist and oxygen to maintain oxygen saturations is crucial, along with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 5.
• 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, with the addition of a short-acting muscarinic antagonist and magnesium sulfate infusion associated with fewer hospitalizations 5.

Role of Inhaled Corticosteroids and Long-Acting Beta-Agonists

• Inhaled corticosteroids (ICS) form the basis for treatment of asthma of all severities, improving asthma control, lung function, and preventing exacerbations of disease 4.
• The addition of long-acting beta-agonist (LABA) therapy with ICS increases the efficacy of ICS effects in moderate-to-severe asthma, with a reduction in severe exacerbation rates and improvement in lung function 4, 6.
• The combination of an ICS and LABA is preferred in patients with moderate persistent asthma, and this combination is better than doubling or even quadrupling the dose of ICS to achieve better asthma control and reduce exacerbation risks 6.

Treatment Outcomes and Tolerability

• Single inhaler combination regimens (budesonide/formoterol and fluticasone/salmeterol) were frequently more effective in improving all treatment outcomes than either monotherapy alone, with no significant differences in tolerability profiles reported between the ICS and LABA options 7.
• The use of fluticasone was associated with significantly greater improvement in lung function and better asthma symptom control than budesonide, while formoterol was associated with significantly greater improvement in lung function and better asthma symptom control compared with salmeterol 7.