What is the treatment for an asthma exacerbation?

From the Guidelines

The treatment for an asthma exacerbation involves prompt use of inhaled short-acting beta-agonists (SABAs) like albuterol, often delivered via a metered-dose inhaler with a spacer or nebulizer, and oral corticosteroids such as prednisone to reduce inflammation. According to the most recent and highest quality study 1, the classification of severity of exacerbations has been simplified, and the use of adjunctive therapies such as magnesium sulfate or heliox is recommended for severe exacerbations unresponsive to initial treatments.

Key Treatment Components

• Inhaled SABAs like albuterol (2-4 puffs every 20 minutes for the first hour, then as needed) to relax airway smooth muscles
• Oral corticosteroids such as prednisone (40-60 mg daily for 5-7 days for adults) to reduce inflammation
• Supplemental oxygen to maintain oxygen saturation above 92%
• Consideration of additional medications like ipratropium bromide (Atrovent) for severe exacerbations
• Magnesium sulfate (2 grams IV over 20 minutes) for severe cases not responding to initial therapy, as recommended by 1

Important Considerations

• The dose of corticosteroids should not be tapered for courses of less than 1 week, and probably not for courses up to 10 days, especially if patients are concurrently taking inhaled corticosteroids (ICSs) 1
• ICSs can be started at any point in the treatment of an asthma exacerbation 1
• Heliox-driven albuterol nebulization can be considered for severe exacerbations, but its use is conditional and requires further study 1
• Consultation with or co-management by a physician expert in ventilator management is essential for patients with severe asthma, as ventilation can be complicated and risky 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 treatment for an asthma exacerbation is albuterol inhalation solution, with a usual dosage of 2.5 mg administered three to four times daily by nebulization for adults and children weighing at least 15 kg 2.

• The dosage may vary depending on the patient's weight and response to treatment.
• It is essential to follow the recommended dosage and administration instructions to ensure effective treatment and minimize potential side effects.
• 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 2.

From the Research

Asthma Exacerbation Treatment

• The mainstay of asthma treatment includes short-acting beta agonist therapy (albuterol) and steroids 3.
• Inhaled ipratropium decreases hospitalization rates, and it should be routinely used 3.
• Noninvasive positive pressure ventilation may be utilized in patients with moderate to severe exacerbations 3.
• Ketamine may be considered in severe exacerbations, but it should not be used routinely 3.
• Magnesium sulfate may be beneficial in severe asthma exacerbations, but routine use for mild to moderate exacerbations is not indicated 3.

Management Strategies

• Asthma action plans help patients triage and manage symptoms at home 4.
• 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 4.
• 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 4.

Treatment Options

• 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 5.
• Long acting beta-agonists salmeterol and formoterol provide more prolonged bronchodilation, greater reduction of symptoms, increased lung function and reduced need for short acting beta-agonists 5.
• Combination therapy, including inhaled corticosteroids and long-acting β2-agonists, is effective in patients for whom inhaled corticosteroids alone are insufficient 6.
• Fixed-dose combination inhalers containing both a steroid and a fast-acting beta₂-agonist (FABA) in the same device simplify inhalers regimens and ensure symptomatic relief is accompanied by preventative therapy 7.

Severity Assessment

• The severity of asthma exacerbations is determined by 3 features: (1) clinical presentation, (2) peak expiratory flow rates, and (3) vital signs 3.
• Spirometry aids in the diagnosis of asthma and measurement of severity, but it is not always required, nor should it be solely relied upon to make disposition decisions 3.