What are the management steps for acute asthma exacerbation?

From the Guidelines

Management of acute asthma exacerbation requires prompt assessment and stepwise treatment, with the most recent and highest quality study recommending the administration of a short-acting beta-agonist (SABA) like albuterol via metered-dose inhaler with spacer or nebulizer, along with systemic corticosteroids for moderate to severe exacerbations 1.

Key Management Steps

• Administer a short-acting beta-agonist (SABA) like albuterol via metered-dose inhaler with spacer (4-8 puffs every 20 minutes for up to 1 hour) or nebulizer (2.5-5 mg every 20 minutes for 1 hour) to address bronchoconstriction.
• Add systemic corticosteroids early for moderate to severe exacerbations: prednisone 40-60 mg orally daily for 5-7 days for adults or 1-2 mg/kg/day (maximum 60 mg) for children to reduce airway inflammation.
• For severe exacerbations, provide supplemental oxygen to maintain saturation ≥93% and consider adding ipratropium bromide (0.5 mg by nebulizer or 4-8 puffs by MDI every 20 minutes for 1-2 hours) to further alleviate bronchoconstriction.
• Continuous monitoring of oxygen saturation, heart rate, and respiratory rate is essential to assess the severity of the exacerbation and the response to treatment.
• For life-threatening exacerbations unresponsive to initial therapy, consider magnesium sulfate (2 g IV over 20 minutes for adults), and prepare for possible intubation.

Post-Stabilization Care

• After stabilization, create a discharge plan including continued controller medications, proper inhaler technique education, and a written asthma action plan to prevent future exacerbations and improve quality of life.
• The approach to managing acute asthma exacerbation should prioritize both bronchoconstriction (with bronchodilators) and airway inflammation (with corticosteroids), the two main pathophysiological components of asthma exacerbations, as supported by the most recent guidelines 1.

From the FDA Drug Label

To administer 2.5 mg of albuterol, administer the entire contents of one sterile unit-dose vial (3 mL of 0. 083% inhalation solution) by nebulization. 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 but not with other drugs.

The management steps for acute asthma exacerbation include:

• Administering albuterol via nebulization as directed by a physician, typically 2.5 mg three to four times daily for adults and children weighing at least 15 kg 2.
• Using ipratropium bromide inhalation solution as directed, which can be mixed with albuterol in a nebulizer if used within one hour 3.
• Seeking medical advice immediately if a previously effective dosage regimen fails to provide relief, as this may indicate worsening asthma.
• Continuing the use of albuterol sulfate inhalation solution as medically indicated to control recurring bouts of bronchospasm 2.

From the Research

Management Steps for Acute Asthma Exacerbation

The management of acute asthma exacerbation involves several steps, including:

• Assessment of the patient's condition, including history, physical examination, and measurement of lung function and oxygen saturation 4
• Administration of short-acting beta2-agonists (SABAs) as the first line of treatment, with the option of adding anticholinergics such as ipratropium bromide for enhanced bronchodilation 5, 6
• Use of systemic corticosteroids to reduce airway inflammation and prevent future relapses, with oral or parenteral administration as early as possible 4, 6
• Consideration of other treatment options, such as magnesium sulfate, heliox, and inhaled corticosteroids, although the evidence for their effectiveness is limited 4, 6
• Monitoring of the patient's response to treatment and adjustment of the treatment plan as needed, with consideration of factors such as previous history of intubation, oxygen saturation, and exacerbation triggers 7

Treatment Options

Some treatment options for acute asthma exacerbation include:

• Inhaled SABAs, such as albuterol, with or without anticholinergics like ipratropium bromide 5, 6
• Systemic corticosteroids, such as prednisone, to reduce airway inflammation and prevent future relapses 4, 6
• Combination therapy with SABAs and anticholinergics, which may provide enhanced bronchodilation and reduced risk of hospital admission 5
• Fixed-dose combination rescue inhalers, such as albuterol-budesonide, which may reduce the risk of severe asthma exacerbation 8

Factors Associated with Treatment Failure

Some factors associated with treatment failure in children with severe asthma exacerbation include:

• Previous history of intubation 7
• Receiving less than 3 doses of nebulized salbutamol in the emergency room 7
• Oxygen saturation less than 92% in the emergency room 7
• Exacerbation triggered by pneumonia 7