From the Guidelines
The initial treatment for asthma patients with high driving pressures should focus on bronchodilation with short-acting beta-agonists (SABAs) such as albuterol, accompanied by systemic corticosteroids to reduce airway inflammation, and consideration of heliox-driven albuterol nebulization in severe cases.
Key Considerations
- The primary goal is to decrease airway resistance and improve lung compliance, thereby reducing the high driving pressures during asthma exacerbations 1.
- Systemic corticosteroids, such as prednisone or methylprednisolone, are essential in reducing airway inflammation, with the total course lasting from 3 to 10 days 1.
- Heliox-driven albuterol nebulization can be considered in severe cases to quickly decrease the work of breathing, although more research is needed to fully understand its benefits and limitations 1.
- Intravenous administration of β2-agonists is not recommended due to the risk of myocardial toxicity, and leukotriene modifiers or noninvasive ventilation are not supported by sufficient evidence for use in acute asthma treatment 1.
Treatment Approach
- Administer albuterol via metered-dose inhaler with spacer or as a nebulized solution every 20 minutes for the first hour.
- Provide systemic corticosteroids, such as prednisone (40-60 mg orally) or methylprednisolone (60-125 mg intravenously), to reduce airway inflammation.
- Consider adding ipratropium bromide (0.5 mg nebulized or 4-8 puffs via MDI) for severe exacerbations.
- Maintain oxygen saturation ≥92% with supplemental oxygen.
- Continuously monitor vital signs, oxygen saturation, and response to therapy, preparing for possible non-invasive positive pressure ventilation or intubation if necessary, with consultation from a physician expert in ventilator management 1.
From the FDA Drug Label
Inhaled beta-2 selective agonists and systemically administered corticosteroids are the treatments of first choice for management of acute exacerbations of asthma The initial treatment for asthma patients with high driving pressures is inhaled beta-2 selective agonists and systemically administered corticosteroids 2.
From the Research
Initial Treatment for Asthma Patients with High Driving Pressures
The initial treatment for asthma patients with high driving pressures involves a combination of medications and therapies.
- The mainstay of asthma treatment includes short-acting beta agonist therapy (albuterol) and steroids 3.
- Handheld inhalers are sufficient for most inhaled therapy, and all patients on inhalers should be provided with a spacer 3.
- Inhaled ipratropium decreases hospitalization rates and should be routinely used 3.
- Noninvasive positive pressure ventilation may be utilized in patients with moderate to severe exacerbations 3.
Medication Options
- Levalbuterol provides little to no advantage over less-expensive racemic albuterol 3, but it may improve pulmonary function to a greater extent than racemic albuterol and reduce the need for costly hospitalizations in patients with acute asthma exacerbations 4.
- Albuterol is a long-acting beta 2-adrenergic receptor-selective drug that relaxes airway smooth muscle 5.
- Aminophylline therapy does not add significant benefit to other standard therapies in hospitalized adult asthmatic patients 6, 7.
Treatment Approach
- The treatment approach for acute exacerbations involves the use of short-acting, inhaled beta2 agonists, oxygen, intravenous fluids, and corticosteroids 4.
- The severity of asthma exacerbations is determined by clinical presentation, peak expiratory flow rates, and vital signs 3.
- Additional testing, such as chest x-ray and blood gas measurements, is reserved for select patients 3.