What is the recommended treatment for outpatient asthma exacerbation?

From the Guidelines

The recommended treatment for outpatient asthma exacerbation includes short-acting beta-agonists (SABAs) like albuterol, administered via metered-dose inhaler with spacer or nebulizer every 20 minutes for the first hour, followed by oral corticosteroids such as prednisone at 40-60 mg daily for 5-7 days for adults. This treatment approach is based on the most recent and highest quality study available, which emphasizes the importance of early treatment and the use of SABAs and oral corticosteroids in managing asthma exacerbations 1.

Key Components of Treatment

• Short-acting beta-agonists (SABAs) like albuterol, administered via metered-dose inhaler with spacer or nebulizer every 20 minutes for the first hour (2-4 puffs or 2.5 mg nebulized)
• Oral corticosteroids such as prednisone at 40-60 mg daily for 5-7 days for adults (1-2 mg/kg/day for children, maximum 60 mg)
• Oxygen supplementation should be provided if oxygen saturation is below 90%
• For moderate to severe exacerbations, adding ipratropium bromide (0.5 mg nebulized or 4-8 puffs) to albuterol can provide additional bronchodilation
• Patients should continue their controller medications and be reassessed after 1 hour of initial treatment

Discharge Criteria

• If symptoms improve significantly with PEFR or FEV1 >70% of predicted or personal best, the patient can be discharged home with a written asthma action plan, continued bronchodilator therapy every 3-4 hours as needed, and follow-up within 2-5 days, as recommended by the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations 1.

Mechanism of Action

• SABAs work by relaxing bronchial smooth muscle to open airways quickly
• Corticosteroids reduce inflammation and swelling in the airways, though they take several hours to begin working
• Ipratropium provides additional bronchodilation through a different mechanism, blocking cholinergic bronchoconstriction, and its use is supported by studies indicating a reduced number of hospital admissions associated with its treatment, particularly in patients with severe exacerbations 1.

Home Management

• Patients should be instructed on how to use a written asthma action plan, recognize early indicators of an exacerbation, adjust their medications, and monitor their response to treatment, as outlined in the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 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

The recommended treatment for outpatient asthma exacerbation is albuterol inhalation solution administered three to four times daily by nebulization, with a dosage of 2.5 mg for adults and children weighing at least 15 kg. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately 2.

From the Research

Outpatient Asthma Exacerbation Treatment

The recommended treatment for outpatient asthma exacerbation involves a combination of medications and therapies. The following are some key points to consider:

• Intravenous Magnesium Sulfate: A study published in 2014 3 found that intravenous magnesium sulfate reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulised short-acting beta2-agonists, and IV corticosteroids.
• Inhaled Magnesium Sulfate: A 2017 study 4 suggested that inhaled magnesium sulfate may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but the confidence in the evidence is low.
• Ipratropium Bromide: Research from 2001 5 and 1998 6 indicates that ipratropium bromide, when used in conjunction with beta2-agonists, improves lung function and decreases hospitalization rates in both adults and children with acute asthma exacerbations.
• Short-Acting Beta Agonist Therapy and Steroids: A 2013 study 7 emphasizes that the mainstay of asthma treatment includes short-acting beta agonist therapy (albuterol) and steroids, with handheld inhalers being sufficient for most inhaled therapy.

Key Considerations

• The severity of asthma exacerbations should be determined by clinical presentation, peak expiratory flow rates, and vital signs.
• Additional testing, such as chest x-ray and blood gas measurements, is reserved for select patients.
• Noninvasive positive pressure ventilation and ketamine may be considered in patients with moderate to severe exacerbations, but their use should be judicious and based on individual patient needs.

Treatment Options

• Combination Therapy: Using a combination of ipratropium bromide and beta2-agonists may provide physiological evidence of benefit without risk of adverse effects.
• Nebulized Magnesium Sulfate: May be beneficial in severe asthma exacerbations, but routine use for mild to moderate exacerbations is not indicated.
• Inhaled Beta2-Agonists: The evidence for the efficacy of β₂-agonists in acute asthma is well-established, and they should be used as first-line treatment.