What is the initial treatment for an asthma flare?

Initial Treatment for an Asthma Flare

The initial treatment for an asthma flare should consist of high-dose inhaled beta-agonists (such as salbutamol 5 mg or terbutaline 10 mg) via nebulizer with oxygen or multiple actuations of a metered-dose inhaler with spacer, along with immediate administration of systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg). 1

Assessment of Severity

Before initiating treatment, quickly assess the severity of the asthma flare:

Features of Severe Asthma:

• Too breathless to complete sentences in one breath
• Respiratory rate >25 breaths/min
• PEF <50% of predicted normal or best
• Heart rate >110 beats/min

Life-Threatening Features:

• PEF <33% of predicted normal or best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma 1

Step-by-Step Initial Treatment Algorithm

1. Administer high-dose inhaled beta-agonists immediately:

   • Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen (in hospital setting)
   • OR via metered-dose inhaler with spacer (2 puffs repeated 10-20 times) 1
   • Metered dose inhalers with spacers are as effective as nebulizers when sufficient puffs (6-10) are administered with proper technique 1

2. Give systemic corticosteroids immediately:

   • Oral prednisolone 30-60 mg
   • OR intravenous hydrocortisone 200 mg
   • OR both in severe cases 1

3. For life-threatening features, add:

   • Ipratropium (0.5 mg) nebulized with the beta-agonist
   • Consider intravenous aminophylline (250 mg over 20 minutes) or salbutamol/terbutaline (250 μg over 10 minutes) 1

4. Provide supplemental oxygen to maintain oxygen saturation >90% 1, 2

5. Monitor response:

   • Measure peak expiratory flow 15-30 minutes after starting treatment
   • Continue oxygen therapy
   • If improving, give nebulized beta-agonist every 4 hours
   • If not improved after 15-30 minutes, give nebulized beta-agonists more frequently (up to every 15 minutes) 1

Important Considerations

Frequency of Beta-Agonist Administration

• For improving patients: nebulized beta-agonist every 4 hours
• For non-improving patients: more frequent administration (up to every 15 minutes)
• Research suggests that as-needed (ad-lib) administration of beta-agonists may be as effective as scheduled administration in hospitalized patients receiving systemic corticosteroids 3

Avoid Common Pitfalls

• Do not underestimate severity - objective measurements (peak flow, pulse oximetry) are essential as clinical assessment alone is often inaccurate 2
• Do not give bolus aminophylline to patients already taking oral theophyllines 1
• Do not administer sedatives - they are contraindicated in asthma flares 1
• Do not delay corticosteroid administration - benefits may not be seen for 6-12 hours 2
• Do not give antibiotics unless bacterial infection is present 1

Criteria for Hospital Referral

Immediate referral to hospital is indicated for:

• Any life-threatening features
• Persistent features of severe attack after initial treatment
• Peak expiratory flow <33% of predicted or best value after nebulization
• Patients seen later in the day or with recent onset of nocturnal symptoms
• Previous severe attacks, especially with rapid onset 1

Emerging Treatment Options

Recent research shows that fixed-dose combinations of albuterol-budesonide as rescue medication may reduce the risk of severe asthma exacerbations compared to albuterol alone in patients with moderate-to-severe asthma 4. However, this approach is not yet part of standard initial treatment guidelines for acute flares.

By following this systematic approach to treating asthma flares, clinicians can effectively reduce morbidity and mortality while improving patient outcomes.