What treatment is indicated for severe asthma exacerbation complicated by hypotension and bradycardia?

From the Guidelines

Severe asthma exacerbation complicated by hypotension and bradycardia should be treated with oxygen, inhaled β2-agonists, and systemic corticosteroids, with consideration of intravenous magnesium sulfate and close monitoring for impending respiratory failure.

Treatment Approach

• Oxygen therapy should be administered to maintain adequate oxygenation 1
• Inhaled β2-agonists, such as albuterol, should be given via nebulization or metered-dose inhaler to help relax airway muscles and improve breathing 1
• Systemic corticosteroids, such as prednisolone, should be administered to reduce airway inflammation, with a dose of 2 g over 20 minutes in adults and 25 to 75 mg/kg in children (up to a maximum of 2 g) 1
• Intravenous magnesium sulfate may be considered in patients with life-threatening exacerbations or those whose exacerbations remain severe after 1 hour of intensive conventional treatment, with a conditional recommendation 1

Monitoring and Management

• Close monitoring for signs of impending respiratory failure, such as an inability to speak, altered mental status, intercostal retraction, worsening fatigue, and a PaCO2 of 42 mm Hg or greater, is crucial 1
• Intubation should not be delayed once it is deemed necessary, and should be performed semielectively and before respiratory arrest occurs, with consideration of maintaining intravascular volume and avoiding high ventilator pressures 1
• Permissive hypercapnia or controlled hypoventilation is the recommended ventilator strategy to provide adequate oxygenation while minimizing airway pressures and the possibility of barotrauma 1

From the Research

Treatment for Severe Asthma Exacerbation

• The treatment for severe asthma exacerbation complicated by hypotension and bradycardia involves the use of short-acting β2 agonists and short-acting muscarinic antagonists as bronchodilators, as well as systemic corticosteroids to reduce airway inflammation 2.
• In severe exacerbations, intravenous magnesium sulfate may be considered as an adjunct therapy, particularly in cases where there is a need for additional treatment beyond standard therapies 2, 3.
• The use of inhaled magnesium sulfate has been studied as an adjunct to standard treatment in severe asthma crisis, and has been shown to improve lung function and reduce hospital admissions in some studies 3, 4.
• Other treatment options for severe asthma exacerbations include the use of helium-oxygen mixtures in patients who do not respond to standard therapies, and the consideration of methylxanthines in refractory cases of status asthmaticus 2, 5.
• The treatment strategy for asthma exacerbations should be aimed at resolving airflow limitation and ameliorating hypoxemia as quickly as possible, and may involve the repeated administration of rapid-acting inhaled bronchodilators, the early introduction of systemic glucocorticoids, and oxygen supplementation 6.

Key Considerations

• The choice of treatment for severe asthma exacerbation should be based on the severity of the exacerbation, the patient's response to initial treatment, and the presence of any contraindications or comorbidities 2, 5.
• The use of intravenous therapies, such as salbutamol or aminophylline, may be considered in cases where the patient is refractory to initial treatments, but the evidence for their effectiveness is not clear-cut 5.
• The treatment of severe asthma exacerbations should be individualized and based on the patient's specific needs and circumstances, and should involve close monitoring and adjustment of therapy as needed 2, 6.