What is the recommended management for an asthma exacerbation in a patient taking Alvesco (ciclesonide), Breo Ellipta (fluticasone furoate/vilanterol), and salbutamol (albuterol)?

Management of Asthma Exacerbation in a Patient on Alvesco, Breo Ellipta, and Salbutamol

For asthma exacerbation management in a patient taking Alvesco (ciclesonide), Breo Ellipta (fluticasone furoate/vilanterol), and salbutamol (albuterol), the primary treatment should include high-dose inhaled short-acting β2-agonists (salbutamol), systemic corticosteroids, and oxygen therapy as needed. 1

Initial Assessment and Classification

First, determine the severity of the exacerbation based on:

• Speech ability (can complete sentences?)
• Respiratory rate (>25 breaths/min indicates severe)
• Heart rate (>110 beats/min indicates severe)
• Peak expiratory flow (PEF) or FEV1 (<50% of predicted/personal best indicates severe)
• Oxygen saturation (<90% indicates severe)

Severity Classification:

• Mild-to-moderate: Normal speech, respiratory rate <25/min, heart rate <110/min, PEF >50%
• Severe: Cannot complete sentences, respiratory rate >25/min, heart rate >110/min, PEF <50%
• Life-threatening: Silent chest, cyanosis, feeble respiratory effort, confusion, bradycardia, hypotension, exhaustion

Treatment Algorithm

1. Immediate Management (All Exacerbations)

• Oxygen therapy: Administer to maintain SaO2 >90% (>95% in pregnant women and those with heart disease) 1
• High-dose inhaled salbutamol:
  • Via nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then as needed
  • Via MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then as needed 1
• Systemic corticosteroids:
  • Oral prednisone: 40-60 mg daily for 5-10 days (no need to taper if course <2 weeks) 1
  • IV hydrocortisone 200 mg if unable to take oral medication or in severe cases 1

2. Additional Treatment for Moderate-to-Severe Exacerbations

• Add ipratropium bromide:
  • Via nebulizer: 0.5 mg every 20 minutes for 3 doses, then as needed
  • Via MDI: 4-8 puffs every 20 minutes for 3 doses 1

3. For Severe or Life-threatening Exacerbations

• Consider IV magnesium sulfate for patients not responding to initial treatment 1
• Continuous nebulization of salbutamol may be more effective than intermittent administration in severe cases 1
• Monitor closely: Vital signs, oxygen saturation, peak flow measurements
• Consider ICU admission if not responding to treatment or worsening

Important Considerations

Regarding Maintenance Medications

• Alvesco (ciclesonide): This is not intended for acute exacerbation management. Patient should be instructed that it's not a rescue medication 2

• Breo Ellipta (fluticasone furoate/vilanterol): Continue maintenance therapy but do not rely on this for acute symptom relief

• Salbutamol: This is the primary rescue medication and should be used at higher doses during exacerbation as outlined above

Monitoring Response

• Reassess after initial treatment (15-30 minutes):
  • If improving (PEF >50-75%): Continue treatment and monitor
  • If not improving or worsening: Intensify treatment and consider hospital admission

Hospital Admission Criteria

• Any life-threatening features
• Severe symptoms persisting after initial treatment
• PEF <33% of predicted/personal best after initial treatment
• Social factors (evening/night presentation, inability to manage at home) 1

Post-Exacerbation Management

1. Review maintenance therapy: Ensure appropriate controller medications are prescribed
2. Assess inhaler technique: Verify proper use of all inhalers
3. Provide written asthma action plan: Include when to increase treatment and seek medical help
4. Schedule follow-up: Within 24-48 hours for severe exacerbations, within 1 week for moderate ones

Common Pitfalls to Avoid

1. Underestimating severity: Objective measurements (PEF, oxygen saturation) are essential as patients and clinicians often underestimate severity
2. Delaying corticosteroid administration: Start systemic corticosteroids early in moderate-to-severe exacerbations
3. Overreliance on bronchodilators alone: Remember that asthma is an inflammatory condition requiring anti-inflammatory treatment
4. Premature discharge: Ensure substantial improvement before discharge (PEF >70% of predicted/personal best)
5. Neglecting follow-up: Arrange appropriate follow-up to adjust maintenance therapy and prevent recurrence

Remember that prompt, aggressive treatment of asthma exacerbations is essential to prevent morbidity and mortality. The combination of bronchodilators, systemic corticosteroids, and oxygen forms the cornerstone of effective management.