Management of Acute Asthma Exacerbation with Leukocytosis
For acute asthma exacerbation with leukocytosis (WBC 17), treatment should focus on standard asthma management protocols with oxygen, inhaled beta-agonists, and systemic corticosteroids, as leukocytosis is commonly seen in asthma exacerbations and does not typically require specific antibiotic treatment unless there is clear evidence of bacterial infection. 1
Initial Assessment and Classification
Assess severity based on:
- Ability to speak in complete sentences
- Respiratory rate (>25/min indicates severe exacerbation)
- Heart rate (>110/min indicates severe exacerbation)
- Peak expiratory flow (PEF) measurement (<50% predicted indicates severe exacerbation)
- Oxygen saturation (<90% indicates severe hypoxemia)
Life-threatening features to identify:
- PEF <33% of predicted/best
- Silent chest, cyanosis, feeble respiratory effort
- Bradycardia or hypotension
- Exhaustion, confusion, or coma 1
Treatment Algorithm
Step 1: Immediate Management
- Administer oxygen to maintain SaO₂ >90% (>95% in pregnant women and patients with heart disease) 1
- Give inhaled short-acting β₂-agonist (albuterol 5 mg or terbutaline 10 mg) via nebulizer with oxygen as driving gas 1
- Administer systemic corticosteroids:
- Oral prednisolone 30-60 mg for adults
- Prednisolone 1-2 mg/kg (maximum 40 mg) for children 1
Step 2: Reassess after 15-30 minutes
If improving (PEF >50-75% predicted):
- Continue oxygen therapy
- Continue nebulized β₂-agonist every 4 hours
- Continue oral corticosteroids
If not improving or life-threatening features present:
Step 3: Further Management
- Monitor response with repeated PEF measurements
- Maintain oxygen saturation >92% 1
- Continue systemic corticosteroids (typically for 5-7 days)
- Increase frequency of nebulized β₂-agonist up to every 30 minutes if needed 1
Addressing Leukocytosis
Modest leukocytosis (elevated WBC) is common in asthma exacerbations and does not necessarily indicate infection 1. The inflammatory response in asthma frequently involves leukocytosis as part of the Th2 lymphocyte-mediated inflammation 3.
When to Consider Antibiotics:
- Only when there is strong evidence of bacterial infection such as:
- Pneumonia on chest X-ray
- Clinical signs of sinusitis
- Purulent sputum with fever 1
Hospital Admission Criteria
Consider hospital admission if:
- Life-threatening features present
- PEF <33% of predicted after initial treatment
- Multiple features of severe asthma persist after treatment
- Poor response to treatment after 1-2 hours
- Unable to maintain oxygen saturation >92% 1
Discharge Criteria
Patients may be discharged when:
- PEF >75% of predicted or best
- Minimal symptoms
- Stable on discharge medications for at least 24 hours
- Patient has demonstrated proper inhaler technique
- Follow-up arranged within 1 week 1
Important Considerations
Medication Dosing: For adults, albuterol should be administered at 5 mg via nebulizer or 4-12 puffs via MDI with spacer every 20-30 minutes for the first hour, then as needed based on response 1, 4.
Common Pitfalls to Avoid:
- Underestimating severity of exacerbation
- Delaying corticosteroid administration
- Overreliance on subjective symptoms without objective measures
- Unnecessary antibiotic use for asthma with leukocytosis alone 1
Evidence for Ipratropium: Adding ipratropium bromide to albuterol has been shown to reduce hospital admission rates by 49% in severe exacerbations, with greatest benefit in patients with FEV₁ ≤30% predicted 5.
By following this structured approach, you can effectively manage acute asthma exacerbations with leukocytosis while focusing on the treatments that will most significantly impact morbidity, mortality, and quality of life.