What is the treatment for status asthmaticus?

Status Asthmaticus Treatment

Status asthmaticus requires immediate aggressive treatment with high-dose inhaled beta-agonists, systemic corticosteroids, and oxygen therapy as the cornerstone of management to prevent mortality and reduce morbidity. 1

Definition and Recognition

Status asthmaticus is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy. It is a medical emergency requiring prompt intervention.

Features of Severe/Life-Threatening Asthma:

• Too breathless to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak Expiratory Flow (PEF) <50% of predicted or best (life-threatening if <33%)
• Silent chest, cyanosis, or feeble respiratory effort
• Exhaustion, confusion, or coma 1

Immediate Treatment Algorithm

Step 1: Initial Management

• High-flow oxygen: Maintain SaO₂ >92% via face mask 1, 2
• High-dose inhaled beta-agonists:
  • Salbutamol/albuterol 5 mg (2.5 mg for young children) or terbutaline 10 mg
  • Deliver via oxygen-driven nebulizer or multiple actuations of MDI with spacer (10-20 puffs) 1, 3
• Systemic corticosteroids:
  • Adults: Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV immediately
  • Children: Prednisolone 1-2 mg/kg (maximum 60 mg) or IV hydrocortisone 1, 2

Step 2: For Life-Threatening Features

• Add ipratropium bromide: 0.5 mg nebulized (100 μg for children) 1, 2
• Consider IV medications if no improvement after initial treatment:
  • IV aminophylline: 250 mg over 20 minutes (5 mg/kg for children) followed by maintenance infusion
  • OR IV salbutamol/terbutaline: 250 μg over 10 minutes
  • Do not give bolus aminophylline to patients already taking oral theophyllines 1

Monitoring and Assessment

1. Measure PEF 15-30 minutes after starting treatment and regularly thereafter
2. Monitor oxygen saturation continuously
3. Obtain arterial blood gases in severe cases (markers of severe attack include):
   • Normal or high PaCO₂ in a breathless patient
   • Severe hypoxia (PaO₂ <8 kPa) despite oxygen therapy
   • Low pH 1

Further Hospital Management

• Continue oxygen therapy
• Continue high-dose steroids: prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours
• If improving: nebulized beta-agonists every 4 hours
• If not improving after 15-30 minutes: increase frequency of nebulized beta-agonists (up to every 15 minutes) 1

Indications for ICU Transfer

• Deteriorating PEF
• Worsening or persistent hypoxia (PaO₂ <8 kPa) despite 60% oxygen
• Hypercapnia (PaCO₂ >6 kPa)
• Exhaustion, feeble respiration, confusion, drowsiness
• Coma or respiratory arrest 1

Indications for Mechanical Ventilation

• Worsening hypoxia or hypercapnia
• Drowsiness or unconsciousness
• Respiratory arrest
• Extreme fatigue with respiratory muscle failure 1, 4

Important Cautions

• Avoid sedation: Any sedation is contraindicated in status asthmaticus 1
• Antibiotics: Only if bacterial infection is present 1
• Monitoring for deterioration: Despite treatment, patients can deteriorate rapidly - continuous assessment is essential 5
• Avoid excessive ventilation if mechanical ventilation is required: Limit minute ventilation and prolong expiratory time to prevent air trapping and barotrauma 4

Discharge Criteria

Patients should not be discharged until:

• Symptoms have stabilized
• PEF >75% of predicted or best value
• Diurnal variability <25%
• No nocturnal symptoms 1

Discharge Medications

• Prednisolone tablets (30 mg daily) for 1-3 weeks
• Inhaled steroids at higher dosage than before admission
• Inhaled beta-agonists as needed
• Clear follow-up plan with primary care within 1 week 1

Status asthmaticus has significant mortality risk if not treated promptly and aggressively. Early recognition and implementation of this treatment algorithm can significantly improve outcomes and prevent respiratory failure.