From the Guidelines
The approach to a patient with an acute asthma exacerbation requires prompt assessment and stepwise treatment, starting with administration of oxygen, inhaled short-acting beta-agonists, and systemic corticosteroids, as recommended by the National Asthma Education and Prevention Program Expert Panel report 3 guidelines for the management of asthma exacerbations 1.
Initial Assessment and Treatment
The initial assessment should include evaluating the severity of the exacerbation through vital signs, oxygen saturation, work of breathing, and mental status.
- Administer oxygen to maintain saturation above 92%
- Give short-acting beta-agonists (albuterol 2.5-5mg via nebulizer or 4-8 puffs via MDI with spacer) every 20 minutes for the first hour, as this is the most effective means of reversing airflow obstruction 1.
- Add ipratropium bromide (0.5mg nebulized or 4-8 puffs) for moderate to severe exacerbations, as it has been shown to reduce hospital admissions, particularly in patients with severe exacerbations 1.
- Start systemic corticosteroids early (prednisone 40-60mg orally or methylprednisolone 60-125mg IV) to reduce inflammation, as their anti-inflammatory effects may not be apparent for 6 to 12 hours 1.
Ongoing Management and Discharge Planning
- Monitor response through clinical assessment, peak flow measurements, and oxygen saturation.
- Hospitalization is indicated for patients with persistent hypoxemia, significant work of breathing, or poor response to treatment.
- After stabilization, ensure the patient has a clear discharge plan including:
- Continued corticosteroids (typically prednisone 40-60mg daily for 5-7 days) to reduce the risk of recurrence 1.
- Optimized controller medications.
- Inhaler technique review.
- A written asthma action plan, which should include self-monitoring, assessing level of asthma control, and recognizing early signs and symptoms of worsening asthma 1.
Special Considerations
- For severe exacerbations unresponsive to initial therapy, consider magnesium sulfate (2g IV over 20 minutes), continuous albuterol nebulization, and possibly epinephrine (0.3-0.5mg IM) if anaphylaxis is suspected.
- Consultation with or co-management by a physician expert in ventilator management is essential for patients requiring mechanical ventilation, as ventilation of patients with severe asthma is complicated and risky 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.
The approach to a patient with an acute asthma exacerbation involves administering albuterol by nebulization as indicated. Key points include:
- Administering the recommended dose of 2.5 mg of albuterol three to four times daily
- Continuing use as medically indicated to control recurring bouts of bronchospasm
- Seeking medical advice immediately if a previously effective dosage regimen fails to provide the usual relief, as this may indicate worsening asthma 2
From the Research
Approach to Acute Asthma Exacerbation
The approach to a patient with an acute asthma exacerbation involves a combination of clinical assessment, diagnostic testing, and pharmacological treatment.
- The diagnosis of asthma is primarily clinical, based on historical features and clinical examination findings 3.
- The severity of asthma exacerbations is determined by clinical presentation, peak expiratory flow rates, and vital signs 3.
Initial Treatment
The mainstay of initial treatment for acute asthma exacerbation includes:
- Short-acting beta agonist therapy (albuterol) 4, 5, 3, 6, 7
- Systemic corticosteroids 4, 5, 3, 6
- Inhaled anticholinergics, such as ipratropium bromide, which may reduce airway obstruction and hospital admissions 3, 6
- Magnesium sulfate, which may provide benefits in severe asthma 4, 6
Delivery of Beta Agonists
- Beta agonists can be delivered via nebulizer or metered-dose inhaler with spacer device, with similar efficacy 6
- Ad-lib administration of albuterol is therapeutically as effective as regular, scheduled administration, and reduces the total dose of beta-agonists received by the hospitalized patient 5
Additional Therapies
- Noninvasive positive pressure ventilation may be utilized in patients with moderate to severe exacerbations 4, 3
- Ketamine may be considered in severe exacerbations, but should not be used routinely 4, 3
- Intravenous fluids should be administered to prevent dehydration and hypotension 4