What is the initial treatment for acute asthma exacerbation?

Initial Treatment for Acute Asthma Exacerbation

The initial treatment for acute asthma exacerbation should include high-dose short-acting beta agonists (SABA) such as albuterol via nebulizer or metered-dose inhaler with spacer, along with early administration of systemic corticosteroids. 1

Assessment of Severity

Before initiating treatment, rapidly assess the severity of the exacerbation:

• Severe asthma features:

  • Too breathless to complete sentences in one breath
  • Respiratory rate >25 breaths/min
  • Heart rate >110 beats/min
  • PEF <50% of predicted normal or best 2

• Life-threatening features:

  • PEF <33% of predicted normal or best
  • Silent chest, cyanosis, or feeble respiratory effort
  • Exhaustion, confusion, or coma
  • Bradycardia or hypotension 2

Immediate Treatment Algorithm

Step 1: Oxygen and Bronchodilators

• Administer high-flow oxygen via face mask to maintain SaO₂ >92% (>95% in pregnant women and patients with heart disease) 1
• Give SABA for inhalation:
  • Nebulizer option: Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 2
  • MDI option: Multiple actuations of albuterol MDI into a large spacer device (2 puffs 10-20 times) 2
  • For children: Use half doses in very young children 2

Step 2: Systemic Corticosteroids (Start Early)

• Adults: Prednisolone 30-60 mg orally or intravenous hydrocortisone 200 mg immediately 2, 1
• Children: Prednisolone 1-2 mg/kg body weight (maximum 40 mg) 2

Step 3: Add Ipratropium for Severe Cases

• Add ipratropium 0.5 mg to the nebulized β-agonist (for adults) 2, 1
• For children: Add ipratropium 100 μg nebulized 6 hourly 2

Monitoring Response

• Repeat PEF measurement 15-30 minutes after starting treatment 2, 1
• Monitor oxygen saturation continuously 1
• Chart PEF before and after each β-agonist treatment 2
• Reassess after initial 3 doses of bronchodilator (60-90 minutes after treatment initiation) 1

Subsequent Management Based on Response

If Improving:

• Continue oxygen
• Continue prednisolone/hydrocortisone
• Continue nebulized β-agonist every 4-6 hours 2

If Not Improving After 15-30 Minutes:

• Continue oxygen and steroids
• Increase frequency of nebulized β-agonist (up to every 15-30 minutes) 2
• Continue ipratropium with nebulizer every 6 hours until improvement starts 2

For Life-Threatening Features or No Improvement:

• Consider IV magnesium sulfate 2g over 20 minutes 1
• Consider IV aminophylline 250 mg over 20 minutes (adults) or 5 mg/kg (children) - do not give bolus aminophylline to patients already taking oral theophyllines 2
• Arrange immediate transfer to emergency department/ICU if deteriorating 1

Important Clinical Considerations

• Metered dose inhalers with spacers can be as effective as nebulizers when sufficient puffs (6-10) are administered with proper technique 2
• Avoid sedatives of any kind in asthma exacerbations 2
• Antibiotics should be reserved only for cases with clear evidence of bacterial infection 1
• Underestimation of severity is common - patients may not appear distressed despite significant airflow obstruction 1, 3

Discharge Criteria

• Patient should have been on discharge medication for 24 hours with inhaler technique checked and recorded
• PEF >75% of predicted or best with diurnal variability <25%
• Provided with PEF meter and written self-management plan
• Follow-up with primary care provider arranged within 1 week
• Follow-up appointment in respiratory clinic within 4 weeks 2

The evidence strongly supports this approach to initial management of acute asthma exacerbations, with particular emphasis on early administration of both bronchodilators and systemic corticosteroids to rapidly improve airflow obstruction and address underlying inflammation.