What is the management of acute asthma exacerbation?

From the Guidelines

Management of acute asthma exacerbation requires prompt assessment and stepwise treatment, with the primary goal of reducing morbidity, mortality, and improving quality of life, as outlined in the most recent guidelines 1. The treatment approach involves a combination of oxygen therapy, inhaled beta-2 agonists, and systemic corticosteroids, with the dose and frequency of administration varying depending on the severity of the exacerbation.

• For mild to moderate exacerbations, start with inhaled short-acting beta-agonists (SABA) like albuterol 2.5-5 mg via nebulizer or 4-8 puffs via metered-dose inhaler with spacer every 20 minutes for the first hour.
• Add systemic corticosteroids early, such as prednisone 40-60 mg orally daily for 5-7 days or methylprednisolone 40-60 mg IV if the patient cannot take oral medications.
• For severe exacerbations, provide continuous albuterol nebulization (10-15 mg/hour), add ipratropium bromide 0.5 mg via nebulizer every 4-6 hours for the first 24-48 hours, and consider magnesium sulfate 2 grams IV over 20 minutes for patients not responding to initial therapy. Supplemental oxygen should be administered to maintain oxygen saturation ≥92%, as recommended in the guidelines 1.
• Monitoring response to treatment with serial assessments of symptoms, vital signs, oxygen saturation, and peak flow measurements is crucial to adjust the treatment plan accordingly. The pathophysiology of asthma exacerbations involves airway inflammation, bronchospasm, and mucus hypersecretion, which is why treatment targets both bronchodilation (beta-agonists) and inflammation (corticosteroids) 1. After stabilization, ensure the patient has a clear discharge plan including continued controller medications, proper inhaler technique education, and a written asthma action plan to prevent future exacerbations, as this approach has been shown to improve quality of life and reduce morbidity and mortality in patients with asthma 1.

From the FDA Drug Label

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 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 management of acute asthma exacerbation with albuterol (INH) involves administering 2.5 mg of albuterol by nebulization three to four times daily. Key points to consider are:

• Continued use as medically indicated to control recurring bouts of bronchospasm
• Seeking medical advice if a previously effective dosage regimen fails to provide the usual relief, as this may indicate worsening asthma that requires reassessment of therapy 2

From the Research

Management of Acute Asthma Exacerbation

The management of acute asthma exacerbation involves a combination of therapies to relieve airflow obstruction, reduce airway inflammation, and prevent future relapses.

• The mainstay of therapy includes:
  • Inhaled, short-acting beta-agonists (SABA) such as albuterol 3, 4, 5, 6
  • Systemic corticosteroids to reduce airway inflammation 3, 4, 5, 7, 6
• Additional therapies that may be used include:
  • Anticholinergics such as ipratropium 4, 5, 7
  • Magnesium sulfate, which may be beneficial in severe asthma exacerbations 5, 7, 6
  • Helium-oxygen mixtures in patients who do not respond to standard therapies or those with severe disease 6
  • Noninvasive positive pressure ventilation in patients with moderate to severe exacerbations 5
  • Ketamine, which may be considered in severe exacerbations, but should not be used routinely 5

Assessment and Monitoring

The assessment of an asthma exacerbation involves determining the severity of the attack and evaluating the response to treatment 4.

• The severity of asthma exacerbations can be determined by:
  • Clinical presentation 5
  • Peak expiratory flow rates 5
  • Vital signs 5
• Additional testing, such as chest x-ray and blood gas measurements, may be reserved for select patients 5.

Treatment Goals

The goals of managing an asthma exacerbation include:

• Prompt recognition and rapid reversal of airflow obstruction 7
• Avoidance of relapses 7
• Prevention of future episodes 7
• Maintenance of adequate arterial oxygen saturation with supplemental oxygen 4