What is the treatment for a severe asthma attack?

Treatment of Severe Asthma Attack

The immediate treatment for a severe asthma attack requires high-dose inhaled beta-agonists (salbutamol 5mg or terbutaline 10mg), systemic corticosteroids (prednisolone 30-60mg or IV hydrocortisone 200mg), and oxygen therapy when available. 1, 2

Recognition of Severe Asthma Attack

A severe asthma attack is characterized by:

• Inability to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Peak expiratory flow (PEF) <50% of predicted or best value
• Heart rate >110 beats/min 1, 2

Life-threatening features include:

• PEF <33% of predicted or best value
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma 1

Step-by-Step Management Algorithm

1. Immediate Treatment (First 15-30 minutes)

• Administer high-flow oxygen via face mask if available 1
• Give high-dose beta-agonist:
  • Salbutamol 5mg or terbutaline 10mg nebulized with oxygen 1
  • Alternative: Multiple actuations of metered-dose inhaler (MDI) with spacer (2 puffs repeated 10-20 times) 1, 2
• Administer systemic corticosteroids immediately:
  • Adults: Prednisolone 30-60mg orally or hydrocortisone 200mg IV 1
  • Children: Prednisolone 1-2mg/kg (maximum 40mg) 1

2. For Life-Threatening Features

• Add ipratropium bromide 0.5mg nebulized to the beta-agonist 1, 2
• Consider IV aminophylline (250mg over 20 minutes) or IV salbutamol/terbutaline (250μg over 10 minutes) 1
  • Important: Do not give bolus aminophylline to patients already taking oral theophyllines 1

3. Monitoring and Assessment

• Measure arterial blood gases in hospitalized patients 1
• Warning signs of life-threatening attack:
  • Normal/high PaCO2 in a breathless patient
  • Severe hypoxia (PaO2 <8 kPa) despite oxygen therapy
  • Low pH value 1
• Arrange chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 1
• Monitor plasma electrolytes and perform blood count 1

4. Hospital Admission Criteria

• Any life-threatening features
• Persistent features of severe attack after initial treatment
• PEF <33% of predicted/best after nebulization 1, 2
• Lower threshold for admission if:
  • Attack occurs in afternoon/evening
  • Recent nocturnal symptoms
  • Previous severe attacks
  • Concerns about patient's assessment of severity
  • Inadequate home support 1

Special Considerations

For Catastrophic Sudden Severe Asthma

This unusual but high-risk group requires:

• Immediate call for help
• High-dose beta-agonist (salbutamol 5mg or terbutaline 10mg)
• Prednisolone 30-60mg
• Immediate transport to hospital 1

Children

• Use age-appropriate dosing (half doses for very young children) 1
• Spacer devices with face masks for young children 1
• Assess severity using age-appropriate criteria 2

Common Pitfalls to Avoid

1. Underestimating severity of attack (often leads to delayed treatment) 1, 3
2. Inadequate initial bronchodilator dosing 3
3. Delaying corticosteroid administration (benefits take 6-12 hours to manifest) 3, 4
4. Failing to recognize life-threatening features requiring immediate intervention 1
5. Not identifying triggers (viral infections, allergen exposure, medication non-adherence) 3, 4

Follow-up After Acute Episode

• Follow-up within 24-48 hours after acute exacerbation 2
• Provide written asthma action plan 2
• Review medication adherence and inhaler technique 2
• Schedule specialist follow-up within 4 weeks 2

Remember that severe asthma attacks are often underestimated in severity, and early aggressive treatment is essential to prevent mortality and improve outcomes.