What is the treatment for an asthma exacerbation secondary to an upper respiratory infection (URI) lasting 5 days?

Treatment of Asthma Exacerbation Secondary to URI

For an asthma exacerbation secondary to an upper respiratory infection lasting 5 days, treatment should include short-acting beta-agonists (SABAs), systemic corticosteroids, and consideration of anticholinergics for moderate to severe cases. 1, 2

Initial Assessment and Classification

Determine the severity of the exacerbation based on:

• Dyspnea severity
• Peak expiratory flow (PEF) measurements
• Oxygen saturation

Severity classification:

• Mild: Dyspnea only with activity, PEF ≥70% of predicted/personal best
• Moderate: Dyspnea interfering with usual activity, PEF 40-69% of predicted/personal best
• Severe: Dyspnea at rest, PEF <40% of predicted/personal best 2

First-Line Treatment

1. Short-Acting Beta-Agonists (SABAs)

• Mild exacerbation: Albuterol 2-4 puffs via MDI with spacer every 20 minutes for the first hour
• Moderate to severe exacerbation: Albuterol 2.5-5 mg nebulized or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed
• Severe exacerbation: Consider continuous nebulization at 10-15 mg/hour 1, 2

2. Systemic Corticosteroids

• Oral prednisone: 40-60 mg daily in single or 2 divided doses for 5-10 days in adults 1
• For children: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1
• No need to taper for courses less than 1 week 1
• Oral administration is as effective as intravenous for most patients 1, 3, 4

3. Anticholinergics (for moderate to severe exacerbations)

• Ipratropium bromide: Add to SABA therapy
• Adult dose: 0.5 mg nebulized or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2
• May be used for up to 3 hours in initial management 1

Oxygen Therapy

• Administer oxygen to maintain SpO₂ >90% (>95% in pregnant women and patients with heart disease) 2
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy 2

Monitoring and Reassessment

• Measure PEF 15-30 minutes after starting treatment and after each subsequent dose 2
• Reassess after initial 3 doses of bronchodilator (60-90 minutes after treatment initiation) 2

Criteria for Hospital Admission

Consider hospital admission if:

• No response or worsening after initial treatment
• PEF remains <40% of predicted after treatment
• Oxygen saturation <90% despite supplemental oxygen
• Signs of impending respiratory failure 2

Discharge Planning

When discharging a patient:

1. Ensure sustained response to bronchodilator therapy for 60 minutes
2. PEF >70% of predicted or personal best
3. Normal oxygen saturation without supplemental oxygen 2
4. Prescribe systemic corticosteroids for 5-10 days 1, 5
5. Provide written asthma action plan
6. Review inhaler technique
7. Schedule follow-up appointment within 1 week 2

Important Considerations and Pitfalls

Medication Administration

• MDI with spacer can be as effective as nebulized medications for delivering bronchodilators 1
• There is no advantage to intravenous corticosteroids over oral therapy if gastrointestinal absorption is not impaired 1, 3, 4

Common Pitfalls to Avoid

1. Delaying corticosteroid administration in moderate-severe exacerbations
2. Underestimating severity due to poor perception of symptoms
3. Discharging patients too early without adequate observation
4. Failing to provide a written asthma action plan
5. Not arranging appropriate follow-up 2

URI-Specific Considerations

• Upper respiratory infections are common triggers for asthma exacerbations
• Continue controller medications during and after the exacerbation
• Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation 1

By following this treatment approach, most patients with asthma exacerbations secondary to URI will experience significant improvement within 5-10 days.