From the Guidelines
Treatment for acute asthma exacerbation should start with a short-acting beta-agonist (SABA) like albuterol (salbutamol) via metered-dose inhaler with spacer or nebulizer, and systemic corticosteroids should be added early to reduce inflammation, as recommended by the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations 1.
Key Components of Treatment
- Bronchodilators: Start with a SABA like albuterol (salbutamol) via metered-dose inhaler with spacer or nebulizer, typically 2-4 puffs every 20 minutes for the first hour or 2.5 mg via nebulizer every 20 minutes for 3 doses.
- Systemic Corticosteroids: Add early, such as prednisone 40-60 mg orally daily for 5-7 days for adults (1-2 mg/kg/day for children, maximum 60 mg) to reduce inflammation, as supported by the guidelines 1.
- Supplemental Oxygen: Consider adding to maintain oxygen saturation above 92%, especially in moderate to severe exacerbations.
- Ipratropium Bromide: May be added for moderate to severe exacerbations, 0.5 mg via nebulizer or 4-8 puffs via MDI every 4-6 hours.
Escalation of Care
If there's inadequate response to initial treatment, consider:
- Magnesium sulfate (2 g IV over 20 minutes for adults) 1
- More aggressive bronchodilator therapy
- Hospitalization
Monitoring and Follow-up
Continuous monitoring of response through symptom assessment, peak flow measurements, and oxygen saturation is essential, as emphasized in the guidelines 1.
Important Considerations
- There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1.
- The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days, and for courses of less than 1 week, there is no need to taper the dose 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
The treatment for acute asthma exacerbation is albuterol inhalation solution administered by nebulization. The recommended dosage is 2.5 mg for adults and children weighing at least 15 kg, administered three to four times daily. For children weighing less than 15 kg, a lower dose of 0.5% albuterol inhalation solution may be used. If symptoms persist or worsen, medical advice should be sought immediately 2.
From the Research
Treatment for Acute Asthma Exacerbation
The treatment for acute asthma exacerbation typically involves the use of inhaled, short-acting beta-agonists and systemic corticosteroids 3. The following are key points to consider:
- Inhaled short-acting beta-agonists provide symptom relief with a rapid onset of bronchodilation, and protect against exercise-induced asthma and the early asthmatic response to allergen 4.
- Systemic corticosteroids are used to reduce inflammation in the airways 3, 5.
- The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 5.
- A fixed-dose combination of albuterol and budesonide, as compared with albuterol alone, as rescue medication might reduce the risk of severe asthma exacerbation 6.
Medication Options
Some medication options for acute asthma exacerbation include:
- Short-acting beta-agonists (e.g. albuterol) 3, 4, 5, 6
- Systemic corticosteroids 3, 5
- Inhaled corticosteroids (e.g. budesonide) 5, 6
- Long-acting beta-agonists (e.g. salmeterol, formoterol) 4, 5
- Anticholinergic agents (e.g. ipratropium bromide) 7
Treatment Strategies
Treatment strategies for acute asthma exacerbation may involve:
- Home management with an inhaled corticosteroid/formoterol combination or a short-acting beta2 agonist 5
- Office-based treatment with a short-acting beta2 agonist and oxygen, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 5
- Hospital-based treatment with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 5