Treatment of Asthma Exacerbation in Adults
For asthma exacerbations in adults, treatment should include short-acting beta agonists (SABAs) via nebulizer or metered-dose inhaler with spacer, systemic corticosteroids (40-60 mg prednisone daily for 5-10 days without tapering), and oxygen supplementation to maintain saturation at 92-95% for moderate to severe exacerbations. 1
Initial Assessment and Classification
Exacerbations should be classified based on severity to guide treatment:
| Classification | Symptoms | PEF Value |
|---|---|---|
| Mild | Mild symptoms, no limitation of activities | ≥80% of predicted or personal best |
| Moderate | Worsening symptoms, some limitation | 50-79% of predicted or personal best |
| Severe | Significant symptoms, significant limitation | <50% of predicted or personal best |
| Life-threatening | Severe symptoms, inability to speak, cyanosis | <25% of predicted or personal best |
Treatment Algorithm
1. Bronchodilator Therapy
Short-acting beta agonists (SABAs): First-line treatment
Ipratropium bromide: Add for moderate to severe exacerbations
- 0.5 mg via nebulizer every 20 minutes for 3 doses, then as needed 1
- Or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, then as needed
2. Corticosteroid Therapy
- Systemic corticosteroids: Required for moderate to severe exacerbations
3. Adjunctive Therapies
- Oxygen: Supplement to maintain saturation at 92-95% 1
- Magnesium sulfate: Consider for severe refractory cases
- 2 g IV over 20 minutes 1
Hospital Admission Criteria
Consider hospital admission for patients with:
- Poor response to initial therapy
- PEF or FEV1 <50% of predicted/personal best after initial treatment
- Persistent symptoms despite treatment
- Oxygen saturation <90% on room air
- History of severe exacerbations requiring intubation
- Presence of high-risk features (altered mental status, exhaustion, poor respiratory effort) 1
Discharge Criteria
Patients should only be discharged when:
- FEV1 or PEF ≥70% of predicted/personal best
- Symptoms are minimal or absent
- Stable response to bronchodilator therapy for 60 minutes 1
Treatment Intervals
For most patients, albuterol via MDI with spacer can be administered at 60-minute intervals with minimal adverse effects. However, patients who show poor initial bronchodilator response should receive treatments at 30-minute intervals for optimal care 3.
Emerging Therapies
Recent evidence supports the use of fixed-dose combination inhalers containing both a corticosteroid and a fast-acting beta-agonist (FABA) as rescue therapy. Albuterol-budesonide combination has been shown to reduce the risk of severe asthma exacerbations by 26% compared to albuterol alone 4.
Post-Exacerbation Management
Before discharge:
- Provide a written asthma action plan
- Ensure proper inhaler technique
- Arrange follow-up with primary care within 1 week
- Consider referral to specialist for patients with:
Common Pitfalls to Avoid
- Delaying corticosteroid administration: Steroids should be given early as benefits may take 6-12 hours to appear 5
- Underestimating severity: Physician subjective assessments are often inaccurate; use objective measures like PEF 5
- Premature discharge: Ensure patients meet all discharge criteria to prevent relapse
- Inadequate follow-up: Ensure proper transition of care with clear follow-up plans
- Overlooking triggers: Approximately 50% of exacerbations are attributable to upper respiratory infections; other causes include medication non-adherence, allergen exposure, and insufficient use of inhaled or oral corticosteroids 5
By following this evidence-based approach to asthma exacerbation management, clinicians can effectively reduce morbidity and mortality while improving quality of life for patients with asthma.