From the Guidelines
Status asthmaticus requires immediate and aggressive treatment to prevent respiratory failure, and the initial management should include high-flow oxygen, continuous nebulized short-acting beta-agonists, and systemic corticosteroids. The treatment approach should prioritize reducing airway inflammation, relieving bronchospasm, and supporting oxygenation until the severe attack resolves 1.
Key Components of Treatment
- High-flow oxygen to maintain oxygen saturation above 92%
- Continuous nebulized short-acting beta-agonists (albuterol 2.5-5 mg every 20 minutes for the first hour, then hourly as needed)
- Systemic corticosteroids (methylprednisolone 60-125 mg IV or prednisone 40-60 mg orally)
- Ipratropium bromide (0.5 mg nebulized every 20 minutes for 3 doses, then every 4-6 hours) should be added to bronchodilator therapy
- For patients not responding adequately, consider intravenous magnesium sulfate (2 grams over 20 minutes) which relaxes bronchial smooth muscle 1
Mechanical Ventilation and Other Considerations
Severe cases may require mechanical ventilation with lung-protective strategies using low tidal volumes and permissive hypercapnia 1. Heliox (helium-oxygen mixture) may be used to reduce airflow resistance in critical situations. Continuous cardiac monitoring, frequent reassessment of respiratory status, and arterial blood gas measurements are essential.
Discharge Planning
After stabilization, patients need a clear discharge plan with controller medications, a tapering course of oral steroids (typically prednisone 40-60 mg daily for 5-7 days), and close follow-up care 1. It is crucial to note that there is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, and the total course of systemic corticosteroids may last from 3 to 10 days 1.
From the FDA Drug Label
In controlled clinical trials, most patients exhibited an onset of improvement in pulmonary function within 5 minutes as determined by FEV1. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm The treatment for status asthmaticus may involve the use of albuterol via nebulization, with the goal of improving pulmonary function.
- The usual dosage for adults and children is 2.5 mg of albuterol administered three to four times daily by nebulization.
- It is essential to monitor patients and seek medical advice if a previously effective dosage regimen fails to provide the usual relief, as this can be a sign of worsening asthma. 2 2
From the Research
Treatment for Status Asthmaticus
The treatment for status asthmaticus typically involves a combination of medications and supportive care. Some of the key treatments include:
- Intravenously administered aminophylline, corticosteroids, nebulized beta-adrenergic agents, and oxygen 3
- Continuous nebulization of albuterol for respiratory failure 3
- Mechanical ventilation for patients who do not respond to pharmacologic therapy 3, 4, 5
- Supplemental oxygen, aerosolized albuterol, and corticosteroids as first-line treatments 6
- Second-line treatments such as intravenous aminophylline, nebulised ipratropium, high dose inhaled corticosteroids, intravenous magnesium sulphate, and inhaled helium oxygen mixtures 7
Management of Acute Severe Asthma
The management of acute severe asthma includes:
- Oxygen, continuous nebulised salbutamol, and intravenous hydrocortisone 7
- Monitoring of the patient's speech, conscious state, pulse and respiratory rate, peak expiratory flow rate, oximetry, and blood gases 7
- Admission to an intensive care unit if there is no improvement or the patient deteriorates 7
Ventilatory Management
The ventilatory management of status asthmaticus includes:
- Non-invasive ventilation (NIV) via a face mask as the primary mode of ventilatory support 5
- Invasive mechanical ventilation for patients who do not respond to NIV or have contraindications to NIV 5
- Avoiding excessive lung inflation by limiting minute ventilation and prolonging expiratory time, despite consequent hypercapnia 4