What is the initial management for acute asthma exacerbation?

Acute Management of Asthma Exacerbation

The initial management for acute asthma exacerbation should include oxygen administration, inhaled short-acting beta-agonists (SABAs) such as albuterol, and systemic corticosteroids. 1

Initial Assessment and Classification

• Classify severity based on:
  • Symptoms: ability to speak, breathlessness, respiratory effort
  • Vital signs: respiratory rate, heart rate
  • Peak Expiratory Flow (PEF): <50% predicted indicates severe exacerbation
  • Life-threatening features: PEF <33% predicted, cyanosis, silent chest, fatigue, altered consciousness 1

Immediate Treatment Protocol

Step 1: Oxygen and Bronchodilators

• Administer oxygen to maintain SaO₂ >90% (>95% in pregnant women and patients with heart disease) 1
• Give nebulized albuterol (salbutamol):
  • 2.5-5 mg via oxygen-driven nebulizer every 20 minutes for first 3 doses 1
  • For severe exacerbations, continuous administration may be more effective than intermittent dosing 1
  • Alternative: 4-8 puffs via MDI with spacer every 20 minutes 1

Step 2: Corticosteroids (Start Early)

• Administer systemic corticosteroids within first hour:
  • Prednisolone 30-60 mg orally OR
  • Hydrocortisone 200 mg IV if unable to take oral medication or very ill 2, 1
• Do not delay corticosteroid administration as benefits may not appear for 6-12 hours 3

Step 3: Additional Medications for Severe Cases

• Add ipratropium bromide:
  • 0.5 mg via nebulizer every 6 hours until improvement begins 2, 1
• Consider magnesium sulfate for severe refractory cases:
  • 2 g IV over 20 minutes 1

Monitoring Response to Treatment

• Repeat PEF measurement 15-30 minutes after starting treatment 2, 1
• Monitor oxygen saturation continuously with pulse oximetry 1
• Assess for clinical improvement: decreased work of breathing, improved air entry
• For severe cases, obtain chest radiograph to exclude pneumothorax, consolidation, or other causes 2, 1

Subsequent Management Based on Response

If Improving:

• Continue oxygen therapy
• Continue prednisolone 30-60 mg daily
• Continue nebulized beta-agonist every 4-6 hours 2

If Not Improving After 15-30 Minutes:

• Continue oxygen and corticosteroids
• Increase frequency of nebulized beta-agonist (up to every 15-30 minutes) 2
• Ensure ipratropium has been added 2
• Consider IV aminophylline or IV beta-agonist infusion if still not responding 2

Critical Care Considerations

• Transfer to intensive care if:
  • Deteriorating PEF despite treatment
  • Persistent or worsening hypoxia
  • Hypercapnia
  • Exhaustion, confusion, drowsiness
  • Respiratory arrest 2, 1

Discharge Criteria and Planning

• Patient should not be discharged until:

  • PEF >75% of predicted or personal best
  • Symptoms have stabilized
  • Minimal need for rescue bronchodilators
  • Patient has been on discharge medications for 24 hours 1

• Discharge plan must include:

  • Written asthma action plan
  • Verification of proper inhaler technique
  • Follow-up with primary care within 1 week 1

Common Pitfalls to Avoid

• Delaying corticosteroid administration
• Underestimating severity based on clinical appearance alone
• Using sedatives of any kind (contraindicated in asthma) 2
• Delaying treatment to obtain laboratory studies 1
• Discharging patients too early before adequate stabilization
• Failing to arrange appropriate follow-up

By following this structured approach to acute asthma management, focusing on prompt administration of bronchodilators and corticosteroids while carefully monitoring response, you can effectively manage most asthma exacerbations and reduce morbidity and mortality.