What are the current recommendations for emergency asthma care?

Current Recommendations for Emergency Asthma Care

The most significant advancement in emergency asthma care is the addition of ipratropium bromide to beta-agonist therapy and early administration of systemic corticosteroids, which significantly reduces morbidity and mortality in acute asthma exacerbations. 1

Initial Assessment and Treatment

Severity Classification

• Assess severity immediately using objective measurements:
  • Mild: Normal speech, pulse <110 beats/min, respiration <25 breaths/min, PEF >50% predicted
  • Severe: Cannot complete sentences in one breath, pulse >110 beats/min, respiration >25 breaths/min, PEF <50% predicted
  • Life-threatening: Silent chest, cyanosis, feeble respiratory effort, bradycardia/hypotension, exhaustion/confusion 1

Immediate Management

1. High-flow oxygen to maintain SaO₂ >92% (>95% in pregnant women and patients with heart disease)
2. Short-acting beta-agonists (SABA):
   • Nebulized albuterol 2.5 mg (for adults and children ≥15 kg) or terbutaline 10 mg 2
   • Can be delivered via MDI with spacer (20 puffs) as an effective alternative to nebulizer 3
3. Systemic corticosteroids within the first hour:
   • Adults: Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV
   • Children: Prednisolone 1-2 mg/kg (maximum 40 mg) 1
4. Add ipratropium bromide 0.5 mg via nebulizer for severe cases 1, 4

Management Based on Response

If Improving (15-30 minutes after initial treatment):

• Continue oxygen therapy
• Continue nebulized beta-agonist every 4-6 hours
• Continue prednisolone 30-60 mg daily
• Monitor PEF and symptoms

If Not Improving or Life-Threatening Features Present:

• Increase frequency of nebulized beta-agonist (up to every 15-30 minutes)
• Ensure ipratropium has been added
• Consider IV aminophylline or IV beta-agonist infusion
• Arrange transfer to intensive care if:
  • Deteriorating PEF despite treatment
  • Persistent/worsening hypoxia or hypercapnia
  • Exhaustion, confusion, drowsiness
  • Respiratory arrest 1

Recent Advancements in Emergency Asthma Care

1. MDI with spacer instead of nebulizer:

   • Equally effective for beta-agonist delivery
   • More cost-effective ($10.11 vs. $18.26 per patient)
   • Particularly useful during respiratory virus outbreaks 3

2. Fixed-dose combination of albuterol-budesonide as rescue therapy:

   • Reduces risk of severe exacerbations by 26% compared to albuterol alone
   • Addresses both bronchospasm and inflammation simultaneously
   • Beneficial for patients with uncontrolled moderate-to-severe asthma 5, 6

3. Earlier addition of ipratropium bromide:

   • Now recommended to be added in the initial treatment for severe cases
   • Can be mixed with albuterol in the same nebulizer 1, 4

Discharge Criteria and Follow-up

Discharge Criteria:

• Symptoms stabilized
• PEF >75% of predicted value or personal best
• Minimal or absent symptoms
• Stable response to bronchodilator therapy for 60 minutes 1

Before Discharge:

• Ensure patient has been on discharge medication for 24 hours
• Verify inhaler technique has been checked and recorded
• Provide PEF meter and written asthma action plan
• Arrange follow-up within 1 week 1

Common Pitfalls to Avoid

• Delaying corticosteroid administration

• Underestimating severity based on clinical appearance alone

• Delaying treatment to obtain laboratory studies

• Discharging patients too early before adequate stabilization

• Using sedatives (contraindicated in asthma) 1

• Failing to identify patients at risk of sudden death (those with history of rapid deterioration) who require special management plans 7

By following these updated recommendations and incorporating recent advancements, emergency asthma care can be optimized to reduce morbidity and mortality while improving patient outcomes.