What are the guidelines for managing acute asthma exacerbations in Australia?

From the Guidelines

The most effective approach to managing acute asthma exacerbations in Australia involves early administration of supplemental oxygen, repetitive or continuous use of short-acting beta-agonists (SABA), and oral systemic corticosteroids to decrease airway inflammation, as recommended by the expert panel report 3 (EPR-3) guidelines 1.

Key Recommendations

• Administer supplemental oxygen to correct significant hypoxemia in moderate or severe exacerbations, with a goal to maintain oxygen saturation above 92% 1.
• Use repetitive or continuous administration of SABA to rapidly reverse airflow obstruction, with dosages as described in Fig 22 of the EPR-3 guidelines 1.
• Administer oral systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations, or for patients who fail to respond promptly and completely to SABA treatment, as outlined in the EPR-3 guidelines 1.
• Monitor response to therapy with serial assessments, including lung function measures (FEV1 or PEF) for children aged 5 years and above, and pulse oximetry for initial severity assessment and prediction of hospitalization need 1.

Home Management

For patients managing asthma exacerbations at home, it is crucial to have a written asthma action plan that notes when and how to treat signs of an exacerbation, and to adjust medications by increasing SABA and, in some cases, adding a short course of oral systemic corticosteroids 1. Patients should also be instructed to recognize early indicators of an exacerbation, remove or withdraw from allergens or irritants, and monitor response to treatment, promptly communicating with their clinician about any serious deterioration in symptoms or peak expiratory flow (PEF) 1.

From the Research

Guidelines for Managing Acute Asthma Exacerbations in Australia

• The guidelines for managing acute asthma exacerbations in Australia are based on international recommendations, which include administration of inhaled bronchodilators, systemic corticosteroids, and titrated oxygen therapy 2
• In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart followed by a reassessment of peak expiratory flow and symptoms may be safely employed at home 3
• Administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta2 agonist therapy in children and adults 3

Treatment Options

• Inhaled ipratropium bromide and intravenous magnesium sulfate should be considered in children with severe asthma exacerbations not responsive to conventional therapy 4
• Subcutaneous and intramuscular β2 agonists such as terbutaline and epinephrine may be considered for children with severe asthma exacerbation who have poor air entry, are uncooperative with nebulized therapy, or have poor response to nebulized therapy 4
• Monoclonal anti-IgE antibody (omalizumab) and humanized monoclonal antibodies targeting interleukin pathway have shown great promise in severe refractory eosinophilic asthma 4

Compliance with Guidelines

• The data suggests that compliance with guideline-recommended therapy in both Europe and South East Asia/Australasia, particularly corticosteroid administration, is sub-optimal 2
• There is also evidence of over-use of antibiotics in the treatment of acute asthma exacerbations 2

Use of Magnesium Sulfate

• Inhaled magnesium sulfate may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but the confidence in the evidence is low and there remains substantial uncertainty 5
• Nebulised MgSO₄ does not appear to be associated with an increase in serious adverse events 5