Outpatient Treatment of Asthma Exacerbation
For outpatient management of asthma exacerbation, administer systemic corticosteroids (prednisolone 30-60 mg daily) within the first hour, along with short-acting beta-agonists (SABA) such as albuterol via nebulizer or metered-dose inhaler with spacer, and consider adding ipratropium bromide for moderate to severe cases. 1
Assessment and Classification
Classify exacerbation severity to guide treatment decisions:
- Mild: Mild symptoms, no limitation of activities, PEF ≥80% of predicted/personal best
- Moderate: Worsening symptoms, some limitation, PEF 50-79% of predicted/personal best
- Severe: Significant symptoms, significant limitation, PEF <50% of predicted/personal best
- Life-threatening: Severe symptoms, inability to speak, cyanosis, PEF <25% of predicted/personal best 1
Measure Peak Expiratory Flow (PEF) 15-30 minutes after starting treatment to assess response 1
Initial Treatment
Short-Acting Beta-Agonists (SABA):
Systemic Corticosteroids:
Oxygen Therapy (if available):
- Maintain SaO2 >90% (>95% in pregnant women and patients with heart disease) 1
Consider Adding Ipratropium Bromide:
- 0.5 mg via nebulizer every 6 hours for moderate to severe exacerbations 1
Treatment Based on Severity
Mild to Moderate Exacerbation (PEF >50% predicted):
- SABA: 2-4 puffs via MDI with spacer every 20 minutes for first hour
- Oral prednisolone 30-60 mg daily
- Reassess after 1 hour; if improved (PEF >70%), may discharge with follow-up plan 1
Severe Exacerbation (PEF <50% predicted):
- SABA: Nebulized albuterol every 15-30 minutes or continuous for first hour
- Ipratropium bromide: Add to nebulized treatment
- Systemic corticosteroids: Start immediately
- Oxygen: To maintain SaO2 >90%
- Consider hospital admission if no significant improvement after initial treatment 3, 1
Discharge Criteria and Planning
- Symptoms have stabilized with PEF above 75% of predicted value or personal best 3, 1
- Stable response to bronchodilator therapy for at least 60 minutes 1
- Patient able to use inhaler devices correctly 3
Discharge Medications
All patients should be discharged with:
- Prednisolone tablets (30 mg daily) for 1-3 weeks according to a written action plan
- Inhaled corticosteroids at a higher dosage than before exacerbation
- Inhaled or nebulized beta-agonists for use as needed
- Consider oral theophylline, long-acting beta-agonists, or ipratropium if required 3
Follow-up
- Arrange follow-up with primary care physician within 1 week of discharge 1
- Hospital follow-up by a respiratory physician within a month 3
- Provide peak flow meter and teach proper use 3
- Develop written self-management plan with clear instructions on when to increase treatment, call doctor, or go to hospital 3, 1
Recent Evidence on Combination Therapy
Recent evidence suggests that a fixed-dose combination of albuterol and budesonide as rescue medication reduces the risk of severe asthma exacerbations by 26% compared to albuterol alone in patients with moderate-to-severe asthma 4. This approach ensures that symptomatic relief is accompanied by preventative therapy, which is particularly beneficial given that poor adherence to regular therapy is common and increases the risk of exacerbations 5.
Common Pitfalls to Avoid
- Delaying corticosteroid administration - administer within first hour 1
- Underestimating severity based on clinical appearance alone 1
- Using sedatives of any kind (contraindicated in asthma) 1
- Discharging patients too early before adequate stabilization 1
- Relying excessively on SABA without addressing underlying inflammation - high SABA use (≥3 canisters/year) is associated with increased risk of exacerbations and healthcare utilization 6