What is the treatment for an asthma flare?

Treatment of Asthma Flare

The first-line treatment for an asthma flare is inhaled short-acting beta2-agonists (SABAs) such as albuterol, administered every 20 minutes for the first hour, followed by systemic corticosteroids within the first hour for moderate to severe exacerbations. 1

Initial Assessment and Classification

Assess the severity of the asthma flare based on:

• Symptoms: Shortness of breath, wheezing, cough, chest tightness
• Peak expiratory flow (PEF) measurements:
  • Mild: PEF ≥80% of predicted/personal best
  • Moderate: PEF 50-79% of predicted/personal best
  • Severe: PEF <50% of predicted/personal best
  • Life-threatening: PEF <25% of predicted/personal best 2

Step-by-Step Treatment Approach

Mild Exacerbation

• Inhaled SABA: 2-4 puffs of albuterol via metered-dose inhaler with spacer, or nebulized albuterol (2.5-5 mg) every 20 minutes for up to 1 hour 1
• Monitor response: If symptoms improve and PEF returns to >80%, continue SABA every 3-4 hours for 24-48 hours

Moderate to Severe Exacerbation

1. Oxygen therapy: Administer to maintain oxygen saturation >90% (>95% for pregnant women and patients with cardiac disease) 2

2. Inhaled SABA:

   • 4-8 puffs of albuterol via MDI with spacer every 20 minutes for 1 hour, or
   • Nebulized albuterol 2.5-5 mg every 20 minutes for 1 hour
   • For severe exacerbations, consider continuous nebulization (10-15 mg/hour) 1

3. Systemic corticosteroids (start within first hour):

   • Adults: Prednisone 40-60 mg orally or methylprednisolone 125 mg IV
   • Children: Prednisone 1-2 mg/kg/day (maximum 60 mg) 1, 2

4. Anticholinergics:

   • Add ipratropium bromide 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for the first hour, then every 6 hours until improvement begins 1, 2

5. Magnesium sulfate (for severe exacerbations not responding to initial therapy):

   • IV magnesium sulfate 2 g infused over 20 minutes 1

Life-Threatening Exacerbation

• All of the above treatments plus:
• Consider epinephrine 0.3-0.5 mg (1:1000) subcutaneously every 20 minutes for 3 doses if not responding to other therapies 1
• Prepare for possible intubation if deteriorating despite maximal therapy

Monitoring and Follow-up

• Reassess symptoms, vital signs, and PEF after each treatment
• For moderate to severe exacerbations, monitor:
  • Oxygen saturation continuously
  • Heart rate, respiratory rate, and blood pressure regularly
  • Consider arterial blood gases in severe cases 2

Discharge Criteria

• PEF or FEV1 ≥70% of predicted/personal best
• Symptoms minimal or absent
• Stable response to bronchodilator therapy for at least 60 minutes 2

Discharge Medications

1. Continue SABA: As needed for symptom relief
2. Oral corticosteroids: For moderate to severe exacerbations, continue for 5-7 days
3. Controller medications:
   • For first exacerbation: Start or increase inhaled corticosteroid (ICS)
   • For patients already on controller therapy: Consider step-up therapy according to guidelines 1

Common Pitfalls and Caveats

• Underestimating severity: Clinical appearance alone may not reflect the severity of the exacerbation. Always use objective measures like PEF when possible 2
• Delaying corticosteroids: Early administration of systemic corticosteroids (within first hour) is critical for moderate to severe exacerbations 1
• Over-reliance on SABAs: Using SABAs alone without addressing underlying inflammation increases risk of future exacerbations 3, 4
• Inadequate monitoring: Patients with severe exacerbations may initially improve with treatment but can deteriorate rapidly 2

Recent Advances in Asthma Flare Management

Recent evidence supports the use of combination ICS/FABA (fast-acting beta-agonist) inhalers as rescue therapy. The MANDALA trial showed that as-needed use of albuterol-budesonide fixed-dose combination significantly reduced the risk of severe asthma exacerbations compared to albuterol alone in patients with moderate-to-severe asthma 4.

Similarly, a Cochrane review found that as-needed FABA/ICS reduced exacerbations requiring systemic steroids compared to FABA alone (OR 0.45,95% CI 0.34 to 0.60) 5.

For patients with persistent asthma who continue to have exacerbations despite ICS+LABA therapy, adding tiotropium has been shown to decrease exacerbation risk by 35% compared to increasing the ICS+LABA dose 6.

Remember that prompt treatment of asthma flares is essential to prevent progression to life-threatening exacerbations and reduce morbidity and mortality.