What is the first line treatment for an asthma exacerbation?

First-Line Treatment for Asthma Exacerbation

The first-line treatment for an asthma exacerbation is administration of short-acting beta-agonists (SABAs) such as albuterol, followed by systemic corticosteroids for moderate to severe exacerbations. 1, 2

Initial Management Algorithm

Step 1: Assess Severity

• Determine exacerbation severity based on symptoms, signs, and if possible, lung function (PEF or FEV1) 2
• Mild: Dyspnea only with activity, PEF ≥70% of predicted or personal best 2
• Moderate: Dyspnea interferes with usual activity, PEF 40-69% of predicted 2
• Severe: Dyspnea at rest, PEF <40% of predicted 2

Step 2: Administer Bronchodilator Therapy

• Administer albuterol via nebulizer or metered-dose inhaler (MDI) with spacer 1, 3
  • Nebulizer dosing: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1
  • MDI dosing: 4-12 puffs every 20 minutes for up to 3 hours 2
• For children weighing <15 kg who require <2.5 mg/dose, use albuterol inhalation solution 0.5% 3

Step 3: Add Systemic Corticosteroids (for moderate to severe exacerbations)

• Administer oral prednisone 40-60 mg in single or divided doses for adults 1, 2
• For children: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 2
• Oral administration is as effective as intravenous administration and less invasive 2, 4
• Short courses (5-10 days) do not require tapering 2, 5

Step 4: Provide Supplemental Oxygen (if needed)

• Administer oxygen to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease) 1
• Monitor oxygen saturation until a clear response to bronchodilator therapy has occurred 1

Adjunctive Therapies for Severe Exacerbations

• Add ipratropium bromide to beta-agonist therapy for severe exacerbations 1, 6

  • Dosing: 0.5 mg every 20 minutes for 3 doses, then as needed 1, 2
  • The combination of a beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 2

• Consider magnesium sulfate for patients with severe refractory asthma 1

  • Standard adult dose: 2 g IV administered over 20 minutes 1, 2

Monitoring and Reassessment

• Reassess 15-30 minutes after starting treatment 1
• Measure PEF or FEV1 before and after treatments 1
• Monitor symptoms, vital signs, and oxygen saturation 1
• Response to treatment is a better predictor of hospitalization need than initial severity 2

Common Pitfalls and Caveats

• Do not delay corticosteroid administration - early administration may reduce hospitalization rates 2, 7
• Oral corticosteroids are preferred over inhaled corticosteroids for acute exacerbations 2, 8
• Antibiotics are not routinely recommended unless there is strong evidence of bacterial infection 2
• Avoid aggressive hydration in older children and adults 2
• Do not use methylxanthines, chest physiotherapy, or mucolytics as they are not recommended for acute exacerbations 2
• Low-dose corticosteroids (equivalent to hydrocortisone 50 mg IV four times daily) appear as effective as higher doses 9

Duration of Treatment

• For outpatient "burst" therapy, use 40-60 mg prednisone in single or divided doses for 5-10 days in adults 2
• For children, use 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 2
• A 1-week course of oral corticosteroids appears to be as effective as a 2-week course 5
• Intramuscular corticosteroids appear as effective as oral agents for preventing relapse 7