What medications are used to manage asthma exacerbation in inpatients?

Medications for Asthma Exacerbation Management in Inpatients

The primary medications for managing asthma exacerbations in inpatients include oxygen therapy, inhaled short-acting beta-agonists (SABAs), systemic corticosteroids, and in severe cases, inhaled ipratropium bromide. 1

Primary Treatment Components

Oxygen Therapy

• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation (SaO₂) >90% (>95% in pregnant patients or those with heart disease) 1
• Monitor oxygen saturation continuously until a clear response to bronchodilator therapy has occurred 2

Inhaled Short-Acting Beta-Agonists (SABAs)

• Albuterol is the first-line bronchodilator treatment for all asthma exacerbations 2
• Administration options:
  • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1
  • MDI with spacer: 4-12 puffs every 20 minutes for up to 3 hours as needed 2
• For severe exacerbations (FEV1 or PEF <40% predicted), continuous administration may be more effective than intermittent dosing 2
• Caution: Albuterol may cause paradoxical bronchospasm, cardiovascular effects, and significant hypokalemia 3

Systemic Corticosteroids

• Essential for all moderate-to-severe exacerbations and should be administered early 2, 1
• Oral administration is preferred and as effective as intravenous administration 4
• Dosing recommendations:
  • Adults: Prednisone 40-80 mg/day in 1-2 divided doses until PEF reaches 70% of predicted or personal best 2
  • Children: Prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) 2
• Total course typically lasts 3-10 days; for courses less than 1 week, no tapering is needed 2
• Low-dose corticosteroid regimens (equivalent to hydrocortisone 50 mg IV every 6 hours) are as effective as higher doses in resolving acute severe asthma 5

Adjunctive Therapies

Inhaled Ipratropium Bromide

• Add to SABA therapy for severe exacerbations 2, 1
• Dosing options:
  • Nebulizer: 0.5 mg every 20 minutes for 3 doses, then as needed 2
  • MDI: 8 puffs every 20 minutes for 3 doses, then as needed 2
• The combination of a beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 1
• Important note: The addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized 2

Magnesium Sulfate

• Consider for patients with severe refractory asthma not responding to conventional therapy 1
• Standard adult dose: 2 g IV administered over 20 minutes 2
• Pediatric dose: 25-75 mg/kg (maximum 2 g) 2

Treatment Strategy and Monitoring

Initial Assessment and Treatment

• Within the first 15-30 minutes: administer oxygen, give first dose of inhaled albuterol, and administer systemic corticosteroids 1
• Reassess the patient 15-30 minutes after starting treatment 1
• Measure PEF or FEV₁ before and after treatments 1

Ongoing Management

• Response to treatment is a better predictor of hospitalization need than initial severity 1
• Continue SABA treatments based on clinical response and lung function measurements 2
• For patients with severe exacerbations, monitor oxygen saturation continuously 1

Important Considerations and Pitfalls

• Inhaled corticosteroids (ICS) should not be used routinely to treat acute exacerbations, as oral corticosteroids are significantly more effective in preventing hospitalizations and improving lung function in severe exacerbations 6
• Increasing the dose of maintenance ICS is not effective for treating exacerbations 7
• Early administration of corticosteroids (within 1 hour of presentation) can significantly reduce relapse rates after treatment 8
• There is no advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 2
• Use albuterol with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension 3
• Monitor potassium levels in patients receiving repeated or continuous albuterol treatments, as significant hypokalemia can occur 3