What is the treatment for acute asthma exacerbation?

Treatment for Acute Asthma Exacerbation

The primary treatment for acute asthma exacerbation consists of oxygen therapy, inhaled short-acting beta-agonists (preferably albuterol), and systemic corticosteroids administered early in the course of treatment. 1, 2

Initial Assessment and Severity Classification

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1) 2
• Mild exacerbation: dyspnea only with activity, PEF ≥70% of predicted/personal best 2
• Moderate exacerbation: dyspnea interfering with usual activity, PEF 40-69% of predicted 2
• Severe exacerbation: dyspnea at rest, PEF <40% of predicted 2
• Life-threatening features: confusion, drowsiness, silent chest, cyanosis 1

Primary Treatment Components

Oxygen Therapy

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

Inhaled Short-Acting Beta-Agonists (SABA)

• Albuterol is first-line treatment for all asthma exacerbations 2, 3
• 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, 2
  • MDI with spacer: 4-12 puffs every 20 minutes for up to 3 hours as needed 2, 4
• For severe exacerbations (FEV1 or PEF <40%), continuous administration may be more effective 1, 5
• MDI with spacer is as effective as nebulizer treatment when used with appropriate technique and dosing 6, 4

Systemic Corticosteroids

• Essential for all moderate-to-severe exacerbations and should be administered early 2, 5
• Oral prednisone 40-60 mg in single or divided doses for adults 2
• 1-2 mg/kg/day (maximum 60 mg/day) for children 2
• Total course typically lasts 3-10 days, with no tapering needed for courses less than 1 week 2, 5

Adjunctive Therapies

Ipratropium Bromide

• Add to SABA therapy for severe exacerbations 1, 2
• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 2
• The combination of beta-agonist and ipratropium reduces hospitalizations in patients with severe airflow obstruction 2, 4

Magnesium Sulfate

• Consider for patients with severe refractory asthma 2
• Standard adult dose: 2 g IV administered over 20 minutes 2

Treatment Strategy and Monitoring

• Initial assessment and treatment within first 15-30 minutes: oxygen, first dose of albuterol, systemic corticosteroids 2, 5
• Reassess 15-30 minutes after starting treatment 1, 2
• Measure PEF or FEV₁ before and after treatments 2
• Response to treatment is a better predictor of hospitalization need than initial severity 2, 5

Prehospital Management

• EMS providers should administer supplemental oxygen and inhaled short-acting bronchodilators 1
• Treatment can be repeated while transporting the patient to a maximum of 3 bronchodilator treatments during the first hour and then 1 per hour 1
• If beta-agonist treatment is not possible, subcutaneous epinephrine or terbutaline can be administered for severe exacerbations 1

Hospital Admission Criteria

• Any life-threatening features 1
• Any features of acute severe asthma present after initial treatment, especially PEF <33% 1
• Lower threshold for admission if: attack in afternoon/evening, recent nocturnal symptoms, recent hospital admission, previous severe attacks 1

Emerging Treatments

• Fixed-dose combination of albuterol and budesonide as rescue medication has shown to reduce risk of severe asthma exacerbations compared to albuterol alone 7, 8

Common Pitfalls and Caveats

• Delay in administering systemic corticosteroids can lead to worse outcomes 1
• Excessive use of inhaled beta-agonists without proper monitoring can lead to adverse effects including paradoxical bronchospasm 3
• Underestimation of severity by patients or healthcare providers is a common cause of preventable asthma deaths 1
• Patients with severe exacerbations may not present with all typical abnormalities, so careful assessment is crucial 1