Treatment for Asthma Exacerbation
The primary treatment for asthma exacerbation consists of oxygen supplementation to maintain SaO₂ >90%, inhaled short-acting beta-agonists (SABAs) such as albuterol as first-line therapy, and early administration of systemic corticosteroids. 1, 2, 3
Initial Assessment and Treatment
- Assess severity based on symptoms, signs, and lung function (PEF or FEV1) to guide treatment intensity 1
- 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 1, 3
Primary Pharmacological Treatment
Short-Acting Beta-Agonists (SABAs)
- Albuterol is the first-line bronchodilator treatment for all asthma exacerbations 1, 2, 4
- Administration options:
- For severe exacerbations (FEV1 or PEF <40%), continuous administration may be more effective than intermittent dosing 1, 3
Systemic Corticosteroids
- Essential for all moderate-to-severe exacerbations and should be administered early 2, 3
- Oral prednisone 40-60 mg in single or divided doses for adults 2, 3
- Treatment duration typically 3-10 days, with no tapering needed for courses less than 1 week 2, 3
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 1, 2
- The combination of a beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 2, 3
Magnesium Sulfate
- Consider for patients with severe refractory asthma 1, 2
- Standard adult dose: 2 g IV administered over 20 minutes 1, 2
Other Adjunctive Therapies
- Helium-oxygen mixtures may be considered in patients who do not respond to standard therapies or those with severe disease 5
- Theophylline has a minimal role but may be considered in refractory cases of status asthmaticus with careful monitoring of toxicity 5
Treatment Strategy and Monitoring
- Initial assessment and treatment within the first 15-30 minutes, including oxygen, first dose of albuterol, and systemic corticosteroids 1, 3
- Reassess patient 15-30 minutes after starting treatment 1, 2
- Measure PEF or FEV₁ before and after treatments 1, 2
- Response to treatment is a better predictor of hospitalization need than initial severity 1, 3
Hospital Admission Criteria
- Consider hospital admission for any life-threatening features (confusion, drowsiness, silent chest, cyanosis) 1
- Admit patients with features of acute severe asthma present after initial treatment, especially PEF <33% 1
- Lower threshold for admission if patient has history of recent nocturnal symptoms, recent hospital admission, or previous severe attacks 1
Emerging Therapies
- Fixed-dose combination of albuterol and budesonide as rescue medication has shown to reduce the risk of severe asthma exacerbation compared to albuterol alone 6
- This combination ensures that symptomatic relief is accompanied by preventative therapy, which may be particularly beneficial in patients with poor adherence to maintenance therapy 7, 8
Potential Complications and Cautions
- Excessive use of inhaled sympathomimetic drugs has been associated with fatalities 4
- Paradoxical bronchospasm can occur with inhaled beta-agonists and can be life-threatening 4
- Immediate hypersensitivity reactions may occur after administration of albuterol 4
- Beta-agonists may have clinically significant cardiac effects in some patients 4