What is the recommended management for an asthma exacerbation?

Management of Asthma Exacerbation

The management of asthma exacerbation requires prompt administration of oxygen to maintain SaO₂ >90%, inhaled albuterol (2.5-5 mg via nebulizer or 4-12 puffs via MDI with spacer every 20 minutes for 3 doses), and early systemic corticosteroids (prednisone 40-60 mg for adults) as the primary treatment components. 1, 2, 3

Initial Assessment and Severity Classification

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1) 1, 2:

  • Mild: Dyspnea only with activity, PEF ≥70% of predicted/personal best
  • Moderate: Dyspnea interfering with usual activity, PEF 40-69% of predicted
  • Severe: Dyspnea at rest, PEF <40% of predicted
  • Life-threatening: Confusion, drowsiness, silent chest, cyanosis 2

• In infants, assessment depends more on physical examination than objective measurements - use of accessory muscles, wheezing, paradoxical breathing, cyanosis, and respiratory rate >60 breaths/min signal serious distress 4

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, 3
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy 1, 3

Bronchodilator Therapy

• Albuterol (short-acting β2-agonist) is first-line treatment for all asthma exacerbations 1, 2, 5

• 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 1
  • For severe exacerbations (FEV1 or PEF <40%), continuous administration may be more effective 2

• EMS providers should administer supplemental oxygen and inhaled short-acting bronchodilators to all patients with asthma exacerbation signs/symptoms, without delaying transport 4

Systemic Corticosteroids

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

Adjunctive Therapies

Ipratropium Bromide

• Add to β2-agonist therapy for severe exacerbations 1, 2, 3
• Dosing: 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2
• The combination of a β2-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 1, 3

Magnesium Sulfate

• Consider for patients with severe refractory asthma 1, 2
• Standard adult dose: 2 g IV administered over 20 minutes 1, 2

Helium

• May be considered in cases of severe asthma exacerbations, although not routinely recommended 4

Treatment Strategy and Monitoring

• Initial assessment and treatment within first 15-30 minutes: oxygen, first dose of albuterol, and systemic corticosteroids 1, 2
• 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, 2

Hospital Admission Criteria

• Any life-threatening features: confusion, drowsiness, silent chest, cyanosis 2
• Features of acute severe asthma present after initial treatment, especially PEF <33% 2
• Lower threshold for admission with history of recent nocturnal symptoms, recent hospital admission, or previous severe attacks 2
• In infants, lack of response to short-acting β2-agonist therapy indicates need for hospitalization 4

Discharge Criteria

• Clinical stability 4
• Improved oxygen saturation and lung function (FEV1 and PEF) 4
• Normal breath rate and absence of chest wall indrawing 4
• Appropriate home care and written asthma action plan arranged 4

Special Considerations

• For hospitalized patients, ad-lib administration of albuterol (as needed for symptoms) may be as effective as regular scheduled administration, while reducing the total dose of β2-agonists received 6

• Recent evidence suggests that fixed-dose combination of albuterol and budesonide as rescue medication may reduce the risk of severe asthma exacerbations compared to albuterol alone in patients with uncontrolled moderate-to-severe asthma 7, 8

• In the prehospital setting, EMS providers should not delay patient transport to the hospital while administering bronchodilator treatment; treatment can be repeated during transport to a maximum of 3 bronchodilator treatments during the first hour and then 1 per hour 4

• Be aware that excessive use of inhaled sympathomimetic drugs has been associated with fatalities 5